Every finding on record at Foltsbrook Center for Nursing and Rehabilitation

Based on observation and interviews during the recertification survey conducted 1/23/2025-1/29/2025, the facility did not ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for 2 of 2 meals reviewed (the 1/24/2025 2nd floor lunch meal and the 1/27/2025 1st floor lunch meal). Specifically, food was not flavorful and was not served at palatable and appetizing temperatures during the lunch meals on 1/24/2025 and 1/27/2025. Additionally, two residents (Residents #24 and #35) stated the food did not taste good and they did not receive enough food. Findings include: The facility policy, Dining Atmosphere, dated 12/2024 documented meals were served in a way that enhanced the individual's dining experience, because the presentation of the meal could directly affect how much an individual ate. Hot food must be hot, and cold food must be cold (as acceptable to the individual being served). During an interview on 1/23/2025 at 10:45 AM, Resident #24 stated the food lacked flavor. During an observation on 1/23/2025 at 12:22 PM, the menu on the wall outside the dining room on the 3rd floor documented lunch was pork barbeque on a bun, macaroni salad, corn, and applesauce. There was a sign documenting they were out of applesauce and the replacement was gelatin with whipped cream. At 12:50 PM, the pork barbeque appeared to be deli sliced ham with barbeque sauce poured on top. During an interview on 1/23/2024 at 12:55 PM, Resident #35 stated they did not like the food, did not get enough of the food they did like, and was provided the alternative meal of hotdogs regularly. During a 2nd floor lunch meal observation on 1/24/2025 at 12:30 PM Resident #11 was served their lunch tray. A replacement tray was ordered, and Resident #11's original meal tray was tested . At 12:30 PM, Certified Nurse Aide #4 verified the measured food temperatures. The lemon pepper fish was measured at 111.6 degrees Fahrenheit, the French fries were 114.3 degrees Fahrenheit, the coleslaw was 58.8 degrees Fahrenheit, the Super pudding was 63.3 degrees Fahrenheit, the apple juice was 48.2 degrees Fahrenheit, and the milk was 64 degrees Fahrenheit. The Super pudding had a slight orange taste, was very dense in texture, and difficult to spoon. The fish was dry, and the French fries were soggy with a visible salt coating. Certified Nurse Aide #4 stated the residents complained about the food every day. It was either too cold, or it was always the same foods. They stated the apple juice was usually frozen. During a lunch meal observation on 1/27/2025 at 11:54 AM, on the first floor, Resident #119 was served their lunch meal tray. A replacement tray was ordered, and Resident #119's original meal tray was tested . Certified Nurse Aide #5 verified the measured food temperatures. The Salisbury steak was measured at 127.4 degrees Fahrenheit, the mashed potatoes were 133 degrees Fahrenheit, the applesauce was 61.9 degrees Fahrenheit, the cooked carrots were 130.8 degrees Fahrenheit, and the milk was 47.1 degrees Fahrenheit. The Salisbury steak appeared and tasted like a plain, frozen cooked hamburger patty with gravy poured on it. The cooked carrots had no flavor and were very soft. During an interview on 1/27/2025 at 1:15 PM, Certified Nurse Aide #6 stated residents complained about the food being cold or not tasting good. The residents preferred the alternatives like the soup and grilled cheese sandwiches. Alternatives were always offered. If the residents did not eat, they could lose weight. During an interview on 1/27/2025 at 1:28 PM, Licensed Practical Nurse #7 stated residents always complained they did not like it the food. The said the food was cold, too salty, and had no flavor. If the resident complained they were offered an alternative item such as sandwiches, hotdogs, or hamburgers. Many times, they also refused the alternative. If they did not eat, they could lose weight. During an interview on 1/27/2025 at 1:48 PM, Registered Nurse Unit Manager #8 stated residents always complained about food stating it was cold, or did not taste good. Sometimes they did not like what was on the menu, and they were offered an alternate. They also notified dietary if a resident did not like something so they could update the resident's menu options. The lunch meal on 1/27/2025 looked like a hamburger with gravy. They stated they tried the Salisbury steak and could not eat it because it did not taste good. If the residents did not eat, they could lose weight. During an interview on 1/28/2025 at 5:13 PM, Dietary [NAME] #9 stated the appropriate service temperature for hot food was 165 degrees Fahrenheit or above but was usually around 175-180 degrees Fahrenheit. The appropriate service temperature for cold food was 38 degrees Fahrenheit or below, the goal was 32 degrees Fahrenheit, but not frozen. Dietary [NAME] #9 stated the fish measured at 111.6 degrees Fahrenheit, Salisbury steak at 127.4 degrees Fahrenheit, mashed potatoes at 133 degrees Fahrenheit, and cooked carrots at 130.8 degrees Fahrenheit were too low. The French fries at 114.3 degrees Fahrenheit was too low as they should be 150 degrees Fahrenheit for a golden-brown appearance. The applesauce at 61.9 degrees Fahrenheit, coleslaw at 58.8 degrees Fahrenheit, Super pudding at 63.3 degrees Fahrenheit, and the milk was 64 degrees Fahrenheit were all too high. They should be 38 degrees Fahrenheit or less. They stated the Salisbury steak was a pre-made frozen patty. It was important food was served at the appropriate temperatures because the food could build up bacteria, and undercooked food was unappetizing. During an interview on 1/28/2025 at 5:23 PM, the Director of Food Service #10 stated food should be presented nicely, taste good, served timely, and at the proper temperature. The appropriate service temperature for hot food was between 150-165 degrees Fahrenheit so it was served above the danger zone of 140 degrees Fahrenheit. The appropriate service temperature for cold food was 35 degrees Fahrenheit, but anything below 40 degrees Fahrenheit was acceptable. The fish measured at 111.6 degrees Fahrenheit, Salisbury steak at 127.4 degrees Fahrenheit, mashed potatoes at 133 degrees Fahrenheit, French fries at 114.3 degrees Fahrenheit, and cooked carrots at 130.8 degrees Fahrenheit were all too low. The applesauce at 61.9 degrees Fahrenheit, coleslaw at 58.8 degrees Fahrenheit, super pudding at 63.3 degrees Fahrenheit, and the milk at 64 degrees Fahrenheit were all too high. They stated that while the applesauce did not have to be refrigerated, the temperature was too high to be enjoyable. It was important residents were served food that was enjoyable and palatable because it was their home and was important for the quality of life they deserved. The recipe for Salisbury steak was a pre-made frozen patty with gravy mix poured over it, it was heated to 165 degrees Fahrenheit, and then put on the tray line for service. The pork barbeque recipe was sliced deli ham (approximately 2-3 slices) on a hamburger bun with barbeque sauce on top. 10NYCRR 415.14(d)(1)(2)

Based on observations, record review, and interviews during the recertification survey conducted 1/23/2025-1/29/2025, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for 1 of 1 main kitchen. Specifically, the main kitchen had soiled and poorly maintained equipment and improper food and food product storage. Findings include: The undated facility policy, Food and Supply Storage, documented all food and supply items were held and stored safely and securely, maintained quality, and were protected against contamination, spoilage, and theft. All storage areas were always kept clean and in good working condition. Stored unused food was wrapped and labeled with the name and date of production. The undated facility policy, Cleaning and Mopping of Floors, documented food particles and other unwanted foreign materials were effectively removed from flooring. All floor areas of the department were swept and mopped at least twice daily. Equipment was cleaned underneath, and no standing water was left on the floor. The following observations of the main kitchen were made on 1/23/2025: - At 11:47 AM there was a large puddle on the floor of the dish room and there were no staff washing dishes. - At 11:52 AM there were soiled areas behind the cookline. There was a coating of grease and food debris on the side, under, and behind the the stove and fryer. - At 11:54 AM the ice machine had a stagnant puddle of liquid on the front edge of the unit. Beside the dish machine the floor was soiled with dried debris and food scraps. - At 12:11 PM the dry storage room beside the C1 walk-in cooler had food debris under the shelving and opened jelly packets dried on the floor. - At 12:17 PM the tray line cooler door was in disrepair and the handle area had exposed insulation. There was a tray of portioned pasta salad uncovered and dried out on top. - At 12:21 PM the dry storage room beside the dish room had heavily stained and soiled areas on the floor tiles. During an interview on 1/23/2025 at 2:57 PM, the Director of Dietary stated the floors were cleaned anytime something was dropped on them. The floors should be cleaned at least every hour or two. Cleaning behind the equipment was supposed to be done the previous night but was not. Dry storage areas, including under the shelving, were swept every shift and mopped as needed. The walk-in coolers were swept and mopped twice daily. They tried to clean the rust from the floor after coolers were moved but despite trying different chemicals it was still not clean. There should not be exposed insulation in the cooler on the tray line because it could not be properly cleaned because the surface was not smooth. Prepared food should have been covered or it could become dry or contaminated. During an interview on 1/23/2025 at 3:14 PM, the Director of Building Services stated there should not have been a puddle of water on the floor and the ice machine should have been cleaned. It was important for infection control that kitchen equipment and floors were clean. 10NYCRR 415.14(h)

Based on observations, record review, and interviews during the recertification survey conducted 1/23/2025-1/29/2025, the facility did not maintain an effective pest control program so that the facility was free of pests for multiple resident areas on 1 of 5 resident units (5th floor) reviewed. Specifically, there were fruit flies on the 5th floor. Findings include: The facility policy, Pest Control, dated 12/2024, documented the facility would take all reasonable measures to prevent and control pests, insects, and rodents through routine cleaning, proper food storage, and regular pest control services. The third-party pest control logs dated 10/17/2024,10/24/2024,10/31/2024,11/07/2024,11/14/2024, 12/05/2024,12/11/2024,1/16/2025,1/23/2025 documented treatments for insects and flies in the facility and the facility was inspected and serviced. The following observations were made on the 5th Floor: - on 1/23/2025 at 10:30 AM there was a fruit fly on the cart in the hallway near room [ROOM NUMBER] - on 1/23/2025 at 11:37 AM on the 5th floor an unknown staff swatted a fly then stated they hated when those little bugs got in their mask. - on 1/24/2025 at 8:43 AM there were multiple fruit flies outside of room [ROOM NUMBER]. - on 1/24/2025 at 1:55 PM there were multiple fruit flies at the nursing station desk. - on 1/27/2025 at 9:50 AM there were multiple fruit flies in the hallway near room [ROOM NUMBER]. - on 1/27/2025 at 10:37 AM there were multiple fruit flies in the dining room. - on 1/27/2025 at 11:35 AM there were multiple fruit flies between rooms [ROOM NUMBERS]. - on 1/27/2025 at 12:07 PM there were multiple fruit flies at the nursing station. - on 1/27/2025 at 1:38 PM there were several fruit flies on the elevator. - on 1/28/2025 at 9:40 AM there was a fruit fly on tray table in the hallway. - on 1/28/2025 at 10:04 AM Resident # 57 swatted a fruit fly away from their nose in the dining area. During an interview on 1/28/2025 at 09:54 AM Licensed Practical Nurse Manager #19 stated the fruit flies were bad. Pest control was in to treat them, but they had not seemed to completely go away. During an interview on 1/29/2025 at 12:22 PM Certified Nurse Aide #18 stated the fruit flies were intermittent and were very annoying. They stated the fruit flies probably had something to do with the poor condition of room [ROOM NUMBER]. The room was very dirty and had a terrible odor. The Certified Nurse Aide #18 stated having fruit flies was not home like, but most residents on that unit lacked the capacity to complain about them due to their cognitive disabilities. During an interview on 1/29/2025 at 12:48 PM Maintenance Director #17 stated the fruit flies on the 5th floor had been a bigger problem during the summer months. The drains were recently treated by the third-party pest control vendor service. The Maintenance Director #17 stated they were not aware of the presence of fruit flies until one was observed on another person who had accompanied them on the 5th floor elevator. 10NYCRR 415.12(a)(3)

Based on observations, record review, and interviews during the recertification survey conducted 1/23/2025-1/29/2025, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for the Physical Therapy gym and for 2 of 5 resident units (Units 1 and 4) reviewed. Specifically, the Physical Therapy gym, Unit 1, and Unit 4 had several walls with patched holes and missing paint. Findings include: The facility policy, Homelike Environment, revised 12/2024, documented the residents were provided a safe, clean, comfortable, and homelike environment. The facility staff and management should to the extent possible, reflect a personalized homelike setting that included clean, sanitary, and orderly environment, inviting colors and decor. Work orders dated 1/1/2025 to 1/29/2025 documented there were multiple open work orders that had not been completed. The following observations were made on Unit 4: - On 1/23/2025 at 10:31 AM, 1/24/2025 at 7:51 AM, and 1/29/2025 at 8:26 AM room [ROOM NUMBER] had 7 orange sized white patches of paint on the bathroom wall. - On 1/23/2025 at 11:04 AM, 1/24/2025 at 7:59 AM, and 1/29/2025 at 8:29 AM room [ROOM NUMBER] W had a grapefruit sized area of missing paint on the wall at the head of the bed. - On 01/27/25 at 3:54 PM, and 1/28/2025 at 10:11 AM room [ROOM NUMBER] D had 3 inch areas of missing paint and sheetrock behind their bed. During an interview on 1/27/2025 at 3:54 PM, Certified Nurse Aide #22 stated when a room or equipment was in disrepair, they completed a work order or called maintenance. They called maintenance if resident walls were missing paint or if there were holes in the wall because it was not homelike. Maintenance entered every room looking for disrepair, however they were not sure how often this occurred. During an interview on 1/28/2025 at 10:11 AM, Licensed Practical Nurse #23 stated if there was an environments issue, they completed a work order in the computer system and the repair was normally completed within 15 minutes. If there was missing paint it should be reported to maintenance for completion. If it was not repaired the room would not look homelike. During an interview on 1/28/2025 at 10:22 AM, Licensed Practical Nurse Unit Manager #20 stated all staff were responsible for reporting environmental concerns to maintenance through the computer program. Issues were normally repaired the same day they were reported. Missing or chipped paint was something that should be reported as it was not homelike. During an observation on 1/29/2025 at 9:17 AM the inpatient physical therapy gym on the first floor had an area of white plaster in the shape of a door on the wall to the right before the kitchen opening. During an interview on 1/29/2025 at 9:24 AM, the Director of Housekeeping stated if they saw walls in disrepair, they completed a work order for maintenance to address. It normally took maintenance a few hours to complete a work order unless they were waiting on a part. They noticed the wall in the physical therapy gym had a large amount of plaster on the walls for several months. It was not homelike and should be painted. The following observations were made on Unit 1: - On 1/27/2025 at 9:59 AM and 1/29/2025 at 8:41 AM there were several large scrapes in the sheetrock behind the bed in room [ROOM NUMBER] R. During an interview on 1/29/2025 at 10:48 AM, Registered Nurse Unit Manager #16 stated when they noticed holes in the walls, chipped paint, or rooms in disrepair they notified maintenance because it was not homelike for the residents. Maintenance usually repaired the issue in 24 hours unless they were waiting for parts. During an interview on 1/29/2025 at 12:17 PM, The Director of Maintenance stated the facility used a computerized work order system and all staff was trained how to complete a work order. Some of the projects addressed were damaged walls, patching, and painting of walls. Most of the projects were completed the same day with others completed within 3-4 days when they were waiting for joint compound to dry. They completed projects on a priority system as they only had three employees in the department. They completed weekly rounds in every room looking for damaged walls, especially behind beds, because the bed caused holes in the walls. If there was missing paint or holes in the walls it was not homelike for the resident. 10 NYCRR 415.29(j)(1)

Based on observation, record review, and interviews during the recertification and abbreviated (NY00351460) surveys conducted 1/23/2025-1/29/2025, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 1 of 3 residents (Resident #115) reviewed. Specifically, there was no documented evidence of a Comprehensive Care Plan for Resident #115's two Stage 2 (partial thickness tissue loss) pressure ulcers. Additionally, the resident had an alternating air pressure relieving mattress (a mattress with air filled cells that inflate and deflate to redistribute pressure) that was not set to their correct weight. Findings include: The facility policy, Support Surface Guidelines, revised 9/2013, documented residents at risk of skin breakdown were assessed for appropriateness of pressure reducing devices. Redistribution support surfaces promoted comfort, prevented skin breakdown, promoted circulation, and provided pressure relief or reduction. Any individual at risk for developing pressure ulcers should be placed on a redistributions support surface, such as foam, static air, alternating air, gel, or air loss device when in bed. The Protekt Aire 3000/3500/3600 (pressure relieving mattress) operational manual documented the Protekt Aire pump and mattress system was indicated for the prevention and treatment of all stage pressure ulcers when used in conjunction with a comprehensive pressure ulcer management program. The controls were set to on, low pressure, static control, and the control knob was set according to the resident's weight. Resident #115 had diagnoses including a Stage 2 (partial thickness tissue loss) pressure ulcers of the left and right buttocks and diabetes. The 12/23/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, did not reject care, was dependent for all activities of daily living, was always incontinent of urine and stool, did not have one or more unhealed pressure ulcers, and weighed 126 pounds. The 12/18/2024 at 3:00 PM admission skin condition assessment completed by the Director of Nursing documented the resident had a 2 centimeters x 1 centimeter and a 3 centimeters x 2 centimeters open area to the right gluteal fold (where the buttocks meet the thigh). The resident did not have a pressure ulcer on admission. The resident was at moderate risk of developing pressure ulcers and required close attention and preventative measures. There was no documented evidence of a Comprehensive Care Plan addressing the resident's two skin impairments assessed on admission. The resident was hospitalized from 12/23/2024-1/13/2025 due to possible (kidney) renal failure. The 1/13/2025 at 6:05 PM readmission assessment completed by Registered Nurse Supervisor #34 documented the resident had two Stage 2 pressure areas to the buttocks measuring 3 centimeters x 1.5 centimeters and 2 centimeters x 1.5 centimeter. The surrounding area was red and excoriated (abrasion). The resident weighed 123 pounds. There were no documented interventions for pressure relief. The Comprehensive Care Plan initiated 1/14/2025 did not include skin impairments or pressure reducing interventions. The Medication Administration and Treatment Administration Records from 1/13/2025-1/27/2025 did not include directions for monitoring of the residents alternating pressure reduction mattress or recommended settings. The Kardex (care instructions) did not document the use of a pressure relieving mattress. The Medication Administration Record for 1/2025 documented obtain weight every Monday for 5 weeks with a start date of 1/20/2025. There were no documented weights on Monday 1/20/2025 or Monday 1/27/2025. Resident #115 was observed in bed with an alternating pressure mattress set to static low pressure at 350 pounds: - on 1/23/2025 at 10:42 AM. - on 1/24/2025 at 7:54 AM. - on 1/27/2025 at 3:51 PM. - on 1/28/2025 at 10:30 AM. During an interview on 1/28/2025 at 10:11 AM, Licensed Practical Nurse #23 stated care plans were completed by the Unit Manager when the resident was admitted and updated by the Unit Manager when there were any changes. If a resident was admitted with skin breakdown or was at risk for skin breakdown interventions included pressure relieving devices. The facility had alternating pressure mattresses, however there were none used on the fourth floor (Resident #115's floor) at this time. When a resident had an alternating pressure mattress it was documented on the care plan and documented on the treatment administration record for nurses to check the function and weight every shift. The pressure was set to the resident's weight and if the setting was not set to the proper weight, it could cause more pressure and increase skin breakdown. During an interview on 1/28/2025 at 10:22 AM, Licensed Practical Nurse Unit Manager #20 stated the Director of Nursing, and the Assistant Director of Nursing completed care plans for residents on the fourth floor because they were just learning the process. If there was required care that was not on the care plan it would not be implemented. If care was not documented, it was not completed. If a resident had pressure or was at risk for pressure interventions could include alternating pressure mattresses. They stated alternating pressure mattresses were set up by central supply. It was important to have the bed set according to the resident's weight. They were unsure who put the settings on the bed, and they were not sure if there was any place to document the mattress was checked but was sure it was not documented on the treatment administration record. Resident #115 was on an alternating pressure mattress, and they observed the bed was set to 350 pounds. They stated if the mattress was not set to the proper weight, it could cause decreased wound healing and increased wounds. During an interview on 1/28/2025 at 10:52 AM, Nurse Practitioner #24 stated when residents were at risk for developing pressure wounds or had wounds they might use an alternating pressure mattress. Use of the mattress did not require an order from them. They believed the nurse made sure it was functioning and set to the proper weight. The bed was set according to the resident's weight and if a resident weighed 125 pounds the bed should not be set at 350 pounds as that could cause increased pressure. During an interview on 1/28/2025 at 10:56 AM, Wound Consultant Nurse Practitioner #25 stated when medically appropriate they recommended an alternating pressure mattress, and the nurse was responsible for ordering it. The nurse was also responsible for making sure the bed was functioning and set at the proper weight every day. If the mattress was not checked every day the bed could be malfunctioning, and the resident would be lying on a hard surface. If a resident was on a mattress that was not functioning or set to the wrong weight that could cause increased pressure and decreased wound healing. The stated if the resident weighed 123 pounds the mattress should not be set at 350 pounds as they could have decreased wound healing and increased pressure. During an interview on 1/28/25 at 3:10 PM, the Director of Nursing stated the care plan was determined by the interdisciplinary team and documented the individual care required for each resident. If the interdisciplinary team met and determined an alternating pressure mattress was appropriate for a resident it was entered as a medical order by the Unit Manager. That order populated to the treatment administration record and the nurse checked the function and weight setting every shift and signed off on the treatment administration record. They expected that residents with an alternating pressure mattress were care planned for the mattress, that it was checked daily for functionality and correct weight settings, and documented as checked every shift on the treatment administration record. 10NYCRR 415.12(c)(1)

Based on observations and interviews during the recertification survey conducted 1/23/2025-1/29/2025, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles and included the expiration date when applicable for 3 of 5 medication carts (1st, 2nd, and 4th floor medication carts), and 1 of 5 treatment carts (1st floor treatment cart). Specifically, the 1st and 4th floor medication carts and the 1st floor treatment cart were left unattended and unlocked; and the 2nd floor medication cart contained 3 insulin pens without an opened or expired/discard date. Findings include: The facility policy, Security of Medication Cart, revised 12/2024, documented the nurse secured the medication cart during the medication pass to prevent unauthorized entry. Medication carts were always locked when out of the nurse's view. The facility policy, Storage of Medications, revised 12/2024, documented drug containers that had missing, incomplete, improper, or incorrect labels were returned to the pharmacy for proper labeling before stored. The facility policy, Insulin Administration, revised 12/2024, documented the steps for insulin injections included to check the expiration date. If a new vial was opened, the expiration date and time were recorded on the vial and the manufacturer recommendation for expiration after opening was followed. During an observation and interview on 1/24/2025 at 9:23 AM, the 1st floor medication cart contained: - Lantus (Insulin glargine) 100 units/milliliter, without an opened date for Resident #236. - Lantus (Insulin glargine) 100 units/milliliter, without an opened date for Resident #226. - Insulin lispro 100 units/milliliter, without an opened date for Resident #226. Registered Nurse #12 stated it was important to know when the insulin pens were opened because they were only good for 28 days. If they did not know the open date, the medication could be expired and not work as well. Resident #226's insulin lispro was discontinued so they knew the resident did not receive that medication. Lantus was an evening medication, so they did not administer those pens and was not sure when they were last administered. The following observations were made: - On 1/23/2025 at 10:29 AM, the 4th floor medication cart was unlocked and unattended and Resident #68 walked past the cart. - On 1/23/2025 at 11:50 AM, the 1st floor medication and treatment carts were unlocked and unattended. The medication cart was opened and contained several multidose bottles of medications in the top drawer. The treatment cart was opened and contained 2 pairs of scissors and other creams in the top drawer. There was no staff present in the area. - On 1/24/2025 at 8:08 AM, the1st floor treatment cart at the nursing station was unlocked and unattended. - On 1/27/2025 at 9:12 AM, the 1st floor treatment cart at the nursing station was unlocked. - On 1/28/2025 at 10:03 AM, the 4th floor medication cart was by the elevator and was unlocked. There were 8 residents in the adjacent dining room, and one resident was in the hallway approximately 5 feet from the cart. The facility treatment cart contents list documented the treatment cart contained medicated creams/ solutions, tweezers, scissors, personal protective equipment, needles, syringes and other various treatment supplies During an interview on 1/28/2025 at 10:22 AM, Licensed Practical Nurse Unit Manager #20 stated medication carts should always be locked so residents could not take medications out. It was also a breach of confidentiality as medications contained resident information. The unit had wandering residents that could remove medications, and it could be a safety concern. During an interview on 1/28/2025 at 3:34 PM, Registered Nurse #12 stated medication carts should always be locked when unattended. Treatment carts should also be locked as they contained medicated creams and scissors. It was important the carts were kept locked for the safety of the residents. During an interview on 1/28/2025 at 4:28 PM, Registered Nurse #21 stated they worked on the 4th floor on 1/23/2025 and had residents that wandered the halls. They recalled answering the phone on 1/23/2025 and did not remember if they locked the medication cart or where the cart was located when they were on the phone. They stated medications carts should always be locked when unattended for the safety of all residents. They did not lock the cart because they were rushing that day. During an interview on 1/28/2025 at 4:55 PM, the Director of Nursing stated they expected medication carts were clean, organized, and without expired medications. Neither the medication cart nor treatment cart should have been unlocked when unattended because someone that was not supposed to be in the cart could access it. The treatment cart had creams, resident specific treatments, scissors, and items the nurses may need for the day. They expected insulin pens to be labeled with an expiration date, a resident label, and stored in the bag provided by pharmacy. Insulin pens should be labeled with an open date, because after 28-30 days the pen expired. If a resident was given expired insulin, there was potential for the insulin to not work. During an interview on 1/29/2025 at 10:48 AM, Registered Nurse Unit Manager #16 stated treatment and medication carts should always be locked for resident safety. Carts should never be unlocked even when they were at the nursing station. 10 NYCRR 483.45 (g)(h)

Based on observations, record review, and interviews during the recertification survey conducted 1/23/2025-1/29/2025, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #112) reviewed, and for 1 of 1 staff bathroom (the basement breakroom bathroom) reviewed. Specifically, Certified Nurse Aide #26 did not use appropriate personal protective equipment when providing care to Resident #112 who was on transmission based precautions (droplet precautions) for influenza; and the soap dispenser in the women's bathroom located off the facility breakroom in the basement was not functional. Findings include: The facility policy, Influenza, Prevention and Control of Seasonal, revised 3/2022, documented all staff received education and training on preventing transmission of infectious agents, including influenza, during orientation to the facility. Contact and droplet precautions were implemented for residents with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever was longer. The facility policy, Hand Hygiene, revised 8/2019, documented hand hygiene was the primary means to prevent the spread of infection. All personnel were trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare associated infections. Alcohol based hand rub containing at least 62% alcohol, or soap (antimicrobial or non-antimicrobial) and water was used after personal use of the toilet or conducting personal hygiene. 1) Resident #112 had diagnoses including Influenza A (a respiratory virus). The 12/3/2024 Minimum Data Set assessment documented the resident was cognitively intact and required substantial assistance with most activities of daily living. The 1/22/2025 nasopharyngeal swab (a sample taken from the nose) laboratory report documented Resident #112 was positive for Influenza A. The Comprehensive Care Plan updated 1/22/2025 documented the resident had Influenza A and interventions included droplet precautions. The 1/22/2025 Registered Nurse Unit Manager #16 progress note by documented Resident #112 was positive for influenza A and was placed on droplet precautions. The provider was notified. The 1/27/2025 Licensed Practical Nurse #28 progress note by documented Resident #112 was positive for the flu and remained on droplet precautions. During an observation and interview on 1/24/2025 at 8:23 AM, the facility Droplet Precaution sign documented STOP, droplet precautions. Wear a procedure mask and a full-face shield, gown, gloves, and wash your hands. The sign was posted on Resident #112's doorframe. Certified Nurse Aide #26 entered Resident #112's room without washing their hands, putting on a gown, putting on gloves, or putting on a face shield. They stated they only went into the room to grab a breakfast tray. They did not look at the sign on the doorframe and was not sure if they should have worn a face shield, gown, gloves, or washed their hands before entering the room. During an interview 1/29/2025 at 8:57 AM, Certified Nurse Aide #30 stated they received training on infection control when they were hired. They followed the infection control practices by looking at the signs before entering a room. If they did not follow the signs they could spread germs to other residents, coworkers, and visitors. During an interview on 1/29/2025 at 10:48 AM, Registered Nurse Unit Manager #16 stated residents that were on isolation precautions had signs outside their doors and alerted staff and visitors to the appropriate personal protective equipment that was required before the room was entered. They expected all staff to read the signs and follow the directions on the signs. When a resident was on droplet precautions gowns, gloves, masks, and face shields were required. During an interview on 1/29/2025 at 12:37 PM, Infection Control Nurse #32 stated all staff were educated on infection control practices on admission, annually, and as needed. If a resident was on precautions, a sign was placed on the door that alerted staff and visitors what protective equipment had to be worn when entering the room. This was important for the safety of anyone entering the room and anyone they came in contact with. They expected staff to follow the directions on the sign to prevent the spread of infection and for the safety of staff, residents, and visitors. When a resident was diagnosed with the flu, they were placed on droplet precautions which required precautions for entering the room including wearing a mask, gown, face shield, and gloves. 2) During an observation on 1/28/2025 at 8:17 AM, the soap dispenser in the basement women's restroom across from the break room was broken and there was no alcohol based hand rub available. During an observation on 01/28/2025 at 11:17 AM, an unidentified housekeeper stated the soap dispenser was broken. During an observation and interview on 1/29/2025 at 8:19 AM, the soap dispenser in the women's bathroom across from the break room was broken and there was no alcohol based hand rub available. Janitorial staff #29 stated they were aware of the broken soap dispenser on 1/28/2025, however was unable to fix the dispenser. They notified their supervisor and maintenance the dispenser was broken on 1/28/2025. They stated soap was needed to clean hands after using the bathroom and not using soap was unsanitary. During an interview on 1/29/2025 at 9:24 AM, Director of Housekeeping and Central Supply #31 stated their department checked soap dispensers and made sure they were full, however broken soap dispensers were repaired by maintenance. It usually only took maintenance a few hours to complete a work order. Soap dispensers that were broken should be fixed quickly as hand hygiene was important to limit the transmission of pathogens. During an interview on 1/29/2025 at 10:48 AM, Registered Nurse Unit Manager #16 stated the most important way to limit the spread of disease was washing your hands. Staff took their breaks on the first-floor basement break area and if women needed to use the restroom when on break, they used the restroom across from the break room. If there was not a working soap dispenser in that bathroom there would be no way for staff to wash their hands. During an interview on 1/29/2025 at 12:37 PM, Infection Control Nurse #32 stated staff took their breaks in the basement and if a woman had to use the bathroom they used the bathroom across from the breakroom. There should be a functioning soap dispenser in the bathroom to prevent the spread of infection. 10NYCRR 415.19(a)(b)

Based on observations, record review. and interviews during the recertification and abbreviated (NY00361906 and NY00351460) surveys conducted 1/23/2025-1/29/2025, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 2 of 5 residents (Resident #116 and #226) reviewed. Specifically, Resident #116 was not shaved, and Resident #226 was not shaved and groomed. Findings include: The facility policy, Activities of Daily Living, revised 3/2018, documented residents were provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who were unable to carry out activities of daily living independently received the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services were provided for residents who were unable to carry out activities of daily living independently including support and assistance with bathing, grooming, dressing, and oral care. 1) Resident #116 had diagnoses including post-traumatic stress disorder, pneumonia, and bladder cancer. The 11/10/2024 Minimum Data Set assessment documented the resident was cognitively intact, able to make their needs known, did not reject care, and required substantial to maximal assistance of one for personal hygiene. The 11/7/2024 Comprehensive Care Plan documented Resident #116 had a self-care deficit related to weakness. Interventions included the resident was offered a shower every Tuesday and as needed and required assistance of one for personal hygiene. The undated Kardex (care instructions) documented staff should ask the resident if they would like to be shaved and assist with shaving facial hair as needed. The following observations of Resident #116 were made: - on 1/24/2025 at 8:32 AM, sitting in their bed with a large amount of stubble covering their lip and chin. The resident stated they did not like facial hair and would like to be shaved. - on 1/29/2025 at 8:54 AM, sitting in their bed with stubble covering their lip and chin. They stated they got a bed bath on 1/28/2025 but were not shaved and would like to be shaved. 2.) Resident #226 had diagnoses including depression, diabetes, and obesity. The 1/16/2025 Minimum Data Set Assessment had not yet been completed. The 1/17/2025 Comprehensive Care Plan documented Resident #226 had a self-care deficit, and interventions included extensive assistance of one for showering and limited assistance of 1 for personal hygiene and oral care. The undated Kardex (care instructions) documented Resident #226 preferred no facial hair. They were to be assisted with shaving as needed and on shower days. Resident #226 was observed: - on 1/23/2025 at 12:22 PM, in bed with a significant amount of facial hair and long unkempt hair. The resident stated they asked several staff for a haircut and shave; staff was looking into it and had never gotten back to them. - on 1/27/2025 at 10:31 AM, in bed with a significant amount of facial hair and long unkempt hair. They stated they asked several staff for a haircut and shave; staff was looking into it and had never gotten back to them. -on 1/29/2025 at 9:17 AM, in the physical therapy room walking with a walker with long uncombed hair and a full beard. Physical Therapy Assistant #33 stated the resident asked for a haircut and they put the resident on the list for the hairdresser. During an interview on 1/28/2025 at 3:34 PM, Registered Nurse #12 stated personal hygiene care was completed daily by the certified nurse aides. Certified nurse aides used the resident Kardex to review required care for individual residents. If a resident wanted a haircut, the unit clerk should be notified however the unit clerk had been out of work for an extended period. Residents should be shaved on their shower day, if they asked, or if staff noticed facial hair was getting long. If someone wanted a haircut and/or shave and did not receive one they might feel dirty and unclean. During an interview on 1/29/2025 at 8:57 AM, Certified Nurse Aide #30 stated they were responsible for completing or assisting residents with personal hygiene care which included shaving and hair care. They looked at the shower book daily for the list of showers for the day and shaved residents on their shower day or when needed. When a resident requested a haircut, they called the hairdresser for an appointment. If a resident asked for a shave and haircut, they would shave them and call the hairdresser to make an appointment for a haircut. During an interview on 1/29/2025 at 10:48 AM, Registered Nurse Unit Manager #16 stated certified nurse aides completed hygiene care for all residents as documented on the individual Kardex. Residents were shaved on shower days. Shaving could be done any day and did not have to wait for the resident's shower day. When residents were admitted they received a coupon for a free haircut from the concierge and the appointment was scheduled by the unit clerk. They had not sent residents to the hairdresser since the unit clerk has been out on extended leave. If a resident wanted to be shaved and/or have their haircut and did not, it could be a dignity issue. 10NYCRR 415.12(a)(3)

Based on observation, interview, and record review during the recertification survey conducted 1/23/2025-1/29/20254, the facility did not ensure the right to reside and receive services with reasonable accommodation of resident needs and preferences for 1 of 1 resident (Resident #4) reviewed. Specifically, Resident #4 was not provided with a meal before going to outside dialysis (filtering of blood during kidney failure) appointments. Findings included: The facility policy, Food Palatability, revised 12/2024, documented the facility provided residents with nutritious, well-balanced, and palatable meals that met their individual dietary needs and preferences. The facility policy, Medical Transport Process, dated 8/12/2024 documented when an appointment was scheduled early in the morning and the resident was not allowed to eat prior to the appointment, dietary was notified and a to go breakfast was prepared for the resident. This pertained to any meal missed when on an appointment. If residents choose not to take a meal, one would be prepared upon return. Resident #4 had diagnoses including chronic kidney disease and dependence on renal dialysis. The 12/3/2024 Minimum Data Set assessment (a health status assessment tool) documented the resident was cognitively intact, required substantial assistance for most activities of daily living, and was dependent on renal dialysis. A physician order dated 10/17/2024 documented hemodialysis on Monday, Wednesday, and Friday. Pick up time 11:00 AM. Send snack/meal with resident to dialysis on Monday, Wednesday, and Friday. Send lunch. The Comprehensive Care Plan initiated 10/26/2024 documented the resident had a nutritional problem and was at risk for malnutrition related to dialysis three days a week. Interventions included monitor labs, a renal diet with a 1200 milliliter fluid restriction was provided, and an alternative was offered if the resident refused their meal. There was no documented evidence the care plan included provision of lunch to the resident on dialysis days. During an observation and interview on 1/24/2025 at 11:00 AM Resident #4 was getting ready for dialysis and did not have a lunch tray in their room. They stated they never received lunch before going to dialysis and would like lunch as it was a long time to go without food from breakfast to dinner. They stated they were offered a bag lunch once or twice but were not allowed to eat at the dialysis center and therefore did not bring the bagged lunch. Additionally, they did not like the bagged lunch and preferred a hot lunch. Resident #4 was interviewed and/or observed at the following times: - on 1/27/2025 at 9:49 AM they stated they attended dialysis every Monday, Wednesday, and Friday and was not given or offered a bagged lunch or hot lunch prior to dialysis on 1/24/2025 and would like to have a hot lunch before going to dialysis. - on 1/27/2025 at 11:49 AM Resident #4 was going to dialysis and was not offered a bagged or hot lunch before they left. - on 1/29/2025 at 8:42 AM they stated they went to dialysis on 1/28/2025 which was not their normal day. It was an extra day because they needed more fluid removed. Staff brought a hot lunch tray before they went to dialysis on 1/28/2025 for the first time ever and reported being very appreciative. They stated they had never been offered a lunch before dialysis and had never refused a lunch before going to dialysis. During an interview on 1/28/2025 at 9:46 AM, Certified Nurse Aide #11 stated it was very important for residents to get three meals a day for proper nutrition. If residents did not get three meals a day, they could have weight loss and skin breakdown. They often prepared Resident #4 for dialysis and brought the resident to the front for transport to dialysis. They never saw the resident get a lunch prior to dialysis and they were not sure why. They stated the resident should get lunch before going to dialysis. During an interview on 1/28/2025 at 3:34 PM, Registered Nurse #12 stated Resident #4 went to dialysis every Monday, Wednesday, and Friday and if they went during lunch, they looked for a bagged lunch for the resident in the refrigerator on the unit. Resident #4 went for an extra dialysis session on 1/28/2025 and was offered a hot lunch and ate it. They were unsure if the resident was ever offered a hot lunch before but had been offered a bag lunch previously and refused the bag lunch. During an interview on 1/29/2025 at 10:22 AM, Dietary Aide #13 stated if a resident had an appointment, they should receive either an early tray or a bagged lunch. Some residents had repeating appointments and received an early tray or bagged lunch, and those residents went on a list. During an interview on 1/29/2025 at 10:27 AM, the Director of Dietary Services #14 stated there was a list of residents who received bag lunches or an early lunch that was kept in the kitchen, however, they were unable to locate the list. It was important for residents to have three meals a day for maintaining general health. During an interview on 1/29/2025 at 10:31 AM, Registered Dietitian #15 stated it was important for residents to have three meals on their dialysis day because they were worn out from the procedure of dialysis. A resident on dialysis had added stress and strain on the body which required more calories and protein. Nursing provided dietary the names of residents who were going to outside appointments, and they were added to a list that was kept in the kitchen. The list documented if the resident received a hot lunch or bagged lunch. The list documented Resident #4 was to have a bagged lunch prepared on Monday, Wednesdays, and Fridays. Registered Dietitian #15 stated they were aware Resident #4 did not like bagged lunches. They were unaware the resident left for dialysis at 11:45 AM and did not return until 4:00 PM. They stated the resident should have been offered a hot lunch before going to dialysis. During an interview on 1/29/2025 at 10:48 AM, Registered Nurse Unit Manager #16 stated it was important that residents received 3 meals a day for nutritional purposes. When residents went to an appointment, they emailed dietary for an early lunch or bagged lunch. Dialysis residents should get three meals a day and if they did not get proper nutrition, they could have weight loss. Resident #4 used to have dialysis earlier in the day and refused lunch because it was too close to breakfast. When the dialysis time changed to 11:45 AM the resident should have been offered a hot lunch. 10NYCRR 415.5(e)(1)

Based on record review and interviews during the abbreviated survey (NY00365213), the facility failed to honor advance directive wishes for 1 of 3 residents (Resident #1) reviewed. Specifically, cardiopulmonary resuscitation (attempt to restart the heart) was implemented on Resident #1 when it was established they were unresponsive and without a pulse before their advance directive wishes were determined; once their advance directives were determined to be do not resuscitate (withhold cardiopulmonary resuscitation and allow a natural death) based on their Medical Orders for Life Sustaining Treatment, cardiopulmonary resuscitation ceased, only to be resumed due to staff appearing on scene and misunderstanding the resident's advance directives. Subsequently, once emergency medical services arrived on scene, cardiopulmonary resuscitation ceased once again due to clarification of the resident's advance directives (do not resuscitate), and the resident expired. Findings include: The facility policy Advance Directives, revised [DATE], documented a resident's advance directives were to be honored in accordance with state law and facility policy. Advance directives, including the Medical Orders for Life Sustaining Treatment form, would be maintained in a designated, clearly marked, and readily accessible area at the nursing station to ensure immediate availability in emergency situations. Advance directives orders were documented within the resident's profile in the electronic medication administration record system for ease of access by authorized personnel as both an order and in the miscellaneous section of the resident's chart. Resident #1 had diagnoses including acute and chronic respiratory failure with hypercapnia (too much carbon dioxide in the bloodstream) and hypotension (low blood pressure). The [DATE] Minimum Data Set assessment documented the resident was cognitively intact and their advance directives were do not resuscitate and do not intubate. The Medical Orders for Life Sustaining Treatment form, signed by the resident (verbal consent) on [DATE] at 12:30 PM, (during their hospitalization and prior to their admission to the facility), documented the resident wished for a do not resuscitate/do not intubate order. The form was witnessed by two registered nurses and signed by a hospital medical doctor on [DATE]. The [DATE] electronic physician order entered by Registered Nurse #8 documented do not resuscitate/do not intubate. The order was signed by Medical Doctor #9 on [DATE]. The comprehensive care plan, initiated on [DATE], documented the resident's advance directives were do not resuscitate/do not intubate, the goal was their wishes were to be honored, and the intervention was to ensure all necessary paperwork went with them upon transfer to the hospital or home. The [DATE] facility incident report documented: - At 4:40 PM Resident #1 was being transferred to bed (via mechanical lift), and their face turned purple. - The certified nurse aides immediately moved the resident back onto the bed, applied oxygen and called out for further assistance. - Licensed Practical Nurse #4 administered 5 liters of oxygen via face mask, identified there was no pulse, and initiated chest compressions until the resident's code status was determined. - Social Worker #5 retrieved the resident's Medical Orders for Life Sustaining Treatment form which confirmed the resident was a do not resuscitate/do not intubate. - Licensed Practical Nurse #4 immediately ceased chest compressions upon that confirmation. - Registered Nurse Supervisor #6 arrived on scene and was made aware of the code status by Licensed Practical Nurse #4. However, they directed that cardiopulmonary resuscitation resumed. - Licensed Practical Nurse #7 then took over chest compressions at the direction of Registered Nurse Supervisor #6, and 911 was called. - An automated external defibrillator (AED) from within the facility was placed on the resident by staff. Emergency medical services arrived and took over compressions. The automated external defibrillator determined the resident was not shockable. - At that time, Social Worker #5 returned to the resident's room with the Medical Orders for Life Sustaining Treatment form in hand to reinforce the resident's do not resuscitate/do not intubate status. - All life-saving measures were immediately ceased and the resident was pronounced deceased at 4:52 PM. Staff statements from the [DATE] facility incident report included: - Licensed Practical Nurse #4 acknowledged their error in initiating chest compressions prior to verification of the Medical Orders for Life Sustaining Treatment, as they were aware of the policy and reacted too quickly. They completed approximately 30 chest compressions when Social Worker #5 arrived with the Medical Orders for Life Sustaining Treatment form, confirming do not resuscitate/do not intubate status, and immediately stopped. When Registered Nurse Supervisor #6 arrived on scene, they instructed Licensed Practical Nurse #4 to resume chest compressions, despite Licensed Practical Nurse #4 stating the resident was do not resuscitate/do not intubate. Registered Nurse Supervisor #6 stated they were going to take over chest compressions and instructed Licensed Practical Nurse #4 to call a Code Blue (a medical emergency usually involving respiratory or cardiac arrest). - Licensed Practical Nurse #7 arrived on scene and Registered Nurse Supervisor #6 instructed them to take over chest compressions. Shortly thereafter, emergency medical services arrived on scene and took over. Social Worker #5 provided the Medical Orders for Life Sustaining Treatment form once again, which was given to Registered Nurse Supervisor #19 (who arrived on scene due to the Code Blue announcement), who then told everyone to cease chest compressions. - Registered Nurse Supervisor #6 noted that when they arrived on scene and Licensed Practical Nurse #4 stated the resident was do not resuscitate, they thought if a resident was do not resuscitate, they had to do cardiopulmonary resuscitation if they did not know whether the resident was do not intubate, until they spoke to a medical provider. Registered Nurse Supervisor #6 was aware the facility utilized Medical Orders for Life Sustaining Treatment forms and the electronic record for code status verification. The [DATE] at 4:33 PM facility investigative summary by the Director of Nursing included: - During a mechanical transfer lift on [DATE], Resident #1 experienced respiratory failure. - Certified Nurse Aides #1, #2 and #3 acted swiftly to recognize the emergency and repositioned and applied oxygen to Resident #1. - Licensed Practical Nurse #4 initiated cardiopulmonary resuscitation while awaiting the resident's code status. - The Medical Orders for Life Sustaining Treatment form was retrieved and confirmed by Social Worker #5 that Resident #1 was do not resuscitate/do not intubate, and resuscitative measures were ceased. - When Registered Nurse Supervisor #6 came on scene, they acted on a misunderstanding of the resident's code status and instructed compressions to resume. - The [DATE] incident was thoroughly investigated. A care plan violation occurred regarding Resident #1's documented do not resuscitate/do not intubate order status. The temporary miscommunication of the resident's do not resuscitate/do not intubate status highlighted the need for improved clarity and adherence to advance directives. The New York State Department of Health Certificate of Death documented the resident was pronounced deceased on [DATE] at 4:52 PM of natural causes, with immediate cause documented as cardiopulmonary arrest due to coronary artery arrest. During an interview on [DATE] at 10:55 AM Certified Nurse Aide #3 stated they were one of three aides in Resident #1's room on [DATE] when the resident's face turned a blue color while they were in the mechanical lift. They put the resident in bed and Certified Nurse Aide #2 ran to get the nurse. They held the resident's head upright and gave them oxygen. Licensed Practical Nurse #4 came in the room and told them to keep the resident's head up. Social Worker #5 met Certified Nurse Aide #1 halfway in the hall and stated the resident was a DNR (do not resuscitate). Certified Nurse Aide #1 came into the resident's room and told Licensed Practical Nurse #4 the resident was a DNR (do not resuscitate). At that moment, Licensed Practical Nurse #4 was not doing compressions on the resident. Advance directives for residents could be found in the pink Medical Orders for Life Sustaining Treatment binder behind the nurses' station or in the electronic chart. After the [DATE] incident, they received inservices on advance directives and code blue. During an interview on [DATE] at 12:30 PM the Director of Nursing stated they believed Registered Nurse Supervisor #6 had a lapse in judgment when they resumed chest compressions on Resident #1 during the [DATE] incident. It had been identified moments earlier that the resident was a do not resuscitate status by Social Worker #5. When they interviewed Registered Nurse #6 after the incident, they had stated because they did not know if the resident was a do not intubate, that chest compressions needed to resume. It was a care plan violation. The do not intubate had nothing to do with the do not resuscitate. They were suspended during the facility investigation and eventually terminated from employment. It did not make any sense that Registered Nurse Supervisor #6 thought they had to know if the resident was a do not intubate in order to stop chest compressions. Licensed Practical Nurse #4 should not have started chest compressions before determining the resident's code status. It was probably less than two minutes when compressions first stopped when they learned the resident was a do not resuscitate. Licensed Practical Nurse #4 was re-educated in person by myself on advance directives and code blue, and also received the additional inservices. There was a full house training for staff on advance directives and code blue after that incident. They had also done some mock code blue drills and inservices prior to the [DATE] incident as a part of their regular trainings. All new hires were trained on advance directives and code blue during orientation and annual inservices. The two problems they saw with the [DATE] incident were: Licensed Practical Nurse #4 should not have started chest compressions without checking on the resident's code status first; and Registered Nurse Supervisor #6 should not have resumed chest compressions after it was clearly identified the resident was a do not resuscitate. During an interview on [DATE] at 12:50 PM, Social Worker #5 stated they were first alerted to the [DATE] incident when they were in another resident room on the unit. They heard yelling in the hall and looked out and an aide mentioned Resident #1 was gurgling and turning blue. They pulled out Resident #1's Medical Orders for Life Sustaining Treatment form from the binder at the nurses station and saw that the resident was a do not resuscitate. They went to the resident's room and Licensed Practical Nurse #4 and Certified Nurse Aide #3 were both in the room. Licensed Practical Nurse #4 was not actively performing chest compressions when they arrived. They told them the code status was do not resuscitate. They left the room to allow staff to perform post-mortem care. While at the nurses station emergency medical services arrived. Licensed Practical Nurse #4 came to the nurses station and asked if a Code Blue had been called and they said No, so Licensed Practical Nurse #4 announced on the overhead a Code Blue. Then, Registered Nurse Supervisor #6 came to the nurses station and made a comment about the emergency medical technicians resuming chest compressions. When they heard that, they reinforced the resident was a do not resuscitate and had the Medical Orders for Life Sustaining Treatment in their hand when they entered the resident's room. That evening they did in-person education for nursing staff on advance directives, Medical Orders for Life Sustaining Treatment and Code Blue. The facility had always had Medical Orders for Life Sustaining Treatment binders on all of the units. They did Medical Orders for Life Sustaining Treatment audits monthly and compared them with the physician orders and care plan. Regarding the [DATE] incident, they remembered everything had seemed peaceful with the situation when it was first identified the resident was a do not resuscitate and chest compressions stopped. Everything changed when Registered Nurse Supervisor #6 came on the scene and restarted compressions. It turned a peaceful death with dignity situation into chaos. During an interview on [DATE] at 2:00 PM Licensed Practical Nurse #4 stated they had been on their medication cart when they heard yelling coming down the hall. When they got to Resident #1's room they were in bed and their color was blue. They told the aides to get the resident's head up as they were gurgling. They could not feel a pulse. They were under the impression they should always start cardiopulmonary resuscitation until they knew the code status. Social Worker #5 came in the room shortly after they started chest compressions. They had only done 30 chest compressions (one set) when Social Worker #5 stated the resident was a do not resuscitate. They were not doing compressions at the time the social worker entered the room with that determination. They could tell the resident was already deceased at that point. Moments later, Registered Nurse Supervisor #6 came into the room and stated they would resume compressions and told them to get the resident's face sheet and call a Code Blue. They told them Social Worker #5 had already determined the resident was a do not resuscitate. Shortly after, Registered Nurse Supervisor #6 came to the nurses station and called 911. They had directed Licensed Practical Nurse #7 take over chest compressions. By that time everybody (facility staff) showed up on the unit due to the Code Blue being announced overhead. Everyone heard the Social Worker #5 and themself reiterate the resident was a do not resuscitate. They were shocked when Registered Nurse Supervisor #6 had stated they were resuming chest compressions. They did not know where that came from. They thought maybe something had changed with advance directives protocol. It was confusing. Looking back on the situation they should not have started chest compressions until they knew the resident's code status. They had only done one set of compressions before it was determined the resident was a do not resuscitate. The training the facility provided after the incident was do not start chest compressions until a resident's code status was known. They had in-person education from the Director of Nursing and Social Worker #5. Medical Orders for Life Sustaining Treatment binders were on all of the units at the nurses' station. Advance directives orders were also in all of the residents' electronic charts. The facility periodically did mock Code Blue drills and provided inservices on advance directives. During an interview on [DATE] at 2:05 PM Certified Nurse Aide #2 stated they had been in Resident #1's room assisting with the mechanical lift when the resident's face turned blue. They helped put the resident in bed and I ran for help to Licensed Practical Nurse #4. They were not in the room when chest compressions started. They received reeducation on Code Blue and advance directives after the incident. During an interview on [DATE] at 2:50 PM Licensed Practical Nurse #7 stated they had been on the other side of the hall when they saw Certified Nurse Aides #1, #2 and #3 grab the crash cart. They came to Resident #1's room and saw Licensed Practical Nurse #4 performing chest compressions. When Registered Nurse Supervisor #6 arrived on scene, they resumed chest compressions even though Licensed Practical Nurse #4 had stated the resident was a do not resuscitate. Licensed Practical Nurse #4 was told by Registered Nurse Supervisor #6 to call a Code Blue, then they had them take over chest compressions. They did two sets of 30 compressions, then emergency medical services showed up and took over. Social Worker #5 came into the room and again stated, with the Medical Orders for Life Sustaining Treatment in hand, that the resident was a do not resuscitate and handed the form to Registered Nurse Supervisor #19, who was standing nearby (they had arrived on the unit when the Code Blue was called). Chest compressions then stopped. They received education after the incident on Code Blue and advance directives. The Medical Orders for Life Sustaining Treatment binder was a pink binder kept at the nurses station. During a phone interview on [DATE] at 9:08 AM Registered Nurse Supervisor #6 stated they had been on another unit passing medications. An aide called them (they did not know who) hysterically and asked if they knew what Resident #1's code status was. They went down to the resident's room and there were four staff in the room at that time. Staff told them they had the resident in the mechanical lift when their face turned a purple color, so they placed them in their bed and Licensed Practical Nurse #4 had started chest compressions. They quickly assessed the resident and Licensed Practical Nurse #4 informed them it was determined Resident #1 was a do not resuscitate. They did not know who had told Licensed Practical Nurse #4 that information. They were always taught once you started chest compressions, you did not stop until the physician was called. They and Licensed Practical Nurse #7 did about three rounds of chest compressions. They called a Code Blue and called 911. The ambulance was at the facility in about two minutes. While they were filling out the paperwork for transfer out of the facility, they saw one of the resident's forms documented they were a do not resuscitate, and on another form it documented they were a do not resuscitate/do not intubate. They knew the resident was already deceased when they were at the nurses' station. The emergency medical services crew came to the nurses' station and had pronounced the resident dead. They called the resident's daughter and left a message, as they did not answer their phone. In the meantime, they had called the Director of Nursing and they were asking them about the incident. They could not remember any trainings they had on advance directives, but they must have had something at some time. They had responded to other Code Blues in the facility during their employment but had never had to look for a resident's code status before because by the time they would get to the scene the nurse on site already knew the code status. After the Director of Nursing spoke to them about the incident, they told them they would be suspended until the completion of the investigation. They were re-educated on advance directives and Code Blue due to the incident. Corporate eventually terminated their employment. Ultimately, it was their responsibility as the Registered Nurse Supervisor to know and follow what a resident's code status wishes were. 10NYCRR 415.3(e)(1)(ii)

Based on observation, record review, and interview during the recertification and abbreviated (NY00290691) surveys conducted 6/22/23-6/30/23, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 5 of 5 occupied resident floors (1st, 2nd, 3rd, 4th, and 5th floors) and for 1 of 1 resident (Resident #53) reviewed. Specifically, there were unclean floors, unclean surfaces, damaged walls, damaged floors on the 1st, 2nd, 3rd, 4th, and 5th floors; resident room [ROOM NUMBER] was cluttered with various items; Resident #53's call light was not within their reach; and there were unacceptable noise levels on the 4th floor. Findings include: The undated facility policy Call System, Residents documented each resident was provided with a means to call staff directly for assistance from their bed, from toileting/bathing facilities, and from the floor. Calls for assistance were answered as soon as possible. Urgent requests for assistance were addressed immediately. Damaged Walls The following observations of damaged walls were made: - on 6/22/23 at 10:43 AM and on 6/28/23 at 5:27 PM, the wall behind the bed in resident room [ROOM NUMBER] was scraped. - on 6/28/23 at 5:35 PM the wall behind the bed in resident room [ROOM NUMBER] had deep scratch [NAME]. - on 6/28/23 at 5:40 PM the wall behind the bed in resident room [ROOM NUMBER] had a 3 inch x 10 inch section of unpainted spackle. During an interview on 6/29/23 at 6:15 PM, the Director of Plant Operations stated that no work orders were found for the damaged room walls. They stated they were aware of the wall patches in room [ROOM NUMBER], this was found during previous room audits, and they had asked the maintenance staff to repair those sections of wall last month. They stated there were no work orders to verify the repairs. They stated it was important that a clean, home-like environment be maintained for residents, guests, and staff. Call Bell Not Accessible Resident #53 was admitted to the facility with diagnoses including non-Alzheimer's dementia and history of (healed) traumatic fracture. The 4/8/23 Minimum Data Set (MDS) assessment documented the resident's cognition was intact and they required extensive assistance of one with most activities of daily living (ADLs). The comprehensive care plan (CCP) initiated 8/25/22 documented the resident was at high risk for falls due to deconditioning. Interventions included to be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The resident needed prompt responses to all requests for assistance. On 6/23/23 at 10:32 AM the resident was observed lying on an air mattress with the right side of their body near the edge of the mattress, and their lower torso sitting in a divot in the mattress. The call light was hanging on the wall behind the bed, draped over the call light outlet, and not within reach of the resident. When the call light was handed to the resident at 10:33 AM they were able to activate it, and an unidentified staff entered the room at 10:35 AM. The unidentified staff stated they would get help and returned at 10:36 AM with registered nurse (RN) Unit Manager #17. RN Unit Manager #17 stated staff must have forgotten to clip the call light to the resident's bed after care. During a follow-up interview with RN Unit Manager #17 on 6/29/23 at 11:11 AM, they stated Resident #53 should have their call light within reach and resident could use the call light appropriately. Damaged and Unclean Floors and Surfaces The following observations were made of unclean floors and surfaces: - on 6/23/23 at 10:50 AM, the 5th floor dining room floor was unclean and covered with a sticky substance. There was food debris under one of the dining tables, and two tables had sticky food debris on them. The unit staff had started a coloring activity in the dining room before the floors and tables were cleaned and several residents were walking through the debris on the floor wearing non-skid slipper socks. - on 6/26/23 at 10:50 AM, resident room [ROOM NUMBER] bathroom had a loose toilet bowl - on 6/26/23 at 11:45 AM, the 3rd floor nursing station had a 2 foot x 15 foot section of floor that was cracked and uneven. During an interview on 6/29/23 at 6:15 PM, the Director of Plant Operations stated the facility was in the process of replacing sections of damaged floors starting from the top floor. They stated they were aware of the 3rd floor flooring issues and maintenance staff had not yet gotten to the 3rd floor. The Maintenance Director was not aware of the loose toilet bowl in resident room [ROOM NUMBER]. They stated that it was important that a clean, home-like environment be maintained for residents, guests, and staff. Cluttered Rooms During an observations on 6/23/23 at 11:59 AM, and 6/28/23 at 6:00 PM, resident room [ROOM NUMBER] was cluttered with various items on the floor. There were boxes in front of and behind the oxygen concentrator, and the continuous positive airway pressure (CPAP) machine used by the resident for obstructive sleep apnea was surrounded by and under stacks of clothing and boxes containing miscellaneous personal items. During an interview on 6/29/23 at 6:15 PM, the Director of Plant Operations stated they were aware of the clutter in resident room [ROOM NUMBER] and it was not acceptable. They stated it was important that a safe and home-like environment be maintained for residents, guests, and staff. During an interview on 6/30/23 at 9:50 AM, the Administrator stated that the resident in room [ROOM NUMBER] had been frequently redirected to maintain their room in a home-like condition, and this was outlined in the admission packet the resident signed when entering the facility. The resident had intact cognition and was on the waiting list for placement in a lower level of care facility. Noise Levels During an observation on 6/26/23 at 11:04 AM, maintenance workers #26 and 27 were working on the 4th floor dining room door and door frame. The maintenance staff were using a hammer and an electric drill to fix the door latch, and an electric grinder to grind down the door frame. There were ten residents in the 4th floor dining room and the television was on. Some of the residents appeared startled by the noise and could not hear the television. Staff had to move closer to each other to hear what they were saying. Resident #94 left their room, stood in the hallway, cursed at the maintenance staff, and went back into their room and closed the door. At 11:17 AM, maintenance workers #26 and #27 continued to work on the 4th floor dining room door and sprayed a lubricant on door while residents were eating and drinking. At 11:28 AM, Resident #94 opened their door after the maintenance workers left and cursed at them. When interviewed and asked if the noise was loud and made them close their door, Resident #94 stated Yeah. During an interview on 6/29/23 at 6:15 PM, the Director of Plant Operations stated if any resident had mentioned the noise to staff the maintenance staff should have temporarily stopped working on the dining room door frame. They stated it was important that a home-like environment be maintained for residents, guests, and staff. 10 NYCRR 415.29(j)(1) 37516 40803

Based on observation, record review, and interview during the recertification survey conducted 6/22/23-6/30/23, the facility did not ensure they provided each resident with a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 3 of 8 residents (Residents #5, 7, and 80) reviewed, and 2 of 2 meal test trays (1 lunch and 1 dinner tray) observed. Specifically: - 1 lunch tray and 1 dinner tray had hot and cold food items that were not maintained at safe temperatures and the food did not taste appetizing or palatable; - Resident #80 did not receive food items listed on their meal ticket and had food items they were not supposed to have; - Resident #7 did not receive food items listed on their meal ticket; and - Resident #5 requested an alternate food item for 2 lunch meals and did not receive the substitution timely. Finding include: The facility policy Food and Nutrition Services revised 10/2017, documented that each resident was provided with a nourishing. palatable, well-balanced diet that met their daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Meals and/or nutritional supplements would be provided within 45 minutes of either resident request or scheduled mealtime, and in accordance with the resident's medication requirements. The facility policy Food and Nutrition revised 11/2017, documented that food and nutrition services staff would inspect food trays to ensure that the correct meal was provided to the resident, the food appeared palatable and attractive, and was served at a safe and appetizing temperature. The facility policy Assistance with Meals revised 3/2022, documented hot foods shall be held at a temperature of 135 degrees (Fahrenheit, F) or above until served. Cold foods shall be held at 41 degrees F or below until served. Nursing and dietary services would establish procedures such that delivery of food to service areas accommodated this requirement. The undated Available Daily Food Items documented a list of food items that would be available to residents who did not want the main meal items or alternate meal items. The list included soup of the day and tossed salad. The undated Tray Service policy documented staff passing trays would check meal tickets to assure all items were present and proper consistencies followed. Test Trays: 1) During an observation on 6/26/23 at 6:40 PM, an extra resident meal tray for the fourth floor dinner meal was plated in the main kitchen and arrived on the unit at 6:44 PM with the other resident meals. At 6:52 PM, the meal tray hot food temperatures were tested after all the residents had received their meals. The chicken breast measured 126.7 degrees F and potato nuggets measured 101 F. The chicken breast and potato nuggets were not warm or palatable. During an interview on 6/26/23 at 6:59 PM, diet tech #10 stated the temperatures measured for the fourth floor dinner meal were not good. They stated hot food items should be served at 140 F or higher and cold food items should be served at 40 F or lower. Diet tech #10 stated that the chicken looked good, and the potato nuggets were smashed. They stated the meal appearance could have been better. During an observation on 6/28/23 at 11:35 AM, an extra resident meal tray for the third floor lunch meal was plated in the main kitchen and arrived on the third floor unit at 11:59 AM with the other resident meals. At 12:21 PM, the meal tray food items were tested after all the residents had received their meals. The milk measured 57 F, the French fries measured 114 F, and the hamburger measured 124 F. The hamburger and French fries were not warm or palatable, and the milk was not cold or palatable. During an interview on 6/29/23 at 11:17 AM, the Food Service Director stated hot food items should be maintained at 135 F when served to the residents. They stated French fries were hard to maintain at 135 F or higher. The potato nuggets were not acceptable at 101.7 F, French fries were not acceptable at 114 F, and a hamburger was not acceptable at 124 F. They stated that cold food items should be maintained at 40 F lower when served to the residents, and 57 F was not an acceptable temperature for milk. The Food Service Director stated that the chicken breast at 126.7 F was borderline and should have been served at 135 F. They stated that the longer the trays sat the food temperatures would get lower. Meal trays should be passed within 10 to 15 minutes. Hot food items and cold food items would not maintain proper palatable temperatures if they sat in a cart at room temperature for 30 minutes. Resident Meal Trays: 2) Resident #80 was admitted to the facility with diagnoses including Parkinson's disease (a progressive neurological disorder). The 2/24/23 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition; choice was very important to the resident; the resident was independent after set up for eating; had a significant weight loss; and was not on a prescribed weight loss program. The 8/25/21 physician disorder documented the resident was to receive a regular diet, regular texture, and thin liquids. The 5/16/23 comprehensive care plan (CCP) documented the resident had activities of daily living (ADL) deficits, Parkinson's disease, poor impulse control, and depression. Interventions included no metal silverware, no sharp objects or anything that could be used as a weapon, independent eating after set-up, lip plate, cups with lids/straws, and preferred to remain in room. The 6/27/23 Kardex (care instructions) documented the resident was not to have any metal silverware, no sharp objects that could be used as a weapon, monitor for any risk for harm to self or others, independent for eating after set-up, lip plate, cups with lids/straws, provide/serve diet as ordered, and obtain food preferences. During an interview on 6/22/23 at 2:56 PM, the resident stated they would like eggs and toast in the morning and staff did not provide everything on the meal ticket they were supposed to. The resident stated when they do send eggs, the eggs were cold. During an observation and interview on 6/27/23 at 12:52 PM, Resident #80's meal tray was being prepared, along with 2 others, from the steam table in the unit dining room. The meal tickets were alternately checked during the tray preparation by certified nurse aide (CNA) #41 and licensed practical nurse (LPN) #31. Resident #80's tray was brought to them in their room. The tray did not contain bread or a roll, had a plastic knife on the tray, and there was a lid that was too large for the smaller plastic cup. CNA #41 stated the resident was provided everything as documented on the meal ticket. The surveyor then went over each item on the tray with the CNA for accuracy. The CNA stated there were items either missing or incorrect and they must have missed them. The CNA stated everyone involved was supposed to verify the tickets prior to serving the resident. During an interview on 6/30/23 at 9:31 AM, CNA #42 stated there was no staff specifically assigned to check trays and meal tickets during meal service. Resident meals were served from the unit dining room. The CNAs gathered the needed equipment and drinks for each tray and the server put the food on the plate and placed it on the tray. Any staff member could deliver the tray. During an interview on 6/30/23 at 9:38 AM, CNA #41 stated there were no specific staff assigned to check meal tickets against the trays and whoever was standing on the line at that time would check. They stated the dietary server put the food on the plates. The nursing staff standing at the tray line put the needed equipment, silverware, and drinks on the tray and sometimes items were missed. During an interview on 6/30/23 at 9:59 AM, registered nurse (RN) Manager #30 stated the food service person served the hot items on a plate and put the plate on the tray on top of the counter. Meals were served per seating order in the unit dining room and then room trays were assembled and delivered. Any staff could verify the meal tickets against the items on the tray. There were usually multiple staff members acting as expediter (person checking tray accuracy) and any staff member could deliver the tray. The RN Manager stated the resident was not to have any type of knife on their tray for safety purposes. The resident was to have lids that securely covered the cup to prevent spillage due to their Parkinson's disease. They stated random audits for meal tray accuracy were done by the facility. During an interview on 6/30/23 at 10:42 AM, dietary server #43 stated they just put the hot food on the plates. Unit nursing staff put the cold food, drinks, and needed equipment on the tray. Unit staff also delivered the tray to the resident. There was no assigned staff to check the meal ticket against what was on the tray. 3) Resident #7 was admitted to the facility with diagnoses including diabetes mellitus (DM) and schizophrenia. The 5/23/23 Minimum Data Set (MDS) assessment documented the resident's cognition was intact and they were independent with eating after setup. The comprehensive care plan (CCP) initiated 5/7/20 and revised 2/28/23 documented the resident had a nutritional problem or potential for nutrition/dehydration problems related to DM. Interventions included a reduced lactose (a type of sugar found in dairy products) diet. During an interview on 6/22/23 at 12:51 PM Resident #7 they stated their meal tickets never matched what was on their meal tray, and they frequently did not receive their lactose free milk (for lactose intolerance). The resident's lunch meal tray was delivered to their room by certified nurse aide (CNA) #16. The meal ticket documented coffee, crackers, and lactose free milk and none of the items were on the resident's meal tray. During an interview on 6/29/23 at 10:56 AM with CNA #16 stated the CNAs checked meal tickets on resident trays before handing them to the residents. If there were missing items, they would call down to the kitchen. Resident #7 could request an alternative food item if they did not like what was on their tray. They could not recall Resident #7 having any recent missing items on their tray. During an interview on 6/29/23 at 11:30 AM registered nurse (RN) Unit Manager #17 stated the CNAs were supposed to check the meal tickets before the trays were given to the residents. The CNAs should have checked Resident #7's tray on 6/22/23 and called down to the kitchen to request any missing items. They stated kitchen staff were supposed to check the meal tickets before the trays came to the unit. During an interview on 6/30/23 at 10:36 AM dietetic technician #10 stated the food service workers checked the meal tickets before the trays went to the units. The staff on the units should check the meal tickets as a double check. Unit 2 had steam tables and the food service workers checked the meal tickets when they were plating the food. Alternate Food Items: 4) Resident #5 was admitted to the facility with diagnoses including diabetes, anxiety, and morbid obesity. The 5/30/23 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, was independent after set-up with eating, and received insulin injections 7 of 7 days. The comprehensive care plan (CCP) initiated 2/6/20 documented the resident had nutritional/hydration problems related to diabetes. Interventions included a no concentrated sweets (NCS) diet, provide, serve diet as ordered, and monitor intake and record every meal. Offer alternate if food or beverage is refused. Food preferences obtained and ongoing. During an interview with Resident #5 on 6/26/23 at 9:48 AM they stated they did not like the lunch yesterday (Sunday 6/25/23) and asked to order a chef salad and 2 bowls of soup (chicken noodle). They stated lunch was served between 12:00 PM- 1:00 PM and they did not receive their requested foods until 5:00 PM. The resident stated unit helper #1 worked and was aware. During an observation on 6/27/23 at 12:59 PM Resident #5 stated they were waiting for a chef salad to come up. At 1:35 PM the resident was seated in their recliner in their room. The resident stated they only drank their coffee and applesauce from their lunch tray and had not received their salad. They stated they did not receive their insulin yet. During an interview on 6/27/23 at 1:02 PM licensed practical nurse (LPN) #3 stated if a resident did not like their meal, they could call down to the kitchen to order an alternate. LPN #3 stated if they knew earlier, they would call it down themself. During an interview on 6/27/23 at 1:06 PM CNA #4 stated when Resident #5 requested something from the kitchen that was not on their menu it took a long time to come up. They stated they called down at about 10:30 AM for the resident's salad and it did not come. They stated they had to call again about 12:45 PM. CNA #4 stated on 6/25/23 they called before lunch and at 12:30 PM. Resident #5's family member called the unit at 2:30 PM and said the resident had not received their lunch (chef salad). CNA #4 stated they called the kitchen and they said they would look into it. CNA #4 stated when they left it still was not there and another CNA was supposed to look into it. During an observation on 6/27/23 at 1:40 PM licensed practical nurse (LPN) #3 administered 31 units of Lispro (short-acting insulin) to the resident. At 1:43 PM LPN #3 stated they were not aware the resident had not eaten their lunch meal. During an interview on 6/27/23 at 5:37 PM LPN #2 stated on Sunday (6/25/23) they were assisting in the dining room and unit helper #1 called the kitchen at around 12:30 PM requesting a salad for Resident #5. At the end of the shift around 2:20 PM they received a call from the resident's family member who said the lunch never came. They stated they left at 3:00 PM and could not recall if the salad came. During an interview on 6/27/23 at 3:24 PM Resident #5 stated they had not yet received their salad ordered for lunch. During an observation and interview on 6/27/23 at 3:41 PM the Food Service Director (FSD) brought Resident #5's chef salad to the 4th floor. They stated they just received a call, made the salad, and brought it to the unit. They stated there was a call down log in the kitchen and anyone could answer the phone, write the request down, and call it out. A substitute food item should be brought up on the meal cart if it was known ahead of time, otherwise the utility worker would bring it up. They stated there was an always available list posted above the phone. During an interview on 6/28/23 at 10:34 AM dietetic technician #10 stated Resident #5 would call down every day for a substitute. Kitchen staff who answered the phone should give their name, take the request, give the request to the runner who would bring the item to the floor. They stated Resident #5 was diabetic and it was important for them to receive their meals timely to ensure stable blood sugars. They stated 3 hours was too long to wait for a substitute food item. 10NYCRR 415.14 37516 40803

Based on observation, interview, and record review during the recertification survey conducted 6/22/23-6/30/23, the facility did not ensure that residents who displayed or were diagnosed with a mental disorder or psychosocial adjustment difficulty, received appropriate treatment and services to correct the assessed problem to attain the highest practicable mental and psychosocial well-being for 1 of 1 resident (Resident #12) reviewed. Specifically, Resident #12 exhibited symptoms of depression and grief following the death of their spouse and continued need for long-term care and did not receive routine psychiatric evaluations or mental health counseling as planned. Findings include: The facility policy Behavioral Assessment, Intervention and Monitoring revised 3/2019 documented the facility would provide and residents would receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with comprehensive assessment and plan of care. Behavioral symptoms would be identified using facility approved behavioral screening tools and a comprehensive assessment. Resident #12 was admitted to the facility with diagnoses including major depressive disorder, dementia, and anxiety. The 3/29/23 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment; felt down, depressed, or hopeless nearly every day; rejected care 1 to 3 of 7 days; required extensive assistance of 1 for most activities of daily living; was independent with eating; was always incontinent of bowel; and received antidepressants every day. The comprehensive care plan (CCP) documented: - initiated on 6/11/2021 the resident was prescribed venlafaxine for depression. Interventions included: psychiatry consult and follow up as indicated; establish a meaningful activities regimen; the resident preferred to stay in their room and watch TV; monitor, document, and report any symptoms of depression; and monitor and report increased anger, labile mood, or agitation. - initiated on 12/15/21 the resident was grieving the loss of their spouse. Interventions included encourage positive reflections of memories with the loved one who passed; encourage social programs to promote social supports and friendships; involve clergy of choice for support if desired; provide empathetic listening for resident to express concerns. - initiated on 4/8/22 the resident had psychosocial well-being problem related to anxiety. Interventions included allow the resident time to answer questions and verbalize feelings, perceptions, and fears; consult with Pastoral Care, social services, psych services; encourage participation in activities of choice; encourage to make choices in daily routines; increase communication between resident/family/caregivers about care and living environment. The 8/15/22 hospital discharge summary documented the resident was adamant about not returning to the nursing facility. The resident was leaving angry messages with their family threatening to hurt themself and others. A psychiatric consult was ordered. Psychiatry increased the resident's antidepressant and started them on Depakote (a seizure medications that can treat psychological conditions). The 8/15/22 hospital psychiatry consult documented the resident was seen due to threats of wanting to kill themself if they had to return to the nursing facility. The resident had a history of depression and dementia. The resident reported they only went to the nursing facility to be close to their spouse. Their spouse passed away in December of 2021. The resident's antidepressant was increased and started on Depakote because it could help someone with dementia feel more stable. A psychiatric nurse practitioner (NP) #44 evaluation dated 8/29/2022 documented recommendations to continue current medications as ordered, monitor the resident for any changes in mood and behavior and report any acute issues, and offer the resident support and redirection as needed. The plan was to follow-up in 1 month or sooner if needed. A psychiatric NP #44 evaluation dated 10/17/2022 documented diagnoses of moderate episodes of recurrent major depressive disorder and dementia. Recommendations included to continue the medication regimen of Depakote 500 mg daily and mirtazapine (antidepressant) 30 mg every day at bedtime; monitor the resident for any changes in mood and behavior and report any acute issues; and offer the resident support and redirection as needed. Follow-up in 2 months or sooner as needed. There was no documented evidence the resident received additional psychiatric treatment as recommended. A progress note by NP #37 dated 1/20/23 by NP #37 documented the resident had a depressed mood affect. Plans included psychiatry consult as needed. A 4/3/23 physician order documented a consult with clinical social worker. A 4/3/23 at 4:23 PM social services progress note by social worker #45 documented a referral was sent to the clinical social worker, the resident would be evaluated and seen by clinical social worker as/if determined it was needed. There was no documented evidence the resident was evaluated by a clinical social worker. The following nursing progress notes were documented in the resident's record: - on 3/1/2023 by licensed practical nurse (LPN) #40 the resident was angry, wanted to go home, and emotional support was provided. - on 3/10/2023 by LPN #36 the resident wanted to leave and was telling staff their discharge from the facility would be soon. - on 4/7/2023 by LPN #35 the resident continued to appear depressed. - on 4/12/2023 by LPN #34 the resident wanted to go home, felt like this was prison, and was very depressed. - on 4/13/2023 by LPN #34 the resident told the LPN they were going home tomorrow. The social worker was called to talk with resident - on 4/26/2023 by LPN #31 the resident repeatedly asking to speak with the social worker to develop a discharge plan for home. A 4/27/23 at 3:06 PM social services progress note by social worker #45 documented the resident was seen by their case manager for a home-based services agency. There were no further social services progress notes. The following observations were made of Resident #12: - on 6/22/2023 at 11:59 AM, in bed, dressed in a facility gown. The resident stated their preference was to stay in bed all day. The resident began to cry and stated that their spouse passed away last year and their daily living pattern, since that time, was to stay in bed and cry all day. The resident reported ownership of their home and wanted to return home. The resident stated there was no reason to get out of bed. The resident reported significant weight loss but was not sure of exact amount of weight loss. The resident's room was dark, the window blinds were closed, and clutter was scattered throughout the environment. - on 6/23/2023 at 9:00 AM, out of bed sitting in a wheelchair in their room, dressed in facility gown with a blanket over them. The resident ate one bowl of oatmeal from the breakfast tray placed it on the bedside table. The resident stated they did not like the food and had provided food preferences. - on 6/26/2023 at 12:31 PM, in their room sitting in their wheelchair, dressed in street clothes. The resident stated they had just returned from physical therapy. They stated they enjoyed physical therapy and it was improving their strength. They stated they hoped to be able to go home soon. - on 6/27/2023 at 12:16 PM sitting in their wheelchair at their bedside dressed in street clothes. The resident stated they did not know they were taking an antidepressant medication. The resident admitted they were depressed. During an interview on 6/29/2023 at 11:11 AM NP #13 stated their medical group commenced services at the facility on 6/1/2023. NP #13 stated they were not familiar with the resident and had no knowledge that the resident was depressed and was prescribed antidepressant medications. NP#13 stated nursing or social services had not discussed with them the resident's mental or emotional status or that the resident continued to display signs of depression. NP#13 stated they expected to be informed of any resident with depression who was on medication and continued to suffer from depressive symptoms. NP #13 stated had there been documentation the resident continued to suffer depression; the resident would have been scheduled for an immediate evaluation by NP#13. NP #13 stated since the change in medical services on 6/1/2023, there was currently no psychiatric services contracted for the residents of the facility. NP#13 stated no medical report was received from the off-going medical team prior to the start of services. During an interview on 6/29/2023 at 11:57 AM licensed practical nurse (LPN) #39 stated the resident was very sad since their spouse passed away. LPN #39 stated they were aware the resident continued to show depressive symptoms despite being on an antidepressant medication. LPN #39 stated the medication prescribed had been an active order for the resident at least since January 2023 but had not appeared to help the resident in a positive manner. LPN #39 stated no verbal report was provided to anyone and no documentation was completed regarding the concern that the medication did not seem to help the resident. LPN #39 stated they should have documented observations and concerns in the electronic medical record (EMR) and in the medical communication binder on the unit, so the medical team was aware of the resident's clinical picture. LPN #39 stated they were not aware of psychiatric or social work involvement with the resident. During an interview on 6/29/2023 at 10:37 AM certified nurse aide (CNA) #32 stated the resident was sad and depressed and preferred to stay in bed all day. The resident had stayed in bed all day until physical therapy was started on 6/23/2023. CNA #32 stated they documented the resident was down and depressed as well as the resident's refusal to get out of bed. During an interview on 6/29/2023 at 12:57 PM Licensed Master Social Worker (LMSW) #38 stated they had been employed by the facility 2/2023. LMSW #38 stated they were qualified to provide 1:1 counseling. LMSW #38 stated the resident was very depressed and they attempted to see the resident at least once per week, in person. They stated the resident was often found in bed on arrival regardless of time of day. LMSW #38 stated their weekly session often focused on the resident's desire to go home. They stated they had not documented any of the weekly visits held with the resident because spending time with the resident took precedence over documentation. Social Worker #38 reported that the resident was referred to the CSW for additional 1:1 clinical counseling. LMSW #38 stated the resident received CSW telehealth visit weekly and the CSW progress notes were in the electronic medical record. LMSW#38 was not able to locate any documentation of CSW telehealth sessions with the resident. LMSW #38 stated they did not routinely review CSW or psychiatry notes and if there were an issue identified by the CSW or psychiatrist they expected to be contacted. They stated the resident was isolated in their room by choice and was encouraged to attend facility activities, but the resident declined. They stated they were not aware of any other staff able to provide 1:1 visitation for support. During an interview on 6/30/2023 at 9:13 AM Resident #12 stated there was no counseling in place to help with their depression and grief. Resident stated they were not interested in attending activities despite the staff providing reminders and invitations. The resident stated they had no desire to be in the long term care facility. The resident became tearful when speaking about their spouse that passed away last year. The resident stated they met with someone occasionally using a computer screen and those sessions had been few and generally they talked about kayaking. During an interview on 6/30/2023 at 9:44 AM RN Unit Manager #30 stated the resident had been depressed since the death of their spouse more than one year ago and felt the resident gave up on life since the death of the spouse. RN Unit Manager #30 stated the resident preferred to stay in bed all day with the lights off and no stimulation and did not allow nursing to assist them to get out of bed. RN Unit Manager #30 stated the resident was focused on going home and despite being told by the Interdisciplinary Team and family members that home was not an option, the resident perseverated on returning home. RN Unit Manager #30 stated that when the resident demonstrated feelings of depression or sadness, the nurses should write a progress note. They stated nursing had notified social services of the resident's struggle with depression but was unable to locate a progress note. RN Unit Manager #30 stated the medical team had not been notified of the resident's ongoing struggle with depression because they were new to the facility were reviewing each resident in a defined process. During an interview on 6/30/2023 at 10:53 AM Activities Director #25 stated the resident was depressed and was not interested in attending social programs. The resident stayed in their room most of the day and did not get out of bed. Activities Director #25 stated the resident received 1:1 visits from the activity assistant on the unit. They stated they did not know when, where, and how often the resident received the 1:1 visits and could not provide documentation of the visits. 10 NYCRR 415.12(f)(1)

Based on observation, record review, and interview during the recertification and abbreviated (NY00317917) surveys conducted 6/22/23-6/30/23, the facility did not ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident (Resident #27) reviewed. Specifically, Resident #27 was administered oxygen (O2) without a medical order. Findings included: The facility policy, Medication and Treatment Orders revised 7/2016 documented medications and treatments shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state; only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners shall be allowed to write orders in the medical record; drug and biological orders must be recorded on the physician's order sheet in the resident's chart; orders are reviewed by the consultant pharmacist on a monthly basis and all drug and biological orders shall be written, dated, and signed by the person lawfully authorized to give such an order. There was no documented facility policy for oxygen orders and administration protocol. Resident #27 was admitted to the facility with diagnoses including chronic respiratory failure with hypoxia (inadequate oxygen), cerebral infarction (stroke) and congestive heart failure (the heart does not pump well). The 4/27/23 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance to total dependence with most activities of daily living (ADLs), and received oxygen therapy. A 2/7/23 at 3:34 PM nursing re-admission assessment by registered nurse Unit Manager (RN) #30 documented Resident #27 was readmitted to the facility and received chronic oxygen therapy at 2 LPM (liters per minute) via nasal cannula. A 2/7/23 re-admission nursing progress note by RN #30 documented the resident had no signs or symptoms of difficulty breathing, no shortness of breath, right and left lungs were clear, and they received oxygen therapy via nasal cannula. Physician orders for the date range of 2/1/23-3/31/23 did not include oxygen administration. The February 2023 medication administration record (MAR) documented oxygen therapy of 3 liters per minute (LPM) via nasal cannula (NC) every shift with a start date of 12/15/22 and a discontinue date of 2/25/23. The resident received oxygen at 3 LPM from 2/7/23 evening shift through the 2/20/23 day shift (hospitalized [DATE]). The comprehensive care plan (CCP) did not include the need for oxygen or administration guidelines. A 3/3/23 hospital discharge summary documented the resident was admitted to the hospital on 2/21/23 for a sacral (lower back) ulcer and anemia and was discharged on [DATE]. The resident had chronic hypoxia (low oxygen levels) and required oxygen at 2 LPM. A 3/3/23 at 3:38 PM clinical admission progress note by RN #30 documented the resident was readmitted to the facility. The resident's oxygen saturation was 97% and the resident was on oxygen via NC. The resident had no difficulty breathing and their lungs were clear. The provider was notified regarding re-admission orders. The was no documented evidence of physician orders for oxygen therapy upon readmission to the facility on [DATE]. The March 2023 through June 2023 MARs did not include oxygen administration orders. The care instructions as of 6/29/23 did not include directions for oxygen use. Resident #27 was observed: - on 6/22/23 at 3:43 PM lying in bed receiving oxygen via nasal cannula set at 3 LPM. The oxygen concentrator was at their bedside and had a humidifier bottle attached to it dated 6/22/23. - on 6/26/23 at 12:27 PM lying in bed receiving oxygen at 3 LPM via nasal cannula. - on 6/29/23 at 12:44 PM the resident stated they were on oxygen, had always had oxygen and never went without it including times they went out to the hospital and came back. During an interview on 6/28/23 at 10:09 AM certified nurse aide (CNA) #32 stated Resident #27 received oxygen and had always received it during their 7 months of employment on the unit. CNA #32 stated they were unsure how many liters of oxygen the resident received. CNAs could not turn oxygen on or off, only nurses were allowed to adjust it. During an interview on 6/28/23 at 10:29 AM licensed practical nurse (LPN) #31 stated the resident was on 3 LPM of oxygen, nurses were responsible for ensuring the oxygen was turned on, and the oxygen should have a physician order. LPN #31 reviewed the resident physician orders and stated Resident #27 did not have an order for O2. During an interview on 6/28/23 at 12:42 PM the Director of Nursing (DON) stated Resident #27 received oxygen therapy, and oxygen was a medication and required a physician order. Resident #27 should have had an order if they received oxygen. During an interview on 6/29/23 at 10:11 AM RN #30 stated Resident #27 did not have a physician order for oxygen therapy as of 6/27/23. They stated they missed the order for oxygen during the resident's re-admission evaluation on 3/3/23. Oxygen was considered a medication and a treatment and Resident #27 should have had an order for O2. RN #30 stated a resident's renewal orders appeared in the electronic medical record (EMR) and when a physician renewed the order, they were responsible to ensure the orders were transcribed onto the resident's MARS. During an interview on 6/29/23 at 10:47 AM nurse practitioner (NP) #13 stated if a resident was on continuous oxygen a physician order was required. Oxygen was considered a drug and could cause poor oxygen exchange if they were receiving it unnecessarily without an order. They stated Resident #27 was oxygen dependent, received oxygen, and should have a physician order for oxygen. 10 NYCRR 415.12(k)(6)

Based on observation, record review and interview during the recertification survey conducted 6/22/23-6/30/23, the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 1 resident (Resident #90) reviewed. Specifically, Resident #90's urinary catheter (removes urine from the bladder into a collection bag) was observed hanging above the level of their bladder for multiple observations, potentially causing urine backflow and risk of infection. Findings include: The facility policy Catheter Care, Urinary revised 8/2022 documented position the [urinary] drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder. Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. Resident #90 was admitted to the facility with diagnoses including diabetes mellitus (DM, the body does use insulin efficiently) and neurogenic bladder (lack of bladder control due to a nerve problem), The 5/16/23 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, required limited assistance of one for most activities of daily living (ADLs), and had an indwelling urinary catheter. Physician orders documented: - on 10/14/21 change urinary catheter drainage bag to gravity (maintain bag below level of bladder) every day shift every 2 weeks on Thursday for urine collection and infection control. - on 8/3/22 change urinary catheter 18 French (size of tube) with a 10 cubic centimeter (cc) balloon as needed for leaking, plugging or if catheter was out. - on 3/2/23 change urinary catheter every 42 days, every night shift for infection prevention. The comprehensive care plan (CCP) initiated on 11/12/21 and revised on 12/22/22 documented the resident had an indwelling catheter. Interventions included Foley (urinary) catheter care per facility protocol and position catheter bag and tubing below the level of the bladder. The resident care instructions as of 6/28/23 did not include documentation on the urinary catheter. Resident #90 was observed: - on 6/26/23 at 2:54 PM lying in their bed, the bed was in the lowest position. Their urinary catheter drainage bag was attached to the top handle of the resident's walker, at the bedside, and was above the level of the resident's bladder. The urinary catheter tubing was looped upwards and was higher than the top of the drainage bag. The catheter was draining amber colored urine at the highest point of the tubing, but urine was not flowing into the drainage bag. - on 6/27/23 at 10:39 AM lying in their bed, the bed was in the low position. The urinary catheter drainage bag was attached to the top handle of the resident's walker, at the bedside. [NAME] colored urine was flowing through the tubing but stopped just before going into the drainage bag due to the height of the bag being above the resident's bladder. - on 6/28/23 at 9:53 AM lying in their bed. The urinary catheter drainage bag was attached to the resident's walker which was at the bedside. The drainage bag was level with the resident's bladder with no visible urine flowing in the tubing. During an interview on 6/28/23 at 10:10 AM, in the resident's room, certified nurse aide (CNA) #16 stated the resident required assistance of one for toileting and hygiene. They stated they would check on the resident and their catheter bag a few times during the shift. They performed catheter care a few times during the shift which included emptying the drainage bag. CNA #16 stated sometimes the resident emptied the drainage bag themself. They usually hanged the drainage bag on the resident's walker or on the bed frame below the bladder. They stated the drainage bag was currently not below the resident's bladder and the urine was not draining into the drainage bag properly which could lead to an infection from the backflow. During an interview on 6/28/23 at 10:28 AM, registered nurse (RN) unit manager #17 stated CNAs provided catheter care during the shift, and they also emptied the urine drainage bags. The CNAs went in and out of Resident #90's room a lot during the day. The CNAs would hang the drainage bag on the resident's bed below the resident's bladder, but the resident would move the drainage bag to the top of their walker. If the drainage bag was not positioned below the resident's bladder there was potential for infection from backflow if the urine was not draining properly. 10 NYCRR 415.12 40803

Based on observation, interview, and record review during the recertification survey conducted 6/22/23-6/30/23, the facility did not ensure residents were provided an ongoing program to support their choice of activities, designed to meet their interests and support their physical, mental, and psychosocial well-being for 1 of 1 resident (Resident #62) reviewed. Specifically, Resident #62 was not offered meaningful activities that included their interests and preferences. Findings include: The facility policy Activity Evaluation revised 6/2018 documented an activity evaluation was conducted as part of the comprehensive assessment to help develop an activities plan that reflected the choices and interests of the resident. The Activities Director was responsible for completing the evaluation and the resident's lifelong interests, spirituality, life roles, goals, strengths, needs, and activity pursuit patterns and preferences were included in the evaluation. The facility policy Dementia Care revised 11/2018 documented for the individual with confirmed dementia, the Interdisciplinary Team (IDT) would identify a resident-centered care plan to maximize remaining function and quality of life. Direct care staff would support the resident in initiating and completing activities and tasks of daily living. Bathing, dressing, mealtimes, therapeutic, and recreational activities would be supervised and supported throughout the day as needed. The June 2023 general activity calendar was posted throughout the facility on each unit. Both the facility-wide and unit activity calendars documented All calendars are subject to change; for any questions, concerns or suggestions contact [Recreational Director #25] . Resident #62 was admitted to the facility with diagnoses including unspecified dementia without behavioral disturbances, Parkinson's Disease (a progressive neurological disorder), and cognitive communication deficit. The 1/4/23 Minimum Data Set (MDS) assessment documented the resident [NAME] severe cognitive impairment and required extensive assistance of 1-2 for most activities of daily living. The resident considered listening to music they liked, doing their favorite activities, and participating in religious activities very important; and having books, newspapers, and magazines to read, being around animals, doing things with groups of people, and going outside to be somewhat important. The comprehensive care plan (CCP) initiated 12/28/22 documented the resident required staff support for meeting emotional, intellectual, physical, and social needs. Interventions included to introduce the resident to other residents with similar backgrounds and interests and facilitate/encourage interactions; assist and escort to activity functions; provide activities calendar and notify of any changes to the calendar; and thank resident for attending activity functions. The Unit 3 Resident Activity Participation Log documented the following activities on the respective dates for June 2023: - 6/22/23 10:15 AM Catholic mass (chapel); 2:00 PM movies and popcorn (lounge & channel 49); 3:00 PM visits and chats; and 7:00 PM Wheel of Fortune or TV. - 6/23/23 10:15 AM bowling (chapel); 2:00 PM toss game (outside); 3:00 PM visits and chats; and 7:00 PM Wheel of Fortune or TV. - 6/26/23 10:15 AM manicures (3rd floor); 2:00 PM balloon volley (chapel); 3:00 PM visits and chats; and 7:00 PM Wheel of Fortune or TV. - 6/27/23 10:15 AM Bingo (chapel); 2:00 PM outside visits and trivia; 3:00 PM afternoon visits and chats; and 7:00 PM Wheel of Fortune or TV. - 6/28/23 10:15 AM Chapel service; 2:00 PM Bingo (chapel); 3:30 PM activity staff meeting; and 7:00 PM Wheel of Fortune or TV. - 6/29/23 10:15 AM concert (lounge); 2:00 PM movies and popcorn (lounge and channel 49); 3:00 PM visits and chats; and 7:00 PM Wheel of Fortune or TV. - 6/30/23 10:15 AM bowling (chapel); 2:00 PM balloon volley (outside); 3:00 PM visits and chats; and 7:00 PM Wheel of Fortune or TV. The June 2023 recreation attendance documentation was blank for Resident #62. Activities listed under an as needed (PRN) basis for Resident #62 included attending family visits, reminiscing, sleeping during activities, drinking/hydration cart, sensory integration, and social dining. During an interview on 6/22/23 at 10:57 AM the resident's representative stated Resident #62 was deeply religious, had always gone to religious services, had only been brought to religious services one time while at the facility, and staff no longer brought the resident to services. They stated they had made staff aware of the resident's preference to attend religious services as well as other programs the resident would enjoy such as music and Bingo. The Resident representative stated the resident should be able to go and listen to the service as it was an activity they enjoyed in the community for many years. Resident #62 was observed: - on 6/22/23 at 11:25 AM sitting at a dining room table and a coloring activity was occurring at the table across from them. There were several residents involved in the coloring activity and Resident #62 was not offered to join the coloring activity. - on 6/26/23 at 9:35 AM sitting in their wheelchair at a table in the unit dining room. There was a coloring activity at the table across from them; registered nurse (RN) #24 was handing out coloring pages to other residents. There were multiple residents engaged in coloring and RN #24 did not offer a coloring page to Resident #62. At 9:47 AM sitting at a table by themself with no engagement by staff or involvement in activities. - on 6/27/23 at 9:11 AM, being wheeled back into the dining room from the hall by licensed practical nurse (LPN) #19. Unit assistant (UA) #18 was tossing a beach ball to multiple residents sitting at tables in the dining room and they did ask Resident #62 if they wanted to participate. Resident #62 was sitting at a corner dining room table by themself watching the activity. At 12:55 PM sitting in the dining room at a corner table towards the front entry. UA # 18 was conducting a balloon toss activity with several residents in the dining room and did not engage Resident #62. The resident raised their right hand and waved it in the air and UA #18 did not acknowledge the resident. During an interview on 6/27/23 at 10:59 AM UA #18 stated they assisted with various tasks such as activities, resident appointments, answering call bells, and making beds. They stated they had no activities training but had attended dementia care in-services in the past. UA #18 stated they were not familiar with Resident #62; it was their first time working on Unit 3, they had been working on Unit 4 and was more familiar with the unit 4 residents. During an interview on 6/28/23 at 11:12 AM certified nurse aide (CNA) #21 stated they thought the resident attended a music concert but had never seen them engaged in any 1:1 activities. During an interview on 6/29/23 at 12:30 PM LPN Unit Manager #19 stated Resident #62 had moved to the 3rd floor a few months ago. They stated they had never seen the resident attend church or any activities. They stated therapy usually took the resident during activities. LPN #19 stated they would know the resident's preferences by talking to their family, but activities usually handled that and not the nurses. During an interview on 6/29/23 at 9:39 AM occupational therapist (OT) #22 stated Resident #62 was able to verbalize yes/no questions, could passively attend activities such as Bingo but would need physical assistance. Therapy had no set times with the residents and based therapy schedules on a resident's activity preferences. Therapy sessions could be paused and resumed later when the activities were completed. OT #22 was not aware of Resident #62's activity preferences. During an interview on 6/29/23 at 9:52 AM the Director of Physical Therapy (PT) stated they were familiar with Resident #62. They stated they knew the resident liked to attend church. They stated therapy sessions lasted from 3 minutes to 75 minutes. They stated if a resident wanted to attend an activity during therapy times, the Director of Recreation would email them. They stated they had not received any emails regarding Resident #62. During an interview on 6/29/23 at 12:11 PM the Director of Recreation stated they were familiar with Resident #62. They had quarterly meetings to update resident preferences, and they were responsible for updating resident care plans. The Director of Recreation stated they knew the resident liked to attend church, music and other programs, there was nothing on the resident's care plan indicating those preferences, and if a resident was in the dining room while activities were being offered, they should be engaged in the activity. 10NYCRR 415.5(f)(1)

Based on interview and record review during the abbreviated survey (NY 620), the facility failed to develop and implement policies and procedures to ensure all staff are fully vaccinated for COVID-19 and include a process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for 2 of 8 staff reviewed (food service worker, FSW, #13 and certified nurse aide, CNA, #14). Specifically the facility permitted two staff to work without getting their second COVID-19 vaccine timely and the facility's policy did not include a contingency plan for partially vaccinated staff. Findings include: The facility's 3/10/22 COVID-19 Vaccination of Facility Staff policy documents all facility personnel and those in the pre-employment screening process, will be required to be up to date with all recommended COVID-19 vaccine doses by 9/27/21 and prior to the start of their employment. The policy did not document a contingency plan for partially vaccinated staff. Staff COVID-19 vaccination records documented: - food service worker (FSW) #13, received their first dose of a multi-dose vaccine on 1/26/22. - Certified nurse aide (CNA) #14, received their first dose of a multi-dose vaccine on 10/29/21. There was no documentation a second dose of the COVID-19 vaccine was given or scheduled to be given for FSW #13 and CNA #14. Staff timecards documented: - FSW #13, worked on 3/6/22, 3/8/22 through 3/11/22, 3/14/22 through 3/17/22, and 3/19/22 through 3/20/22. - CNA #14 worked on 3/6/22, 3/8/22 through 3/10/22, 3/15/22 through 3/17/22, and 3/19/22 through 3/20/22. On 3/21/22 and 3/22/22 (during the on-site investigation), FSW #13 and CNA #14 were not on duty and not observed. On 3/21/22 at 12:04 PM and 3:05 PM, the Administrator stated in an interviews they were responsible for tracking staff COVID-19 vaccinations. They also stated FSW #13 and CNA #14 were taken off the schedule until they received their second COVID-19 vaccines and both staff had been tested weekly for COVID-19. On 4/12/22 at 2 PM, the Administrator stated in an interview, they were under the impression FSW #13 and CNA #14 could not be forced to receive the second COVID-19 vaccine and as long as the facility tested therm weekly for COVID-19, they could continue to work. He stated he later realized that was not the case and removed FSW #13 and CNA #14 from the schedule until they received their second COVID-19 vaccine. 10 NYCRR415.19(a)(1-3)

Based on record review and interview during the abbreviated survey (NY 620), the facility failed to provide specialized rehabilitative services or obtain the required services from an outside resource for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1 had two falls and the recommended post-fall therapy evaluations did not occur timely. The resident subsequently sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: The facility's Falls - Clinical Protocol, undated, documents staff will evaluate and document falls that occur while the individual is in the facility including where falls happened and any observations of events. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. After more than one fall, the physician should review the resident's gait, balance, and medications that may be associated with dizziness or falling. The staff and the physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or that finding a cause would not change the outcome or the management of the falling and fall risk. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling. If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling and will re-evaluate the continued relevance of current interventions. The facility's Therapy Referral from Nursing Policy, undated, documents any resident having a fall or recognized showing signs of decline and/or improvement with but not limited to mobility, activities of daily living (ADL), positioning, feeding, swallowing and cognition will have an assessment completed by the appropriate discipline, physical, occupational (PT/OT) and/or speech therapy to determine resident status. Upon recognition of the need for potential therapy, nursing will write up a referral noting the difficulties and/or improvements resident is having and email/scan to the Director of Rehabilitation. Appropriate therapy discipline will evaluate resident and make recommendations deemed appropriate. Therapy staff will email unit manager and Director of Therapy of recommendations. All new recommendations will be placed by unit manager in the residents care plan and Kardex. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/26/22 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired, they were independent with activities ADLs, required no set-up or physical help from staff, and had 1 fall with no injury since the prior assessment. The 1/19/22 Nursing Referral and Rehabilitation Screen documented the resident had a fall from a straight back chair and appeared to be trying to get dressed and their pant leg got stuck over their shoe. OT screened the resident and educated the resident on safety with dressing and to dress while seated. The resident verbally and physically demonstrated understanding and successfully dressed with no issues. No further skilled intervention was warranted at that time. The 4/16/21 comprehensive care plan (CCP) documented the resident had [CONDITION(S)], was at high risk of falling due to unsteady gait and had an ADL deficit. The resident was able to transfer independently in and out of bed and on the unit, they frequently refused to get in bed and wandered at night sleeping on and off in a chair. Interventions included call light in reach, prompt response to all resident requests for assistance, fall protocol, PT evaluation and treatment as needed, and educate on safety measures. The 2/3/22 at 7:15 AM, accident and incident report completed by licensed practical nurse (LPN) #2 documented the resident had an witnessed fall in the hallway. The resident slid out of a straight back chair they were sleeping in and landed on their buttocks and had no injury. Certified nurse aide (CNA) #9's statement, attached to the report, documented the last time they saw the resident was at 7 AM, sleeping in a chair and they found the resident sitting under the table. Recommendations included a PT/OT referral. There was no documented evidence a therapy evaluation was completed following the 2/3/22 fall. The 2/8/22 nurse practitioner's (NP) progress note documented the resident was seen after a fall and had no injuries. The resident remained at high risk of falling due to poor safety awareness and noncompliance with fall risk precautions. PT/OT was recommended as needed. The 2/9/22 at 1:15 AM, accident and incident report completed by registered nurse (RN) #7 documented the resident had an unwitnessed fall in the hallway from a straight back chair and had no injury. CNA #9's statement, attached to the report, documented the last time they saw the resident was at 1 AM, seated in the hallway and they later found resident sitting on the floor in front of chair. The plan was a therapy referral and the CCP was updated to promote activity that encouraged exercise. There was no documented evidence a therapy evaluation was completed following the 2/9/2022 fall. The 3/3/22 at 11:40 PM, accident and incident report completed by RN #7 documented the resident fell asleep in a straight back chair and had an unwitnessed fall to the floor, sustaining no injury. CNA #9's statement, attached to the report, documented they last saw the resident at 11:15 PM, falling asleep in a chair in the dining room when the resident refused to get up to go to bed. They found the resident lying on the floor in the dining room near the table and the resident stated their head hurt. The report's conclusion documented the resident had not been sleeping well at night and was sleeping on and off in a regular chair. There was no documentation a therapy referral was recommended for the resident after the 3/3/22 fall. The 3/7/22 at 4:41 AM, RN #12's progress note documented they were called to see the resident who had some facial bruising and bruises were old and dark purple color. The darkest areas were at the upper bridge of nose on both sides. There was some bruising noted to both eyelids, light in color and appeared that there may have been some drainage to the nose from those areas. The resident fell on [DATE] and the bruises could have been residual bruising from the fall. The 3/7/22 at 11:40 AM, LPN Manager #10's progress note, written as a late entry on 3/8/22 at 11:31 AM, documented the resident presented with bruising to the nose and eyes and was rubbing their neck. Orders were obtained for facial and c-spine x-rays and showed an odontoid fracture (through a specific part of 2nd bone (C2) in neck). The NP was updated and ordered to send the resident to the hospital. The 3/8/22 Director of Nursing's (DON) Investigative Summary for the 3/3/2022 fall documented the resident was often non-compliant with care, often resistant, and had poor safety awareness. On 3/3/22, the resident was seated in the dining room, staff encouraged the resident to go to bed and they refused. On 3/7/22, the resident was seen holding their neck and facial bruising on the bridge of their nose and eyelids was seen. An x-ray was obtained and found a odontoid fracture. The resident's ADLs and ambulation status had not changed since the fall. The resident was sent to the hospital on 3/7/22. The DON's investigation did not identify that prior recommended therapy evaluations did not occur. On 3/22/22 at 12 PM, LPN #2 stated in an interview, they were a Nurse Manager, though not of the resident's unit. Following all resident falls, a therapy referral was needed. Therapy referrals were sent to the Director of Therapy and evaluations were completed that day or the next day. On 2/3/22, they were the only Nurse Manager in the building when the resident fell and the staff on the resident's unit called them after the resident fell . They stated they sent a therapy referral for the resident and because they were not the Manager on the resident's floor, they did not follow-up to ensure the referral occurred. LPN Manager #10 would have been responsible to follow-up and obtain the therapy referral. They stated they left the accident and incident report on LPN Manager #10's desk. On 3/22/22 at 1:18 PM, CNA #9 stated in an interview, the resident was independent with ADLs, could be combative and did not like anyone to do things for them. They worked the night shift, and the resident was awake most nights and would sleep in a straight back chair and sometimes a recliner. If the resident was sleeping in a chair and was awoken to go to bed, they would become combative. On 3/3/22, the resident was sleeping in a straight back chair, was starting to slouch to the side, and they were afraid they were going to fall. They woke the resident up and the resident refused to go to bed. The resident repositioned themselves in the chair and they seemed safe at that time. On 3/28/22 at 1:02 PM, RN #7 stated in a telephone interview, for the resident's 2/9/22 fall, if they put a check mark in the therapy referral box on the accident and incident report, that meant they sent a therapy referral for the resident. Therapy referrals were written on paper and put in the Nurse Manager's box because the therapy office doors were locked on the night shift. Every time a resident fell , a therapy referral was needed. They assumed they sent the referral on 3/3/22 because they always did. On 3/29/22 at 10:04 AM, LPN Manager #10 stated in a telephone interview, anytime a resident fell , a therapy evaluation was needed. Therapy was notified via email of the referral or in morning report. They believed the Director of Therapy tracked referrals to be sure they were completed. They stated if nursing sent a referral for therapy, then therapy was responsible to ensure the evaluation was completed. They were not aware a therapy referral was sent on 2/3/22 and did not occur. On 2/9/22, they saw the therapy referral on their desk and assumed RN #7 emailed it to therapy. They believed RN #7 was trained on the process of therapy referrals. On 3/29/22 at 12:51 PM, the Director of Therapy stated in a telephone interview, therapy was involved after a resident fell . Nursing sent them referrals and they were typically emailed and sometimes information was passed on verbally during morning report. They tracked all incoming referrals and made sure all evaluations were scheduled. The last referral they received and completed for the resident was on 1/19/22 when the resident fell from a straight back chair. If the resident's recent falls all involved falling asleep in straight back chairs, then therapy would want to be involved to assess the resident so they could provide interventions such a Dycem (non-slip mat) to prevent sliding out of the chair. On 4/13/22 at 8:51 AM, the DON stated in a telephone interview, therapy referrals were required for all falls. The nurse completed the referral on a paper form and either dropped the form in the therapy mailbox or scanned and emailed it to the Director of Therapy. Every resident that fell should be assessed by therapy to look at the resident's environment, ambulation status and possible interventions to prevent recurrence and therapy evaluations should occur within 48-72 hours. They were not aware therapy referrals did not occur for all 3 of the resident's falls and they should have. 10NYCRR 415.16(a)(2)

Based on observation, record review, and interview during the abbreviated surveys (NY 768 and NY 093) conducted on 10/18/21, the facility failed to provide adequate supervision to prevent accidents (resident to resident incidents) for 3 of 5 (Resident #2, 3 and 4) residents reviewed. Specifically, - Residents #2 was not protected from physical abuse from Resident #1 when Resident #1 hit Resident #2 over the head with a wheelchair leg rest causing a head laceration. - Resident #1 was moved to a different unit and a plan was not implemented to prevent abuse. Resident #1 struck Resident #3, causing a sprained finger, a contusion of the chest wall, and injury of the head. - Resident #4 exhibited behaviors in the dining room and was physically abusive towards Resident #5. Resident #5 pushed Resident #4 away in self-defense resulting in Resident #4 falling and fracturing their hip. This resulted in actual harm to Residents #2, 3, and 4 but, was not an immediate jeopardy. Findings include: The 12/2008 facility policy Care Planning - Interdisciplinary Team documents the interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. The 4/2010 facility policy Accidents and Incidents - Investigation and Reporting did not contain any information related to prevention of accidents/incidents. The 5/1/19 facility Abuse Policy documents residents identified to be potentially abusive shall have individualized care plans with interventions to prevent abuse. After all possible interventions are implemented, and the potentially abusive resident continues to be considered threatening to other residents, the facility will issue a transfer in accordance with government regulations. Residents #1 and #2 1) Resident #1 resided on Unit 1 and had diagnoses including dementia, Alzheimer's disease, and major depressive disorder. The 8/27/21 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment and was independent for transfers, locomotion on the unit in a wheelchair, and toileting. Resident #2 resided on Unit 1 had diagnoses including Type 2 diabetes, major depressive disorder, and muscle weakness. The 8/14/21 MDS documented the resident had intact cognition, exhibited verbal behaviors directed towards others (threatening, screaming, cursing), and was independent for transfers, locomotion on and off the unit, dressing, toileting, and hygiene. The Kardex Report (care instructions) for Resident #1 dated 7/1/21 documented safety interventions included: monitor/document/report to the physician as needed for risk of harming others (increased anger, agitation, feeling threatened, or thoughts of harming someone, possession of weapons or objects that could be used as weapons). Resident #2's comprehensive care plan (CCP), initiated 7/7/21, documented the resident had moderate depression. Interventions included monitoring for signs/symptoms of depression, encouraging the resident to express their feelings, and assisting the resident in developing a program of activities of interest. The resident received [CONDITION(S)] medications for depression. Interventions included monitor/record occurrence of target behavior symptoms (pacing, wandering, disrobing, inappropriate response to verbal communication, aggression toward others) and document per facility protocol. Licensed practical nurse (LPN) #26's progress note documented on 7/29/21 at 12:20 AM, Resident #2 was in the television area and Resident #1 entered and was yelling, swearing, calling names, and attempted to go towards Resident #2. Resident #1 was redirected back to their room and returned to the television area minutes later with their cane, yelling they were going to kill that [expletive]. Resident #2 then began yelling back. A Supervisor was called while the nurse remained between them. Resident #2 was brought to their room. There was no documented evidence either Residents #1 or 2's CCPs were updated following the 7/29/21 incident and there was no documentation of a plan for increased supervision to prevent incidents. Progress notes in Resident #1's medical record documented: - On 8/17/21 at 6:48 PM, LPN #7 noted the resident continued with episodes of sundowning (restlessness, agitation, irritability, or confusion that can begin or worsen as daylight begins to fade), was redirected as much as possible, became angry when redirected, and it was better to go with what [the resident] comes up with. - On 8/26/21, the physician noted the resident was easily re-directable. Resident #1's CCP, initiated on 2/1/21 and revised on 8/25/21, documented the resident had moderate depression and was prescribed an antidepressant. Interventions included: psychology consultation and follow-up as needed; monitor, document, and report as needed for any risk of self-harm, risk to harm others, increased anger, labile mood, agitation, feeling threatened, thoughts of harming someone, or possession of weapons or objects that could be used as weapons. LPN #7's progress note documented on 8/29/21 at 8:13 PM: - Resident #1 was yelling at and threatening Resident #2, who was yelling at another resident. - Resident #1 went after Resident #2, who raised their hand as if to hit Resident #1 and both continued to yell and threaten each other. - Resident #1 was redirected to their room, returned, and started another fight. - Staff removed plastic knives from Resident #1's room as Resident #1 threatened to kill Resident #2 in their sleep. - Resident #2 refused to go back to their room, continued yelling at the unidentified resident, and tried to push the resident in their wheelchair. There was no documented evidence Residents #1 and 2's CCPs were updated following the 8/29/21 interaction and no documentation of a plan of care to provide supervision to prevent incidents. There was also no documentation that either resident was referred for a psychological evaluation. On 9/2/21, nurse practitioner (NP) #14's progress note documented Resident #1 had increased behaviors, was yelling and threatening others, and irritated with staff and other residents. The NP noted the resident was refusing oxygen which could be causing the increased behaviors and confusion. The plan included obtaining a chest x-ray and blood work to address possible CO2 ([MEDICATION(S)]) due to refusal of oxygen as elevated CO2 levels may be contributing to behaviors. LPN #16's progress note documented on 9/11/21 at 5:39 PM, Resident #1 had increased behaviors, was up and down the halls saying they were going to hurt anyone who was yelling out. The 9/12/21 facility investigation documented: - on 9/12/21 at 3:43 AM, CNA #7 observed Resident #1 had a butter knife in their hand and was yelling at Resident #2 to put their shirt on. CNA #8 took the knife from Resident #1, and Resident #1 took a leg rest from a nearby wheelchair and struck Resident #2 in the head causing a 5 centimeter (cm) cut on the top of Resident #2's head. Resident #2 called the police, and later went to the hospital for evaluation. - CNA #8's statement, included with the facility investigation, documented as CNA #8 was walking down the hall, Resident #2 was lying on the couch in the lounge. Resident #1 was behind the couch with a butter knife and yelling at Resident #2 to put on their shirt CNA #8 ran to get the butter knife, and Resident #1 turned and grabbed a leg rest from a wheelchair, stood up, and hit Resident #2 with it. Resident #2 got up and went toward Resident #1, CNA #8 stood between them and pleaded with Resident #2 to go to their room. - Registered nurse Supervisor (RNS) #11's statement, included with the facility investigation, documented RNS #11 was not on the floor at the time of the incident and upon arrival, RNS #11 was told Resident #1 had a butter knife and tried to stab Resident #2. RNS #11 was also told CNA #8 took the knife away and then Resident #1 hit Resident #2 over the head with a leg rest from a wheelchair. Resident #2 then went to their room. RNS #11 went to Resident #2's room and the resident had called the police and then went to the hospital for evaluation. The 9/12/21 emergency room (ER) report for Resident #2 documented the resident arrived via ambulance at 3:52 AM and reported they were struck in the head with a metal wheelchair leg rest. The resident reported slightly more blurry vision than usual (in the absence of their glasses). The ER staff were not able to reach the facility for report. The resident had a 1 cm superficial laceration to the top of the scalp on the left side. No acute abnormality was noted on the CT (computerized tomography, more detailed x-ray) scan and the resident was cleared for discharge back to the facility. During an interview with Resident #2 on 9/27/21 at 11:10 AM, the resident stated the incident on 9/12/21 was the third time they had an altercation with Resident #1. The first 2 times occurred in the lounge area, Resident #1 came into the area yelling and swearing at them and came at them until staff intervened. The third time, on 9/12/21, Resident #2 was lying on the couch and Resident #1 came after them out of nowhere and hit them on the head with a leg rest from the wheelchair. Resident #2 became dizzy and fell back onto the couch. The resident expressed a great deal of anger toward Resident #1 and the facility and stated the resident should have been closely supervised due to their behaviors. When interviewed on 9/27/21 at 11:30 AM, the Director of Social Services stated Resident #1 became upset when Resident #2 disrespected others. Resident #1 monitored the unit and told people what to do or not to do. There were prior verbal altercations between the 2 residents and Resident #1 was triggered by Resident #2. During the 9/12/21 incident, Resident #1 was triggered by Resident #2 not wearing a shirt. The Director of Social Services stated they were not aware of care planned interventions for the residents as nursing was responsible for behavioral CCPs. In response to the 9/12/21 incident, the Director of Social Services stated they recommended [CONDITION(S)] medication to help with Resident #1's anxiety in the evening, when they were more anxious, easily triggered, and there were not enough staff to supervise them. CNA #4 stated in an interview on 9/27/21 at 4:13 PM, Residents #1 and #2 had altercations of screaming and swearing at each other. CNA #4 recalled a time when Resident #1 tried throwing a leg rest from a wheelchair at Resident #2. The CNA stated they intervened before anything else happened and called a Supervisor. CNA #4 stated they were unaware of any specific interventions for Residents #1 and 2 and was told by the nurses to keep an eye on them when able. During an interview on 9/28/21 at 12:35 PM, LPN #7 stated Residents #1 and 2 had prior verbal altercations and Resident #1 did not like Resident #2. LPN #7 stated they were unaware of any interventions to prevent incidents between the 2 residents except that Resident #1 was not supposed to have access to knives. During an interview with CNA #8 on 9/28/21 at 12:58 PM, they stated the night of 9/12/21, Resident #2 was on the couch in the lounge, not wearing a shirt. Resident #1 wheeled up to Resident #2 and Resident #1 had a butter knife in their hand. CNA #8 took the knife from Resident #1 and went to the desk to put it down and when CNA #8 returned a few minutes later, Resident #1 had a leg rest and struck Resident #2 on the head, swearing, and yelling at Resident #2 to put on their shirt. CNA #8 stated the leg rests were sometimes left in chairs in the lounge or in the hallway. CNA #8 stated on 9/12/21, Resident #1 was triggered by Resident #2 not having a shirt on. CNA #8 stated Resident #1 had been bothered by Resident #2 not wearing a shirt in the past as well. CNA #8 stated Interventions in place were plastic knives only for Resident #1 and to keep an eye on Residents #1 and #2. CNA #8 stated during the night, both residents liked to go to the lounge and when there were few CNAs on duty. The CNA stated they were not always in the lounge with the residents. CNA #10 was interviewed on 9/30/21 at 6:52 PM and stated they worked on the 9/11/21 evening shift (2 PM-10 PM) and during that time, Residents #1 and 2 were arguing and threatening to kill each other, holding their fists up to each other, and yelling and swearing. CNA #10 was unaware of any interventions to prevent altercations or stop them once it started. When interviewed on 10/1/21 at 10:55 AM, RN Manager #17 stated Resident #1 did not like Resident #2's behaviors. RN Manager #17 stated there was an intervention in place of removing butter knives from Resident #1 and to refer them to activities when they were behavioral. RN Manager #17 stated they were unaware of other interventions to address Resident #1 and 2's interactions. RN Manager #17 stated when Resident #1's behaviors were reviewed by the team, the team could not identify any other possible interventions aside from monitoring the resident. During a telephone interview on 10/18/21 at 12:22 PM, NP #14 stated Resident #1 was seen for increased behaviors in 9/2021 following an incident where they struck another resident. NP #14 stated they were not aware of prior altercations and threats of violence between Residents #1 and #2. If Resident #1 threatened to harm Resident #2 the NP would expect the residents be separated to ensure their safety. A strike over the head with a wheelchair leg rest could cause serious injury. Resident #1 remained at risk to harm other residents and should be monitored with appropriate interventions in place to prevent further injury. Residents #1 and #3 2) Resident #1 had diagnoses including dementia, Alzheimer's disease, and major depressive disorder. The 8/27/21 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, was independent for transfers, locomotion on the unit, and toileting. Resident #3 had diagnoses including [CONDITION(S)], major depressive disorder, and chronic pain syndrome. The 7/12/21 MDS assessment documented the resident had intact cognitive function, exhibited no behavioral symptoms, and was independent for all activities of daily living (ADLs). Resident #3's CCP, updated 5/21/21, documented the resident had the potential to be abused by others due to their soft-spoken, quiet demeanor. Interventions included to praise the resident when they told staff if others were being invasive or aggressive without retaliation. The resident had a behavior problem of correcting others and was at risk for being verbally abusive. Interventions included: assist the resident to develop more appropriate methods of coping; offer 1:1 support, explain all tasks; offer a drink or snack, encourage activities; provide positive interaction, stop and talk to resident as passing by; discuss behavior, explain, or reinforce why the behavior is inappropriate. Social worker #23's progress note documented on 9/13/21, Resident #1's room was changed from Unit 1 to Unit 2. Resident #1's CCP, updated 9/13/21, documented the resident had a room change to Unit 2. Interventions included: explain all care giving procedures; offer support and reassurances; and orient to peers, staff, and environment. The CCP was not updated following the 9/12/21 incident with Resident #2 with a plan for supervision to prevent further incidents with other residents. The 9/16/21 psychological services progress note for Resident #1 documented the resident was seen for a diagnostic evaluation. The resident was more irritable and had outbursts with staff and residents. The resident may be sundowning and this may be addressed with medications. The resident was diagnosed with major depressive disorder and treated with [MEDICATION(S)] (anti-depressant medication), scored low on the PHQ-9 (personal health questionnaire, an assessment for depression), they rated depression at 6 out of 10, anxiety 7, and irritability 6 and recognized this as worse in the afternoon. Recommendations included empathic listening, participation in pleasant activities, positive reinforcement, redirection, verbal and/or written reminders, and consider psychiatric follow-up. The 9/17/21 at 8:10 PM, facility investigation documented: - Resident #1 was recently transferred to Unit 2 (after having a resident to resident incident on Unit 1) and at approximately 8:10 PM, Resident #1 went behind the nurse's station to use the staff bathroom. Resident #3 attempted to intervene by pulling at Resident #1's wheelchair and verbally telling them to stop. Resident #1 became agitated and struck Resident #3 in the chest. Resident #3 fell and stated they hurt their pinky finger. Resident #3 called the police and was then transported to the hospital. - Resident #1 was started on [MEDICATION(S)] (used as a mood stabilizer) 125 milligrams (mg) twice per day and the team would review the possibility of providing a private room. Staff statements included with the investigation documented: - CNA #10 reported they were in another room, heard the nurse yelling, and came out and found Resident #3 standing up and Resident #1 getting out of their chair screaming at Resident #3 with their fist raised going after Resident #3. - LPN #9 reported they came out of a room and heard commotion behind the nurse's station and found Resident #1 hitting Resident #3 with a closed fist and knocking Resident #3 to the floor. The 9/17/21 hospital emergency room (ER) report for Resident #3 documented the resident arrived at the ER via ambulance at 9:21 PM. The resident had diagnoses including a sprain of the right little finger, contusion of the chest wall, injury of the head, and strain of neck muscle. The resident stated they were trying to stop someone from going somewhere they were not supposed to, and the other resident sucker punched me with both barrels right to the chest, I hit the floor like a ton of bricks. and they hit their posterior (back) head after trying to catch themselves. The resident reported they lost consciousness for a few seconds and had slightly blurry vision. There was no documented evidence Resident #1's CCP was updated timely after the incident with Resident #3 on 9/17/21. On 9/27/21 at 5:27 PM, Resident #1 was observed in the hall in their wheelchair on Unit 2. They had no leg rests on the wheelchair and the resident was seen self-propelling in the wheelchair with their legs. The resident approached an empty wheelchair with 2 leg rests on the seat of the wheelchair located in the hallway. Resident #1 took one of the leg rests to their room. The resident set the leg rest on the floor inside their door. Multiple staff walked by and did not remove the leg rest. When interviewed on 9/27/21 on 4:50 PM, Resident #3 stated when the altercation occurred with Resident #1 on 9/17/21, Resident #1 was new to the unit. Resident #3 liked to try and help staff and they saw Resident #1 behind the nurse's desk, shuffling through papers, and then headed toward the staff bathroom. Resident #3 polity asked Resident #1 to not go in there and Resident #1 turned around and punched them hard in the chest two times. The resident fell back, hit their head, and sprained their pinky. Resident #3 stated they were calm and politely and did not want any trouble, as they had medical concerns and feared being injured. Since then, Resident #3 felt intimidated by Resident #1, who would swear, threaten, and yell at them. Resident #3 kept to themselves and when Resident #1 saw them, Resident #3 was told to stay away, and staff did not do anything to address what Resident #1 was doing. Resident #3 was becoming increasingly angry and frustrated over Resident #1's behaviors and stated if they continued to try and go after them, Resident #3 would retaliate. On 9/27/21 at 5:17 PM, unit assistant (UA) #6 was interviewed and stated when Resident #1 was transferred to that unit, they were not advised of any concerns or supervision needs for the resident. UA #6 witnessed Resident #1 yelling and swearing at other residents and when that happened, they got another staff member to help them. UA #6 had not been told to observe for utensils, wheelchair leg rests or other items that Resident #1 should not have. CNA #10 was interviewed on 9/30/21 at 6:52 PM and stated they worked the evening shift on 9/17/21, when the altercation occurred between Residents #1 and #3. CNA #10 stated they were the only CNA on the unit that evening and upon exiting a resident room, they heard the residents yelling and observed Resident #1 standing and hitting Resident #3 in the chest and Resident #3 fell backwards. CNA #10 stated they were unaware of behavioral interventions for Resident #1 aside from keeping Resident #1 away from Resident #2 and since the incident on 9/17/21, CNA #10 was not aware of any new interventions for Resident #1. CNA #10 stated Residents #1 and #3 continued to argue at times. CNA #10 stated they were not told of any objects that Resident #1 was not supposed to have such as wheelchair leg rests or utensils. During an interview on 10/1/21 at 10:15 AM, RN Manager #15 stated when Resident #1 was transferred to their floor (Unit 2), they were not aware of the resident's specific behavior plan and expected any safety issues would have been on the CCP. The RN stated this past week, the Director of Nursing (DON) told the RN to ensure wheelchair leg rests were removed and to check the resident's room for items that could be used as weapons. When interviewed on 10/1/21 at 11:10 AM, the DON stated steps to protect other residents from Resident #1 included medical review and heightened observations. During a telephone interview with physician #12 on 10/15/21 at 10:43 AM, they stated they were not aware of the incident between Residents #1 and #3 and stated any residents with aggressive behaviors should have a care plan, interventions, and monitoring in place. During a telephone interview on 10/18/21 at with NP #14 they stated Resident #1 remained at risk to harm other residents and should be monitored with appropriate interventions in place to prevent further injury. The NP was not aware of the incident with Resident #3 and stated any residents with behavioral issues and physical aggression should be closely monitored to ensure the safety of other residents. Residents #4 and #5 3) Resident #4 had diagnoses including dementia, delusional disorder, and mild intellectual disabilities. The 9/2/21 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, was independent for activities of daily living (ADLs), and utilized a walker. Resident #4's comprehensive care plan (CCP) revised 6/30/21 documented the resident used [CONDITION(S)] medications related to delusional disorder. Interventions included administering and monitoring for side-effects to medications, behavioral health consults as needed, assisting in identifying coping skills, monitoring for risk of self-harm, refusing medications, and impaired judgement or safety awareness. Resident #5 had diagnoses including paranoid [CONDITION(S)], drug induced dyskinesia (involuntary movement disorder), and [CONDITION(S)] disorder. The 8/31/21 MDS assessment documented the resident had intact cognitive function, exhibited no behavioral symptoms, and was independent for ADLs. Nursing progress notes for Resident #4 on 5/14/21, 5/17, 5/18, 5/19, 5/24, 5/25, 5/26, 5/30, 6/15, 7/7, and 8/20/21 documented the resident's behaviors included being bossy, controlling, and argumentative with other residents, predominantly in the dining room over the seating arrangements. The 9/3/21 at 1:35 PM nursing progress note documented Resident #4 had negative behaviors in the dining room that morning due to the seating arrangement, being bossy, childish, and demanding, arguing with staff and other residents at the table. Social worker (SW) #23's progress notes for Resident #4 documented on 5/14, 5/17, 5/19, 5/25, 5/26, and 7/1/21, the social worker spoke with the resident about the resident's concerns in the dining room. The resident reported being concerned with other residents' seat assignments and other residents sitting in certain chairs. The social worker reminded the resident that other residents could sit wherever they wanted in the dining room. On 5/17, 5/19, 5/25, 5/26, and 7/1/21, the resident yelled at other residents in the dining room because of where they were sitting and was reminded by the social worker those residents could sit where they wanted. There was no documented evidence Resident #4's CCP was updated to reflect the behaviors exhibited by Resident #4 in the dining room or with a plan to ensure safety when the resident approached and yelled at others related to their seating choice in the dining room. Nursing and social work progress notes for Resident #5 from 7/1/21 to 9/5/21 did not document the resident had any behaviors directed toward other residents. The 9/6/21 facility investigation documented at approximately 5:20 PM: - a resident reported to licensed practical nurse (LPN) #20 that Resident #5 hit Resident #4. - Resident #4 reported they hit Resident #5 because Resident #5 was in their seat and Resident #5 hit back, causing Resident #4 to fall. - Resident #4 complained of hip pain and was sent to the hospital. - Resident #5 reported they were seated in a chair at a table in the dining room, Resident #4 approached them and hit them in the face 3 times and hit them with their walker. Resident #5 pushed Resident #4 away, Resident #4 lost their balance and fell backwards. - A visitor was in the dining room and reported Resident #4 attempted to get by Resident #5, who was seated in a chair that was against the wall. Resident #4 hit Resident #5 with their walker, Resident #5 extended their arm in a protective manner, and Resident #4 fell backwards. - Resident #5 had no prior incidents of any nature with any other resident since their admission in 11/2019. - CNA #21, Unit assistant (UA) #22, and LPN #20 were the staff working on the unit at the time of the incident and they were completing other tasks in other areas of the unit and were not in the dining room when the incident occurred. The 9/6/21 hospital emergency room report documented Resident #4 was admitted following an altercation with another resident over a chair. They sustained a lip laceration and a right hip injury and had obvious shortening to the extremity. The x-ray report documented the resident had a closed non-displaced intertrochanteric fracture of the right femur (fractured hip) On 9/27/21 at 10:30 AM, Resident #5 was interviewed and stated they had not seen Resident #4 prior to the altercation. Resident #5 kept to themselves, sat in the dining room sometimes, not often, and had no concerns with Resident #4 or anyone else. The resident stated Resident #4 came up and got in their face and was hitting them on the shoulder. Resident #5 stated Resident #4 would not leave them alone, and they moved their arm to keep Resident #4 from getting in their face and hitting them, and Resident #4 fell back. When interviewed on 9/27/21 at 11:30 AM, the Director of Social Services stated interventions for Resident #4 included keeping a close eye on the resident in the dining area to prevent escalation. On 9/27/21 at 10:45 AM, LPN #2 was interviewed and stated there were no prior issues with Resident #5. Resident #4 hit others with their walker before, told residents what to do, and had a seat in the dining room they were very protective over. Resident #4 would tell others to move if they were in their seat or did not normally sit at their table, would get in other residents faces, and tell them to move. LPN #2 was unaware of any specific interventions for Resident #4 besides keeping an eye on them in case they escalated. On 10/1/21 at 1:14 PM, CNA #18 was interviewed and stated Resident #4 was very bossy with others and very strict about seating. The resident had a seat they always sat in, and if the seat was taken, the resident would make whoever sat there move by going right up to them and yelling at them until they moved. CNA #18 stated when they worked, they set up place mats and wrote the residents' names on them to avoid any issues in the dining room. CNA #18 stated they typically sat the residents at the same table for each meal and this was based on behaviors, preferences, and needs for assistance. CNA #18 stated they were told by the Supervisor they could not make a seating chart for the dining room per regulations, but they felt when they made seat assignments, it was effective in managing issues in the dining room. When interviewed on 10/1/21 at 1:35 PM, Unit Assistant (UA) #19 stated they had no instructions to stay in the dining room at mealtimes to supervise residents. They stated Resident #4 always sat in the same seat and the UA was not advised of any concerns or behaviors that needed monitoring. During a telephone interview with LPN #20 on 10/13/21 at 10:23 AM, they stated before meals, residents wandered in an out of the dining room and staff checked them every 15 minutes. Resident #4 had behaviors, tried to hit residents in the past, and was fixated on the same chair in the dining room. If someone else occupied their chair, Resident #4 would yell or make attempts to remove the other resident. The LPN was unaware of any interventions for Resident #4 for this behavior. During an interview with social worker #23 on 10/14/21 at 11:15 AM, they stated Resident #4 acted as if they oversaw the unit and their behaviors escalated if any resident did something they did not like or approve of. The social worker stated Resident #4's primary concern was their dining room seat (having their same seat). There was no seating assignment and residents could sit where they wanted. The social worker addressed the behaviors when talking to Resident #4 and thought the resident understood. The social worker was unaware of any specific interventions to address the resident's behaviors or prevent incidents in the dining room. During a telephone interview on 10/14/21 at 10:49 AM, RN Manager #1 stated Resident #4 had behaviors of being bossy with other residents in the dining room. Resident #4 would yell at and redirect the other residents if they sat in Resident #4's preferred seat. On occasion, residents were left alone in the dining room and the RN Manager did not think any residents were at risk. Physician #12 was interviewed by telephone on 10/15/21 at 10:43 AM and stated they were aware Resident #4 sustained a fractured hip following the altercation with Resident #5. The physician would expect a care plan to be in place for residents with behaviors to ensure monitoring and interventions for prevention of altercations. If a resident confronted other residents and was verbally threatening or physical, they were at risk of harm as well as the other resident. 10 NYCRR 415.12(h)(1)(2)

Based on observation, record review, and interview during the abbreviated surveys (NY 768 and NY 093) conducted on 10/18/21, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental, and psychosocial needs for 3 of 5 residents reviewed (Residents #1, 2 and 4). Specifically, - Residents #2 exhibited behaviors that triggered Resident #1 and a plan of care was not developed and implemented to prevent incidents. Residents #1 and 2 had verbal and physical altercations and plans of care were not developed and implemented timely to address behaviors or prevent further incidents. - Following the physical incident with Resident #2, Resident #1 was moved to a different unit and interventions were not implemented to prevent further incidents. Resident #1 then had a physical altercation with Resident #3. - Resident #4 exhibited multiple behaviors in the dining room and a plan of care was not developed or implemented to address the behaviors. Resident #5 pushed Resident #4 away when they were exhibiting behaviors resulting in Resident #4 falling and sustaining a femur (leg bone) fracture. Findings include: The 12/2008 Care Planning - Interdisciplinary Team policy documents the interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. 1) Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/27/21 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, was independent for transfers, locomotion on the unit, and toileting, and required set-up help for dressing, eating, and hygiene. The Kardex Report (care instructions) for Resident #1 dated 7/1/21 documented safety interventions included monitor/document/report to the physician as needed for risk of harming others (increased anger, agitation, feeling threatened, or thoughts of harming someone, possession of weapons or objects that could be used as weapons). Licensed practical nurse (LPN) #26's progress note documented on 7/29/21 at 12:20 AM, Residents #1 and #2 had a verbal exchange. Resident #1 was yelling, swearing, calling names, and attempted to go to Resident #2 and was redirected back to their room. Resident #1 returned with their cane, yelling they were going to kill that [expletive], and Resident #2 began yelling back. A Supervisor was called. Resident #2 was brought to their room. There was no documented evidence Residents #1 's CCP was updated following the 7/29/21 incident and did not include a plan to prevent further incidents. Nursing progress notes documented on 8/9/21, Resident #1 waved a butter knife at the nurse and after a room check wad done, staff removed 2 butter knives, 2 plastic knives, and 3 razors from the room, and on 8/17/21, Resident #1 was angry and redirected as much as possible. LPN #7's progress note documented on 8/29/21 at 8:13 PM Residents #1 and 2 had a verbal exchange and after re-direction, Resident #1 started another fight. Resident #2 raised their hand as if they were going to hit Resident #1. Staff removed plastic knives from Resident #1's room as Resident #1 threatened to kill Resident #2 in their sleep. Resident #1's comprehensive care plan (CCP), initiated on 2/1/21 and revised 8/25/21, documented the resident had moderate depression and was prescribed an antidepressant. Interventions included: psychology consultation and follow-up as needed, monitor, document, and report as needed for any risk of self-harm, risk to harm others, increased anger, labile mood, agitation, feeling threatened, thoughts of harming someone, or possession of weapons or objects that could be used as weapons. The 9/12/21 facility investigation documented at 3:43 AM, Resident #1 was yelling at Resident #2 with a butter knife in hand and when CNA #7 took the knife away and left the area, Resident #1 obtained a wheelchair leg rest and hit Resident #2 over the head with it. Resident #2 sustained a 5 centimeter (cm) cut on the top of their head, called the police, and went to the hospital for an evaluation. Social worker (SW) #23's 9/13/21 progress note documented Resident #1's room was changed from Unit 1 to Unit 2. Resident #1's CCP, updated 9/13/21, documented the resident had a room change to a different unit. The CCP contained no further updates related to the incident with Resident #2 on 9/12/21, including a plan to prevent further incidents. The 9/17/21 at 8:10 PM facility investigation documented Residents #1 and #3 had a physical altercation when Resident #1 went behind the nurse's station to use the staff bathroom and Resident #3 attempted to intervene by pulling at Resident #1's wheelchair and verbally telling them to stop. Resident #1 struck Resident #3 in the chest and Resident #3 fell . Resident #3 was sent to the hospital. The 9/17/21 hospital emergency room (ER) report for Resident #3 documented Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's CCP, updated 9/19/21, documented the resident had the potential to abuse others due to aggressive behaviors and poor impulse control. Interventions included: distract with conversation, television, music, snacks, magazines, books; provide quiet and relaxing environment when overstimulated; psychology referral as needed; separate from others who cause the resident to respond aggressively. There was no documented care plan for behavioral symptoms prior to 9/19/21. There was no documentation in the care plan related to the resident's behavioral triggers, or individualized interventions. On 9/27/21 at 5:27 PM, Resident #1 was observed in the hall in their wheelchair. They had no leg rests as the resident self-propelled the chair with their legs. The resident approached an empty wheelchair in the hall, the wheelchair contained 2 leg rests on the seat, and Resident #1 took one of the leg rests to their room. The resident set the leg rest on the floor inside the door. Multiple staff walked by and did not remove the leg rest. Resident #1's CCP and Kardex contained no documentation related to the resident's prior incident of hitting a resident over the head with a wheelchair leg rest. When interviewed on 9/27/21 at 11:30 AM, the Director of Social Services (DSS) stated they were was not aware of any care planned interventions for Resident #1 as nursing was responsible for behavioral care plans. In response to the 9/12/21, the DSS recommended [CONDITION(S)] medication to help with Resident #1's anxiety in the evening, when they were more anxious, easily triggered, and there were not enough staff to supervise them. CNA #4 was interviewed on 9/27/21 at 4:13 PM and stated Residents#1 and #2 had altercations of screaming and swearing at each other. The CNA was unaware of any specific triggers or interventions for Resident #1 and was told by the nurses to keep an eye on them. CNA #5 was interviewed on 9/27/21 at 4:24 PM and stated they intervened during a prior altercation between Residents #1 and #2 and they were unaware of any specific interventions for either resident aside from keeping an eye on them. During an interview on 9/28/21 at 12:35 PM, LPN #7 stated they were unaware of any behavioral CCP or of the resident's triggers except the resident was not to have knives in their room as they used to threaten others with them and to keep an eye on the resident. CNA #10 was interviewed on 9/30/21 at 6:52 PM and stated they were unaware of any interventions involving Resident #1 or to prevent altercations or stop them once it started. When interviewed on 10/1/21 at 10:55 AM, RN Manager #17 stated for Resident #1 there was an intervention of removing butter knives and to refer Resident #1 to activities. Activities were not successful, and the RN Manager was unaware of other interventions to address Resident #1's behaviors. The RN Manager was unaware of the reason care plan interventions were not in place to address Resident #1's specific behaviors, as the team could not identify any other possible interventions aside from monitoring. During an interview on 10/1/21 at 10:15 AM, RN Manager #15 stated when Resident #1 was transferred to their floor (Unit 2), they were not aware of the resident's specific behaviors or triggers and expected any safety issues would be on the CCP. The Director of Nursing (DON) recently (this past week) told RN #15 to ensure leg rests were removed and to check the room for items that can be used as weapons. When the altercation occurred with Resident #3 on 9/17/21, the staff should have been aware of Resident #1's potential to strike out and they were unsure if staff were aware. CCPs should include resident specific behaviors, triggers, and interventions so that staff were aware of what to look for and how to protect other residents. Resident #1 had identified behaviors and triggers and these were not included on their CCP. CCPs and updates were the responsibility of Unit Managers and RN Manager #15 stated they had not had ample time to address Resident #1's specific behaviors When interviewed on 10/1/21 at 11:10 AM, the DON stated there was no care plan for Resident's #1's behaviors until 9/19/2021 due to there being no other interventions they could think of. Prior to the 9/12/21 altercation, Resident 1's threats of violence although serious were only verbal. When Resident #1 was moved to Unit 2, the DON expected the Unit Managers to communicate any behavioral issues or concerns. On 9/27/21 at 5:17 PM, unit assistant (UA) #6 was interviewed and stated when Resident #1 was transferred to that unit, they were not advised of any concerns or supervision needs for Resident #1. The UA had not been told to observe for utensils, wheelchair leg rests or other items that Resident #1 should not have. CNA #10 was interviewed on 9/30/21 at 6:52 PM and stated they were unaware of behavioral interventions for Resident #1 aside from keeping Resident #1 away from Resident #2. Since that evening, the CNA was not aware of any new interventions. The CNA was not made aware of any safety precautions of ensuring Resident #1 had no objects that could be used as weapons, such as wheelchair leg rests or meal utensils. 2) Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/14/21 MDS documented the resident had intact cognition, exhibited verbal behaviors directed towards others (threatening, screaming, cursing), was independent for transfers, locomotion on and off the unit, dressing, toileting, and hygiene. Resident #2's comprehensive care plan (CCP), initiated 7/7/21, documented the resident had moderate depression and was prescribed an antidepressant medication. Interventions included: monitor for signs/symptoms of depression (negative statements, hopelessness, anxiety, sadness); encourage the resident to express feelings; assist in developing a program of activities of interest. The resident used [CONDITION(S)] medications related to depression. Interventions included pharmacy consult and monitor/record occurrence of target behavior symptoms (pacing, wandering, disrobing, inappropriate response to verbal communication, aggression toward others) and document per facility protocol. Resident #2's medical record documented: - Registered nurse (RN) #25 noted on 7/6/21 at 9:40 PM, Resident #2's room was changed due to verbal aggression and a strong threat of violence between the resident and their roommate. There was no documented evidence Resident #2's CCP was updated to reflect the noted behaviors or room change on 7/6/21, and no documentation of a plan to prevent incidents with other residents. - LPN #7 noted on 8/22/21, Resident #2 was in the lounge with no pants on, their hand in their underwear, was asked to put pants on, refused, yelling at the nurse and other residents present. LPN #7's progress note documented on 8/29/21 at 8:13 PM, Residents #1 and #2 had a verbal altercation and Resident #2 raised their hand as if they were going to hit Resident #1. Resident #1 was redirected to their room, returned, and started another fight. Resident #2 refused to go back to their room and continued yelling. There was no documented evidence Resident #2's CCPs was updated following the incidents with other residents and no documentation of a plan to prevent recurrence. The 9/12/21 facility investigation documented at 3:43 AM, Resident #1 had a butter knife in hand and was yelling at Resident #2. Resident #1 then took a wheelchair leg rest and hit Resident #2 over the head with it. Resident #2 went to the hospital for evaluation. There was no documented evidence Resident #2's CCP was updated following the incident with Resident #1 on 9/12/21. When interviewed on 9/27/21 at 11:30 AM, the Director of Social Services (DSS) stated they were not aware of CCP interventions as nursing was responsible for behavioral care plans. In response to the 9/12/21, the DSS recommended psychological services for Resident #2 and they declined. CNA #4 was interviewed on 9/27/21 at 4:13 PM and stated they were unaware of any specific triggers or interventions for Residents #1 and 2 and was told by the nurses to keep an eye on them when able. CNA #5 was interviewed on 9/27/21 at 4:24 PM and stated they were unaware of any specific interventions for Resident #2 aside from keeping an eye on them. During an interview on 9/28/21 at 12:35 PM, LPN #7 stated they were unaware of any behavioral CCPs or of the resident's triggers. The LPN was not aware of any interventions for Resident #2 prior to the 9/12/21 altercation aside from keeping an eye out for any issues. When interviewed on 10/1/21 at 10:55 AM, RN Manager #17 stated they were unaware of other interventions to address Resident #2's behaviors aside from education as the staff educated them about their behaviors because they had intact cognitive function. When interviewed on 10/1/21 at 10:55 AM, RN Manager #17 stated on 9/27/21, a new CCP was initiated to address Resident #2's behaviors. Prior to 9/27/21, staff would try and redirect the resident. Resident #2 was educated about their behaviors as they had intact cognitive function. When interviewed on 10/1/21 at 11:10 AM, the Director of Nursing (DON) stated Resident #2 had no CCP for their behaviors as they were cognitively intact and could be educated. There should have been CCP interventions for all residents involved both potential to be a victim and aggressor to ensure staff were aware of the behaviors. Residents with behaviors of approaching other residents, yelling at them, or threatening them were at risk of harm. CCPs should address specific behaviors and interventions. 3) Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/2/21 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, was independent for activities of daily living (ADLs), and utilized a walker. Resident #4's comprehensive care plan (CCP) revised 6/30/21 documented the resident used [CONDITION(S)] medications related to delusional disorder. Interventions included administering and monitoring for side-effects to medications, behavioral health consults as needed, assisting in identifying coping skills, monitoring for risk of self-harm, refusing medications, and impaired judgement or safety awareness. Nursing progress notes for Resident #4 on 5/14/21, 5/17, 5/18, 5/19, 5/24, 5/25, 5/26, 5/30, 6/15, 7/7, and 8/20/21 documented the resident's behaviors of being bossy, controlling, and argumentative with other residents, predominantly in the dining room over the seating arrangements. Social worker (SW) #23's progress notes for Resident #4 documented they met with the resident on 5/14, 5/17, 5/19, 5/25, 5/26, and 7/1/21 as Resident #4 was concerned with other residents sitting in certain chairs in the dining room. SW #23 explained to Residnet #4 that other residents could sit wherever they were comfortable in the dining room. The 9/3/21 at 1:35 PM nursing progress note documented the resident had negative behaviors in the dining room this morning due to the seating arrangement, being bossy, childish, and demanding, arguing with staff and other residents at the table. Resident #4's CCP contained no specific documentation related to behaviors in the dining room addressed by nursing or social services and no interventions related to those behaviors. The 9/6/21 facility investigation documented a resident reported to licensed practical nurse (LPN) #20 that Resident #5 hit Resident #4. Resident #4 reported they hit Resident #5 because they were in their seat, and Resident #5 hit back, causing Resident #4 to fall. Resident #4 complained of hip pain and was sent to the hospital. The 9/6/21 hospital emergency room report documented Resident #4 sustained a lip laceration and right hip injury that was diagnosed to be a right femur (leg bone) fracture. Resident #4's CCP, updated 9/8/21, documented they had the potential to be abused by others due to aggressive behaviors towards others and frequent yelling out. Interventions included: distract when agitated with conversation, television, music, snacks, magazines, books, etc; offer unit activities when becoming agitated, wandering or repetitive; provide quiet and relaxing environment when overstimulated; and psychologist/psychiatrist referral as indicated. There was no behavioral care plan prior to 9/8/21 (the resident was discharged [DATE]) and the CCP contained no documentation related to the resident's specific behaviors in the dining room or a plan to address those behaviors. When interviewed on 9/27/21 at 10:40 AM, registered nurse (RN) Manager #1 stated Resident #4 was sometimes bossy with other residents, very particular about seating arrangements in the dining room, would tell people to move, or tell them where to sit. The RN Manager was unaware if there were any CCP interventions to address Resident #4's behaviors. On 9/27/21 at 10:45 AM, LPN #2 was interviewed and stated Resident #4 hit others with their walker before, told residents what to do, and had a seat in the dining room they were very protective over. Resident #4 would tell others to move in they were in her seat or did not normally sit at her table, would get in their face, and tell them to move. The LPN was unaware of any specific interventions and stated they just keep an eye on the resident to see if an issue escalated. When interviewed on 9/27/21 at 11:30 AM, the Director of Social Services (DSS) stated Resident #4 had an issue with one resident who they were antagonizing and pushing their walker at the resident. Interventions included keeping a close eye on Resident #4 in the dining area to prevent escalation. The DSS was not responsible for updating CCPs and stated nursing did the behavioral care plans. On 10/1/21 at 1:14 PM, CNA #18 was interviewed and stated Resident #4 was very bossy with other residents and was very strict about seating. The resident had a seat they always sat in, and if the seat was taken, the resident would make whoever sat there move by going right up to them and yelling at them until they moved. The CNA did not know of any specific interventions in the CCP to address these behaviors. When interviewed on 10/1/21 at 1:35 PM, UA #19 stated they had no instructions to stay in the dining room at mealtimes to supervise residents. They stated Resident #4 always sat in the same seat and the UA was not advised of any concerns or behaviors that needed monitoring. During a telephone interview with SW #23 on 10/14/21 at 11:15 AM, they stated they met with Resident #4 after behavioral incidents as the resident was demanding toward other residents and acted as if they oversaw the unit. Resident #4's behaviors escalated if any resident did something they did not like or approve. Resident #4's primary concern was their dining room seat (having their same seat). There was no seating assignment and residents could sit where they wanted. The SW addressed the behaviors when talking to the resident. The SW was not certain if a seating chart was implemented on the unit and knew there was one CNA who used placemats with resident names. The care plan was completed by the nurse manager and that would address any behaviors or interventions. The SW was unaware of any specific interventions to address the resident's behaviors. During a telephone interview on 10/14/21 at 10:49 AM, RN Manager #1 stated CCPs were completed by the Unit Managers and other staff members could add information. Resident #4 had behaviors of being bossy with other residents in the dining room and when another resident sat in Resident #4's preferred seat. Resident #4 would yell at and redirect other residents if they were in her seat. On occasion, residents were left alone in the dining room and the RN Manager did not think any residents were at risk. The RN Manager stated they did not feel the resident required a behavioral care plan as their behaviors were not aggressive. They did not believe Resident #4 or other residents were at risk. A behavioral CCP was initiated for Resident #4 on 9/8/21, following the incident with Resident #5. During a telephone interview with the Director of Nursing (DON) on 10/14/21 at 11:34 AM, they stated the RN Manager was responsible for CCPs and behavioral CCPs should have been completed for Resident #4. The resident was territorial about their seat in the dining room and would tell other residents to move and the behaviors were daily. The DON was unaware of the reason a care plan was not completed. 10 NYCRR 415.12(h)(1)(2)

Based on observation, record review and interview during the recertification and abbreviated surveys (NY 612 and NY 726) conducted on 6/1/21- 6/9/21, the facility did not ensure the environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistive devices to prevent accidents for 2 of 4 residents (Residents #93 and #141) reviewed. Specifically, - Resident #93, who had intact cognition and a diagnosis of [CONDITION(S)] (paralysis), sustained [CONDITION(S)] from food/beverages on multiple occasions. On 1/2/21, the resident microwaved soup and spilled it on their leg causing a 9.5 by 5.5 centimeter second-degree burn, which is currently a non-healing wound. On 1/9/21, Resident #93 microwaved a beverage and spilled it, sustaining a cluster of blisters on their abdomen. On 4/27/21, staff microwaved soup and provided it to Resident #93, who was lying in bed; the resident spilled the soup on their abdomen, sustaining a 12 by 26 centimeter second-degree burn. The facility did not have a policy addressing safely re-heating foods. Staff interviewed were not able to state a policy for ensuring food was re-heated to safe temperatures. Two staff members were observed microwaving foods/beverages for residents. Thermometers are not available on the units for staff to monitor the temperatures of the food. The provider's failure to prevent [CONDITION(S)] caused by foods and drinks microwaved to unsafe temperatures placing 144 residents at immediate risk to their health and safety. This resulted in actual harm that was Immediate Jeopardy/Substandard Quality of Care to resident Health and Safety for Resident #93 and Immediate Jeopardy to the facility's other 144 resident (including Resident #141). Findings include: The facility's Microwave Oven - Operational Procedures (undated) documented a procedure for operating a microwave and documented microwaves could be used by both residents and staff. The policy did not address temperatures that food should be heated to or how long to microwave food/beverages. 1) Resident #93 had diagnoses including [CONDITION(S)] due to C6-C7 spinal fracture (paralysis). The 1/16/21 Minimum Data Set (MDS) assessment documented the resident had intact cognition, required extensive assistance from 1 person for most activities of daily living (ADL), required supervision and physical assistance from one person for eating, had no functional limitation in range of motion in either upper extremity (shoulder, elbow, wrist, hand), had functional limitation in range of motion in both lower extremities and used a wheelchair. The comprehensive care plan (CCP), initiated 2/22/19 and revised on 5/7/19, documented the resident had nutrition/hydration problems and an ADL self-care deficit related to [CONDITION(S)]. Interventions included occupational therapy (OT) to screen and provide adaptive equipment for feeding as needed. The CCP did not include specific recommendations for adaptive eating equipment. The resident required the assistance of 1 person for personal hygiene and oral care and the resident's eating ability was not addressed in the CCP. The resident was hospitalized [DATE]-[DATE] with a diagnosis of a closed left hip fracture. The 12/23/20 Admission/Re-Admission assessment documented the resident returned from the hospital at 4 PM and the following skin findings/conditions were noted: a healing burn to the chest that measured 2.5 centimeters (cm) X 0.6 cm, and a healing burn to the abdomen measuring 4 cm x 2.8 cm. The OT Evaluation and Plan of Treatment with a start of care date of 12/24/20 documented the resident required set-up assistance with feeding. The resident's range of motion in both upper extremities was impaired due to [CONDITION(S)]. The resident had impairments in fine and gross motor coordination resulting in limitations and/or participation restrictions in the area of self-care, mobility and general tasks and demands. Due to physical impairments and associated functional deficits, the resident was at risk for further decline in function and increased dependency upon caregivers. There was no documentation of the resident's requirement for adaptive feeding equipment. The 12/30/20 Kardex (care instruction) documented staff were to inspect the resident's skin weekly, the resident needed set-up by staff for meals, received a regular diet, and used a lipped plate and sip cup. The 1/2/21 at 9:29 PM, RN #25's progress note documented they were called to the resident's room to evaluate the resident's left ankle because it looked burned. The resident stated they spilled their soup they had heated in the microwave. The plan was to have the skin team evaluate the resident. There was no documented evidence of a skin assessment completed by the RN. The 1/2/21 Accident and Incident report documented while staff were providing care to the resident, they noticed a large intact blister to the inner left ankle. The resident stated they spilled soup on their pant leg and due to lack of sensation they were not aware of the burn. The resident was to be evaluated by OT for microwave safety, dietary was to provide lidded cups, and the resident was educated about requesting assistance from staff for all microwave use. OT #23's progress note dated 1/6/21 did not address the resident's ability to safely use a microwave. The 1/9/21 at 10:02 PM RN #25's progress note documented the RN was asked to go the resident's room. Upon entering the resident was at the sink and asked the nurse to look at their stomach and mid-abdomen, there was a burn mark with peeling skin. The resident stated the spout to their teacup spilled. The resident noted their shirt was wet but did not think anything happened. The DON (Director of Nursing) was made aware and medical and family were notified. OT #23's progress note dated 1/13/21 documented the resident was educated on the risks of carrying hot liquids and ways to improve safety with task and was encouraged to wear clothing protectors provided by staff and ask for assistance to transport hot mugs to prevent [CONDITION(S)]. There was no documentation the resident's CCP was revised to include lidded cups or microwave use. There was no documented evidence the CCP was reviewed or revised with a plan of care to prevent further [CONDITION(S)] following the identification of the burn on 1/9/21. The 4/6/21 Braden Scale for predicting pressure ulcer risk documented the resident's sensory perception was slightly limited which limited the resident's ability to feel pain or discomfort. The resident was at high risk for pressure ulcers. The 4/27/21 Accident/Incident Investigation and Root Cause- Injury of Unknown Origin and Initial Wound Assessment documented the resident sustained a burn that was a cluster of blisters and redness on the chest and abdomen measuring 26 cm x 12 cm. The physician was notified and ordered [MEDICATION(S)] (antibiotic ointment) and dry dressing cover twice daily to the wound. The resident stated they were eating soup while lying down. Interventions included to encourage the resident to wear a clothing protector while eating, position upright when eating, and provide lidded tops to all hot beverages and foods. The 4/29/21 OT progress note documented the OT was asked to discuss the resident's recent burn from spilling hot soup. The resident used a plastic microwavable mug with lock lid. Staff microwaved for the resident according to directions. The resident was agreeable to have staff microwave the food for less time so that soup was still hot but not scalding. The resident was not able to lift the mug with the lid to drink due to poor grip and decreased dexterity. The resident was to utilize clothing protectors and staff were to microwave for less time to prevent [CONDITION(S)]. There was no documented evidence the CCP was revised to include the OT recommendations from 4/29/21. On 5/21/21, the CCP was revised to include the resident may not use the microwave. The 5/22/21 at 9:45 PM licensed practical nurse (LPN) #37 nursing progress note documented the resident asked staff to warm up soup in the microwave. Resident #93 then proceeded to remove the hot liquid from the microwave without waiting for staff to assist. The resident was educated on the importance of waiting for assistance. During an interview on 6/1/21 at 10:30 AM, Resident #93 stated they sustained a burn to the chest and upper abdomen from tomato soup. They stated the burn happened because of a late return to the facility from an appointment. The resident returned after dinner and was hungry, so they asked the CNA to warm up some soup. The resident refused the clothing protector because they were eager to eat. They explained they were a quadriplegic and very shaky at times. When they put the soup up to their mouth, the hot soup dripped on their abdomen. During an interview on 6/2/21 at 11:40 AM, while observing lunch tray pass, CNA#34 stated staff were not trained in reheating food. CNA #34 stated they microwave food 30 seconds to one minute. There were no probe thermometers available for use. The Kardex, dated 6/3/21, documented the resident required set-up only to eat and received a regular diet with thin liquids and a lipped plate. There was no documentation the resident required any adaptive feeding equipment (cup or bowl) or assistance with the microwave. During an interview on 6/3/21 at 9:15 AM, CNA #27 stated they were usually assigned to the resident in the evening and they recalled the resident went to the hospital for a test or procedure in 4/2021 and when the resident returned, they were hungry. The resident had a lot of canned food in their room. CNA #27 heated up a can of soup for the resident in a container that clicked locked on both sides. CNA #27 stated it was the resident's personal container which was a cup with a handle on the side. CNA #27 followed the heating instructions on the soup can and warmed it for about 2-3 minutes. CNA #27 stated they were not trained on how to heat food to safe temperatures. That night, the resident ate in their room sitting up in bed. The resident had a shirt on but refused a clothing protector. CNA #27 stated they often microwaved food for residents when it arrived cold from the kitchen. During an interview on 6/03/21 at 9:45 AM, with CNA #28, they stated food was warmed in the microwave all the time and they were not sure how to tell if the temperature was safe. The CNA stated they could not recall warming up food for any residents, but there were microwaves available on all units. During an interview on 6/03/21 at 11:37 AM with RN Manager #22 they stated they thought the [CONDITION(S)] the resident sustained to the abdomen in 12/2020 were from spilling hot tea on themselves. On 1/2/21, the resident sustained a burn to the left ankle and thought it was from soup or tea. RN Manager #22 stated the resident had been using the microwave independently. The resident refused clothing protectors, would not allow staff to apply lids to soup containers and/or hot drinks and the resident would remove the lids. The 6/3/21 lunch meal ticket for Resident #93 documented a Lip Plate and a regular diet. There was no documentation that the resident required covered mugs, or covered soup bowls or any adaptive feeding equipment. During an interview on 6/03/21 at 12:59 PM, Resident #93 stated the night they burned their chest (4/29/21) they were not wearing a shirt because they asked to be helped into bed after their outside appointment. The resident stated at the time the facility dishwasher was broken and they were given a plastic spoon which did not work well with their palm assistant because the plastic spoon was too short. The resident stated the soup must have dripped on their stomach. The resident explained they also warmed up tea in the microwave and when placing the hot tea on the wheelchair footrest, it spilled, and they burned themself. On 06/03/21 at 7:17 PM Resident #93 was observed with an empty green soup cup/mug on their lap. They stated this was not the mug they used all the time. They explained the cover on the mug was really clamped down and used for soup because it had a vent in it, and they had ordered it online. They stated they could use the facility mug. They stated when they used the mug for soup, they did not use the lid and they sustained the [CONDITION(S)] when using the soup mug without a lid. They were not wearing a shirt or clothing protector and the soup dripped off the spoon when using the facility mug and they were burned. During an interview on 6/03/21 at 2:57 PM with OT #23, they stated the resident used to use the wheelchair footrest to carry things between their feet when going back and forth to the microwave. OT #23 stated in 12/20, the resident had a blue cup and would put it on their la or rest it on the footrest and the cup tipped and spilled. The interdisciplinary team determined the resident was unable to safely manage use of the microwave therefore staff were going to heat foods up for the resident. Routinely, staff would heat the food up for the resident. The resident bought their own large mug with a handle and locked top containers for soup and drinks. OT #23 stated they thought the resident was using these. The OT recalled it was recommended the staff not heat foods up to burning hot. They stated they had not recommended any adaptive equipment, as the resident already uses the universal cuff (gives persons with limited grip or dexterity controlled use of items such as eating utensils and writing tools). The OT did recommend the resident not transport the hot food items and should be at a table or sitting up in a chair because the resident had a poor grip. The OT stated they recommend a clothing protector if eating in bed and to wear a shirt because the resident was prone to spilling what they were consuming. The resident bought the bowl and the cup, the OT did not recommend them, but stated they thought the items were safe. The OT stated it was safe for the resident to eat in their room alone. The resident was cognitively intact but needed to be in the best position and use adaptive equipment such as the blue mug for hot tea at night. The OT stated they were asked to do a microwave safety assessment for the resident in April 2021, and recommended the resident not warm up foods independently because of the lack of sensation and lack of grip. The OT stated the resident's current meal ticket did not document anything about the bowl or mug. There was no documentation for the nursing staff to know how to transfer the hot liquids into the large handled mug with the lid, or the shallow bowl with the lock top. The resident had cans of soup in their room that they had staff warm the soup up at night. The OT stated the care plan should be updated with OT recommendations. When these details are on the care plan, the aides will see it on the Kardex and would need to check that task off as part of their care. The OT stated the resident care plan should have documented no use of the microwave by the resident. During an interview on 6/03/21 at 3:55 PM RN Manager #22 stated the resident came back from the hospital on 12/23/20. When the readmission assessment was completed it was noted the resident had [CONDITION(S)] to the abdomen and chest. There was no documentation the [CONDITION(S)] had been previously reported. RN Manager #22 and the DON were not aware the resident had [CONDITION(S)] prior to the hospitalization because there was no documentation about the [CONDITION(S)] on the abdomen and chest. They recalled an incident on 1/2/21 when the resident burned their left foot with hot soup. The resident warmed up soup in the microwave in the kitchenette at around 9:00 PM and spilled the soup on themself when getting the soup out of the microwave. The resident had their own personal cup with a lid and had a big handle mug they would pour the can of soup into and warm up. An incident report was completed on 1/2/21 and it was immediately decided the resident needed to be educated about not using the microwave without supervision. The RN stated the microwave was still on the unit. On 1/9/21, the resident burned their abdomen heating up a drink in the microwave after being told not do so without assistance. On 4/29/21 the resident sustained a burn to the chest and abdomen from hot soup that a staff member microwaved for the resident in the unit dining room/ kitchen area. The RN Manager #22 confirmed the resident's care plan did not include the resident's personal dishes and/or personal food and it should have. They stated the care plan updates the Kardex for the care and tasks to be completed by the CNA. Food that needs to be warmed up should be sent to the kitchen. The RN Manager #22 stated the CNAs did not have a way to check temperatures of microwaved items. The resident currently had a locked lid shallow bowl and a blue big handle mug. The RN Manager #22 stated the resident was able to remove the lids and did not use the bowl and mug in a safe or appropriate manner. During a telephone interview on 6/03/21 at 5:59 PM, attending physician #26 stated they were not familiar with the resident, as they started as their provider in the beginning of 4/21. After review of the burn incident, they stated it seemed as if the resident was not doing well with the hot liquids and may need to be reevaluated to ensure that the resident is safe Physician #26 stated the resident did not appear to be capable of feeding themself safely. Staff needed to know how to check food temperatures for safety with hot food. During an interview on 6/3/21 at 6:30 PM, RN Manager #22 stated they talk to the resident in the past about their safety concerns, but the resident refused to use a clothing protector. The resident did not feel the [CONDITION(S)] were significant. The care plan documented their noncompliance but did not include the resident's need for adaptive dishes and assistance with microwaving foods. During an interview with the DON on 6/3/21 at 4:10 PM they stated the resident had spilled coffee and soup on themself and all incidents had been investigated. They offered clothing protectors and heat resistant pads and the resident refused those items. They stated safety lids and containers were also attempted but the resident had taken the lids off. The resident received extensive education on different occasions about food preparation safety. The resident purchased their own type of lids because they preferred the way the lid went on and came off. Assistive devices should be listed under the dietary care plan. The microwave was removed temporarily when the resident had first spilled hot liquid, but other residents also used it, so it was returned, and the resident had not been using it when it was returned. The 6/4/21 electronic communication from the facility Administrator documented there was no investigation related to the burn observed in December 2020 when the resident returned from the hospital. 2) Resident #141 had diagnoses including [CONDITION(S)] (COPD), oxygen dependence, and anxiety. The 2/5/21 Minimum Data set (MDS) assessment documented the resident was cognitively intact and independent with activities of daily living (ADL). The resident required set-up assistance for eating. The 6/4/19 physician's order documented a regular diet, regular texture, thin liquids. The 2/26/18 comprehensive care plan (CCP) updated 3/5/21 documented the resident had potential/actual skin impairment to left third finger related to a self-inflicted burn from a hot microwave meal. Interventions included identify cause of skin impairment and eliminate, follow facility protocols for treatment of injury, monitor size, location, document, notify the physician of failure to heal, signs and symptoms of infection, resident agrees to ask for assistance when heating food in the microwave, verbalizes complete understanding (safety), [MEDICATION(S)] treatment until healed. The 4/14/20 Kardex (care instructions) documented the resident required set-up help for eating. The 3/4/21 at 1:06 AM, licensed practical nurse (LPN) #42's progress note documented they were told by the resident at 12:55 AM, the resident had a fluid filled blister on their left third finger. The blister measured 3.6 centimeters (cm) X 1.0 cm. The resident reported they had a CNA (not identified) heat up noodles in a Styrofoam cup in the microwave. When the resident grabbed the cup, some of the water got on their finger. The resident put cold water on it right away. The Supervisor was notified. Skin prep (a clear protective liquid film) was applied. The 3/4/21 Accident and Incident report completed at 1:14 AM by LPN #42, documented the resident sustained a 3.6 cm x 1.0 cm burn to their third left finger. Skin prep was applied. The CCP documented staff would heat items in the microwave. The resident accidentally spilled hot water on their finger and was educated to wait to let the food cool. The probable cause of the accident was identified as accidental, education provided to allow items to cool. The CNA assigned was CNA #43. The 3/5/21 at 12:32 PM registered nurse (RN) Manager #40's progress note documented that per nurse practitioner (NP) #12, start treatment with [MEDICATION(S)] cream and monitor until healed, care plan involved staff heating food in microwave to avoid injury, resident agrees. The progress note did not document what was to be treated with [MEDICATION(S)] cream. The CCP initiated 3/5/21 documented the resident had impairment in skin integrity of the left hand 3rd finger related to a burn from a hot microwave meal accidentally self-inflicted. The CCP was updated on 3/9/21 to include the resident agreed to ask for assistance when heating up items in the microwave. The wound assessment, effective 3/9/21, documented the resident had a self-inflicted burn on the left third finger measuring 3.6 x 1 x 0 cm, no odor, slight inflammation. The wound was discovered on 3/4/21 and the provider and family were notified on 3/5/21. Treatment was for [MEDICATION(S)] cream with dry sterile dressing (DSD); wound team to see, care plan updated to ask for help with microwave. The 3/9/21 at 3:41 PM RN Manager #40 progress note documented the resident's wound was healed, [MEDICATION(S)] treatment discontinued. The 3/9/21 Director of Nursing (DON) accident summary (for the 3/4/21 incident) documented the resident was independent once in their electric wheelchair and made their own decisions. The resident went to the kitchenette in their wheelchair and heated up a container of noodles. When they returned to their room, they opened the lid and drops of water spilled onto their finger. The resident immediately ran cold water on it. Initially there was nothing there, then at 12:00 AM, the resident noticed the blister and notified the LPN. The resident had no prior known concerns with the microwave. The resident was educated to let the staff microwave and open the food items to prevent reoccurrence and the resident understood. When interviewed on 6/8/21 at 2:41 PM, RN Manager #40 stated they recalled the resident's burn. They treated the burn with [MEDICATION(S)] cream, and it healed within a week. At that time, the resident was alert. They warmed up something in the microwave and it was common for the resident to go in the kitchen and heat up food. The microwave sat on the counter at the height of the resident's chest. Prior to the burn, there had been no second thoughts regarding the resident using the microwave. The resident was then care planned to ask for assistance when heating food in the microwave and verbalized understanding. When interviewed on 6/9/21 at 8:56 AM, LPN #42 stated Resident #141 was alert and had no difficulty using their hands or manipulating their wheelchair. The resident used the kitchenette often and LPN #42 never questioned their ability to use the microwave. The resident notified staff if they needed help but would take hot foods back to their room. The resident placed their cup of noodles in a bowl and held the bowl with one hand on the outer part of the armrest and used their other hand to drive their electric wheelchair. They stated the resident did not tell LPN #42 if the burn happened in the kitchenette or in their room, or if a CNA had cooked the noodles for them. The blister was fluid filled but the skin was intact. LPN #42 was not sure if the facility went over any staff training about hot foods. Dietary used to check the temperature of the hot coffee, but LPN #42 had not seen them do that recently. LPN #42 stated there used to be a thermometer on the unit but did not know what happened to it. When interviewed on 6/9/21 at 9:16 AM, CNA #43 stated the resident was self-sufficient and would ring if they needed anything. CNA #43 stated it was not common for the resident to use the microwave themself. The resident kept food in their room and asked if they needed something warmed up but had never asked the CNA to heat anything. CNA #43 stated, they did not recall the resident getting burned. ------------------------------------------------------------------------------------------------------------ The Immediate Jeopardy was removed on 6/4/21 based upon the following: - All microwaves were removed from each units and staff breakrooms. The ability to warm food up was prohibited until dietary staff arrive in the AM. There was not hot food available from 9:00 PM until 5:00 AM. - Eighty percent of staff were educated regarding the removal of microwaves and all food would be heated up by food service staff only until all nursing staff and dietary employees have been educated on safe food heating methods. 10 NYCRR 415.12(h)(1)(2)

Based on record review and interview during the abbreviated survey (NY 045), the facility did not ensure 2 of 4 residents (Residents #1 and 3) reviewed for quality of care, received treatment and care in accordance with professional standards of quality. Specifically, Resident #1's physician orders for wound care were not complete and thorough after he was admitted to the facility and when the resident's skin status changed it was not monitored or communicated to the physician. Additionally, the resident did not receive his intravenous (IV) antibiotic for 3 days as ordered. The resident was transferred to the hospital [MEDICAL CONDITION] and gangrene where he expired. This resulted in actual harm to Resident #1 that was not immediate jeopardy. Resident #3 exhibited a change in condition and was not provided with emergent care timely. Findings include: A facility New Admission/Re-Admission Nursing Policy updated ,[DATE] documented the Admission Order Set should include medications and wound care per discharge/transfer orders. The nurse contacts the accepting physician and reviews/verifies all orders and treatments. A second nurse will transcribe the orders from the Admission Order set to the MAR (medication administration record) and TAR (treatment administration record) using this as a second check of the discharge medication reconciliation. The nurse will mark the order as noted with the date and initials once this is complete. The nurse on the 11 PM- 7 AM shift will perform a complete review of the admission orders [REDACTED]. A facility Change in Resident's Condition or Status policy, updated ,[DATE] documented the nurse supervisor/charge nurse will notify the resident's attending physician or the on-call physician of a significant change in the resident's physical/emotional/mental condition. There was no documented policy for ordering IV antibiotics at the time of the resident's admission. 1) Resident #1 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The [DATE] Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired, required extensive assistance to total dependence for most activities of daily living (ADLs), had a surgical wound and received surgical wound care and had not received antibiotics in the past 7 days. WOUND CARE AND SKIN STATUS A hospital discharge summary dated [DATE] documented the resident was admitted to the hospital for debridement (removal of dead tissue) of the surgical incision of the right [MEDICAL CONDITION]. The hospital discharge instructions documented to apply Xeroform (petroleum dressing), gauze, and Kerlix wrap to the resident's wound daily. An admission skin assessment dated [DATE] did not identify any discoloration, bruising or skin alteration of the left lower extremity. The assessment documented the resident had an incision on the right stump amputation site that was 9 inches long with dried blood on the incision. There was no drainage or sign or symptoms of infection. The [DATE] admission physician orders did not include any dressing or treatment to the resident's right stump incision. The admission orders [REDACTED]. There were no other initials or signatures on the physician orders indicating the orders had been checked or verified by a second nurse. The ,[DATE] treatment administration record (TAR) did not include any treatment or dressing to the right stump incision. On [DATE] at 11:00 PM LPN #9 documented the toes on the resident's left foot were cold and discolored. There was no documented evidence an RN or physician was notified of the documented changes in the status of the resident's skin on the left foot or evidence of any further monitoring of the change in status. A physician admission history and physical dated [DATE] documented the resident had a gangrenous lesion on the left second and third toe and the foot was very cold. The resident was admitted on [DATE] but right now it is looking like the patient developed some gangrenous (tissue death) lesion in the left lower extremity. The resident would be sent to the emergency room for evaluation. A hospital physician consultation dated [DATE] documented the resident was discharged from the hospital 4 days ago and now comes with [MEDICAL CONDITION] (a mixture of serum and pus) drainage of the right below-knee amputation stump. The entire left forefoot which previously looked pretty good, is ischemic (lack of blood supply) and is blue and cold. The hospital discharge summary documented the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident expired on [DATE]. IV ANTIBIOTICS A hospital discharge summary dated [DATE] documented the resident was admitted for debridement (removal of dead tissue) of the surgical incision of the right [MEDICAL CONDITION]. He would remain on oxygen and intravenous (IV) antibiotics and discharged back to the nursing home on [MEDICATION NAME] (antibiotic) 1 gram (gm) IV daily until [DATE]. The hospital medication administration records documented [MEDICATION NAME] 1 gram (gm) IV daily at 5:00 PM. The resident did not receive the antibiotic in the hospital on [DATE]. The Hospital medication reconciliation record documented the [MEDICATION NAME] 1 GM IV was due on [DATE] at 5:00 PM. A nursing progress note dated [DATE] documented the resident arrived at the facility at 3:30 PM via stretcher. Physician admission orders [REDACTED]. The physician orders were signed as completed by RN #11. The ,[DATE] Medication Administration Record [REDACTED] -[MEDICATION NAME] 1 gm every 24 hours at 8:00 AM, when arrives from pharmacy. The start date for the [MEDICATION NAME] was [DATE] at 8:00 AM. There was no documented evidence it was administered on [DATE] as ordered. A nursing progress note dated [DATE] at 2:35 PM documented they would start the IV antibiotic when available from pharmacy. A nursing progress note dated [DATE], a late entry for [DATE] completed by RN #3, documented she was notified at 2:00 PM on [DATE] the resident had not received his IV antibiotic. A call was placed immediately to the pharmacy and the facility did not receive a call back before the shift ended. This information was reported to the oncoming nursing supervisor. A nursing progress note dated [DATE] at 7:00 AM completed by RN #3, documented she was advised that the IV antibiotic had not yet arrived. The physician was immediately notified, and an order was obtained for an IM (intramuscular, via a needle) dose of the antibiotic to be obtained from the emergency supply and administered. The pharmacy was contacted and would have the medication there by Monday ([DATE]) morning. The resident remained sleepy. A nursing progress note dated [DATE] documented the first dose of the IV antibiotic was administered at 8:00 PM. During an interview with the resident's attending physician on [DATE] at 11:30 AM he stated he had taken care of the resident while he was in the hospital and had written his discharge orders for the nursing home on [DATE]. When the nursing home called him on [DATE] after the resident arrived at the facility, he asked the nurse if she had any questions about the orders he had written, she said no, and he told her he would be in after the weekend to see the resident. The resident's hospital course included an infected surgical incision to the stump. It was surgically debrided as it was infected, and the resident required an extensive course of IV (intravenous) antibiotics. The wound to the stump looked really good prior to being discharged to the facility. He received a call from the facility on Sunday afternoon ([DATE]) and was told the resident had not been given his IV antibiotic. The nurse told him the medication was unavailable. He was upset they had not notified him sooner. If the antibiotic was not available, he would have kept the resident in the hospital longer to receive the IV antibiotic. At that time, he ordered an IM dose of antibiotic which was kept in the facility's emergency supply. The IV antibiotic was more effective because of its bioavailability but he wanted the resident to have an antibiotic then. When he arrived at the facility after the weekend the resident was very sick. The resident had only received one dose of IV antibiotic at that time. The surgical incision to the stump was covered with blackish tissue and he had developed gangrene on his left toes. The surgical incision had not looked like that when the resident was discharged from the hospital and neither did the toes on the left foot. He had not been notified of the worsening incision or the discoloration of the right foot. He could not recall if the resident had a specific treatment to the stump but if he ordered it on the discharge summary then the nurses should have implemented those orders. He stated it was possible the resident not receiving the ordered IV antibiotic or the ordered wound treatment caused the condition of the stump wound to worsen and could have contributed toward the development of gangrene on the other foot. These conditions could have hastened his death. During an interview with licensed practical nurse (LPN) #2 on [DATE] at 10:40 AM he stated there had been no treatment or dressing ordered for Resident #1. When he went in to see the resident on [DATE] with the physician the date on the dressing on the right stump was dated [DATE] and was saturated and unclean. The physician removed the dressing from the incision and there was a lot of drainage. The resident's left foot was discolored and cold. The physician had been very upset and sent the resident back to the hospital. That day LPN #2 had not been notified in report about the resident's foot being discolored and cold but had been notified the resident was lethargic. The LPN stated he did not understand how the condition of the left foot was missed. During an interview with RN #3 nursing supervisor on [DATE] at 11:10 AM she stated she was notified the resident's IV antibiotic was not available on [DATE]. The facility used a different pharmacy to obtain their IV medications. When she was notified she immediately called that pharmacy and they told her they had not been notified and they would call her back. It became late in the shift and she notified the oncoming supervisor to follow up and call the physician if the pharmacy did not deliver the IV antibiotic. When she arrived the next morning, it had not been delivered and she immediately called the physician who was upset and ordered a dose of IM antibiotic. She administered the medication and called the pharmacy. They said they would send the medication the next day. The resident had a history of [REDACTED]. She did recall talking with the resident about what was happening with the IV antibiotic that weekend. The right stump had a dressing on it and she did not remove the dressing to assess the incision site. During an interview with the Director of Admissions on [DATE] at 1:20 PM, she stated she would go to the hospital and screen residents for admission. She was not a nurse, so she would send information back to the facility for a nurse, usually the DON, to review and determine if they were able to meet the resident's needs if they were admitted . If a resident was on an IV antibiotic the pharmacy would be called and the IV antibiotic should be delivered before or shortly after the resident arrived at the facility. They had not been notified by the hospital Resident #1 was going to be on IV medication. During an interview with the DON on [DATE] at 2:00 PM she stated she would review potential admissions from the hospital to determine if the facility could meet their needs. She did not think she had reviewed the records for Resident #1 before he was readmitted . She stated a nurse was responsible for completing the admission orders [REDACTED]. The nurse would write out the orders and call the physician to verify the orders. The overnight shift was supposed to do a second check of the orders to make sure they were transcribed correctly and contained everything from the discharge instructions. The nurse would compare the hospital instructions to the physician orders and to the Medication Administration Record [REDACTED]. She was not sure if there was any documentation or signature that would indicate the second check had been done and there was no policy. She reviewed the admission physician orders and the hospital discharge summary. She stated there was no order for a dressing change as instructed by the hospital and it was possible the same dressing had been on from his admission on [DATE] until his discharge on [DATE]. A dressing change should have been ordered and done for the resident. If an LPN noted a change in skin, she should call the RN or the physician. The facility had investigated after the resident did not receive his antibiotic and they had determined the Unit Manager, who no longer worked at the facility (RN #11), had not called the pharmacy when the resident was admitted alerting them of the need for the IV antibiotic. Nursing had not notified the physician timely when the IV antibiotic was unavailable. During an interview with LPN #9 on [DATE] at 3:07 PM, she stated if a resident had a change in skin status or change in condition she would document it and notify the nursing supervisor. She did not do any dressing changes or treatments to the resident's right stump. She did recall that she had noticed the left foot and toes were discolored and cold to the touch. She had notified the nurse supervisor (RN #10) who said they had been like that. During an interview with RN supervisor #10 on [DATE] at 12:10 PM she stated she had done the resident's admission skin assessment on [DATE] and removed a dressing to the resident right stump and assessed the surgical incision. The incision did not have any drainage or signs of infection. She had reapplied another dry dressing. She was not aware of any specific treatment or dressing orders for the resident, so she applied a dry dressing to protect the incision. She did not recall the resident having any discoloration or temperature concerns to his left leg/foot on admission as she would have documented that on the assessment. Looking at the feet and assessing heels was part of the skin assessment, especially with a resident who had a history of [REDACTED]. If she knew she would have notified the physician. She stated she had been notified when the resident's IV antibiotic was not available, and the previous supervisor had notified the pharmacy. When the pharmacy made a delivery later in the evening they did not bring the antibiotic. She did not call the physician but reported the information to the supervisor the next morning. She was later informed that IV antibiotics were received from a different pharmacy. An attempt was made to contact RN #11, who no longer worked in the facility, on [DATE] at 1:00 PM and she was not available for interview. 2) Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. The [DATE] Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired and she required total dependence for all activities of daily living (ADLs). The comprehensive care plan (CCP) dated [DATE] documented the resident had a [MEDICAL CONDITION] disorder. Interventions included to not leave the resident alone during a [MEDICAL CONDITION], lower to the floor if not in bed and protect from onlookers. A progress note dated [DATE] at 11:11 AM completed by registered nurse (RN) #3 documented at 8:55 AM the resident had a sudden onset of tonic-clonic [MEDICAL CONDITION] (the body becomes rigid, followed by uncontrolled body jerking with loss of consciousness) and her eyes deviated to the left with a left-sided facial droop. The episode lasted approximately 5 minutes. A call was placed to the physician. At 9:45 AM the resident began to seize again. There had been no return call from the physician. An attempt was made to contact the Director of Nursing (DON) with no response. A call was placed to the physician's answering service with a request to call the physician personally as this was an emergency. The resident had been on 5 liters of oxygen and her oximetry (amount of oxygen in bloodstream) was in the low 80's (normal above 95) and staff were unable to obtain a blood pressure due to the excessive shaking. At approximately 10:45 AM the administrator was called and while the nurse was on the phone with the Administrator, the physician called back. By that time the resident had been seizing constantly for over one hour. This was considered [DIAGNOSES REDACTED], and since we do not have the proper treatment here, the decision was made to send her to the hospital. 911 was called and the resident left the facility in an ambulance at 11:10 AM. During an interview with the resident's attending physician #1 on [DATE] at 11:30 AM, he stated he was called on Sunday morning [DATE] and notified the resident had a [MEDICAL CONDITION]. He asked how many, as that would dictate the course of action, and he was told the resident was continuously seizing. He directed the nurse to send the resident to the hospital. If the nursing staff could not get a hold of him or if there was an emergency, they should call his mobile phone directly. The nursing staff could also send the resident to the hospital without his order. They should not leave a resident to seize for an hour while they waited for a response from him. Allowing a resident to consistently seize for one hour could cause a resident to have trouble breathing, which could lead to [MEDICAL CONDITION] (lack of oxygen to the brain) and possible brain damage/death. He stated he took over the resident's care in the hospital and the resident had come into the emergency room actively seizing and was currently in the Intensive Care Unit (ICU). During an interview with licensed practical nurse (LPN) #2 on [DATE] at 10:40 AM, he stated he was working on [DATE] when Resident #3 had a [MEDICAL CONDITION]. At 8:45 AM he notified the supervisor (RN #3) the resident was having a [MEDICAL CONDITION]. The resident was in her Geri chair and she was making noises, her arms and feet were twitching and her eyes were rolling back in her head and going from side to side. RN #3 responded and told LPN #2 to keep an eye on the resident and time how long the [MEDICAL CONDITION] lasted and she would call the physician. The resident remained in her Geri chair and the [MEDICAL CONDITION] lasted about 5 minutes. A little while later, the resident started to seize again, LPN #2 called the supervisor (RN #3), she responded and again instructed him to time the [MEDICAL CONDITION] and keep an eye on the resident as she was still waiting for the physician to call her back. He kept the resident in her Geri chair near his medication cart to keep an eye on her while he finished up his medication pass. The resident seized for about an hour before she was sent to the hospital as it took the physician a long time to call back. LPN #2 stated he had been very nervous as he did not know what was going to happen to the resident and he had never seen someone have a [MEDICAL CONDITION] for that long. During an interview with RN #3 on [DATE] at 11:10 AM she stated she was the nursing supervisor when Resident #3 was seizing on [DATE]. She was initially notified by the LPN the resident was having a [MEDICAL CONDITION]. She assessed the resident and the [MEDICAL CONDITION] only lasted a couple of minutes. She called the physician and while she was waiting for him to return her call she attended to another situation in the facility. She left the resident in the Geri chair so the LPN could keep an eye on her. Around 9:45 AM she was called again by the LPN and he told her the resident was having another [MEDICAL CONDITION]. When she responded to the unit the resident was having the same [MEDICAL CONDITION] activity as before. She called the physician's answering service again and told them to call him immediately as it was an emergency. She tried to call the DON and did not receive a return call. She called the Administrator to tell her she did not know what to do and while on the phone with the Administrator the physician called. By that time the resident had been seizing for over one hour. She reported the information to the physician and he told her to send the resident to the hospital. She called 911 and sometime after 11:00 AM the resident was transported to the hospital. She could have made her own nursing judgment except the resident had just returned from the hospital and they say don't send them back. If there was an emergency she would send the resident out before physician called back. The resident had a history of [REDACTED]. She did have access to the physician's personal cell phone number but did not call that number as he would get angry at her. During an interview with the Director of Nursing (DON) on [DATE] at 3:25 PM she stated she had not been aware prior to today regarding the resident having a [MEDICAL CONDITION] for greater than one hour. The nurse should have sent the resident out when she did not stop seizing and should not wait for the physician to call her back. 10 NYCRR 415.12

Based on observations, record review and interview conducted during the recertification survey, the facility did not ensure 1 of 8 resident (Residents #26) reviewed for pressure ulcers, received care and services to promote healing and to prevent new pressure ulcers from developing. Specifically, Resident #26 was admitted with a pressure ulcer, the area was not assessed by qualified professional from 01/17/18 - 02/15/18 during which time the pressure ulcer worsened. This resulted in actual harm to Resident #26 that is not immediate jeopardy. Findings include: The 12/2017 facility policy and procedure for pressure ulcer prevention documented the facility was to have a system/procedure to assure assessments were assessed timely and appropriately, changes of condition were recognized and evaluated, reported to the physician or medical provider, the family was aware and the pressure ulcer was addressed. Documentation in the resident's medical record included all assessment data, the type of wound care provided and any changes in the residents condition. Resident #26 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 01/30/18 Minimum Data Set (MDS) assessment documented the resident's cognition was moderately impaired, she required extensive assistance with bed mobility and transfers, and she had an unstageable pressure ulcer. The 01/20/18 comprehensive care plan (CCP) documented the resident was at risk of impaired skin integrity related to immobility and incontinence, and she had a pressure ulcer. Interventions included turning and positioning every 2-3 hours in bed and every 1-2 hours out of bed, heels elevated while in bed, and skin checked every shift during care. The 01/17/18 at 02:30 PM registered nurse (RN) #6 admission progress note documented the resident had a coccyx (tail bone) pressure ulcer that measured 3.5 cm x 2.5 cm x 0.3 cm. The ulcer had 50 % slough (dead tissue). The 01/17/18 physician order [REDACTED]. The 01/23/18 physician note documented the resident was seen for an acute visit and noted she was anemic on recent blood work. The plan was to continue supportive care and repeat blood work in 2 weeks. The note did not document an assessment of the resident's pressure ulcer. There was no documented evidence in the resident's record the coccyx ulcer was assessed by a qualified professional from 01/17/18-2/14/18. An Incident/Accident report dated 02/15/18 documented that licensed practical nurse (LPN) #7 had asked nurse practitioner (NP) #9 to see the resident's wound because it had deteriorated. The report documented the resident was readmitted [DATE], skin sheets were not completed and the ulcer not followed on skin rounds, and RN Unit Manager #8 did not follow up. The report documented that RN #6 and RN Unit Manager #8 were no longer employed by the facility. NP #9's progress notes documented: - On 02/15/18, the resident was seen for a worsening pressure ulcer that measured 4 cm x 2 cm. The depth was not determined however depth was present. There was 90% slough and 10% granulation tissue, and [DIAGNOSES REDACTED] surrounded approximately 2 cm of wound. The plan was to ensure packing of wound with Santyl soaked gauze. - On 02/19/18, the resident's pressure ulcer measured 4.0 cm x 2.0 cm x 2.0 cm, however unable to get a definite depth due to 80% slough. The surrounding tissue was dark pink in color. The plan was to continue Santyl and obtain an x-ray of the coccyx. The 02/19/18 physician order [REDACTED]. The 02/19/18 (not timed) nursing note documented the resident's x-ray showed subtle cortical erosion (tissue and bone erosion) of the coccyx which could reflect osteo[DIAGNOSES REDACTED] and consider an MRI (magnetic resonance imaging). The NP was made aware and orders obtained. The Dermal Tracking sheet dated 02/22/18 documented the resident's pressure ulcer measured 4.3 cm x 4.0 cm x 2 cm. NP #9's progress note dated 02/22/18, documented the resident's x-ray results showed that osteo[DIAGNOSES REDACTED] of the coccyx was not able to be ruled out and an MRI was ordered. The MRI was not obtained at the time of survey exit. On 02/23/18 at 01:39 PM and again at 03:41 PM, the Director of Nursing (DON) stated in an interview that LPN #7 reported the resident's ulcer looked worse on 02/15/18, that was when they realized her ulcer was not being tracked and started an investigation. They found that RN #6 had documented the resident's coccyx pressure ulcer in the record on 02/15/18; however, she did not place a Dermal Tracking sheet in the skin book so that weekly monitoring could begin. She stated RN Unit Manager #8 would have been responsible to follow up and review the resident's admission assessment to ensure skin tracking was implemented and she did not do that. She stated both RN's no longer worked at the facility. On 02/26/18 at 11:25 AM, the resident's pressure ulcer dressing change was observed with LPN #7. The resident's dressing was removed and the ulcer had 80% slough, was without odor and bone was visualized in the wound bed. The LPN cleansed the wound, place two 2 x 2 Santyl infused gauze pads into the ulcer and covered it with a dressing. During the dressing change LPN #7 stated in an interview the resident's ulcer measured approximately 5.0 cm with 40% slough. When she observed the ulcer getting worse she reported it to the RN, she could not recall when, and she did not notify the physician as she expected the RN to do that. She stated the area continued to worsen and that was when she notified NP #9. On 02/26/18 at 01:30 PM, physician #19 stated in an interview he did not know the resident had a pressure ulcer and when he did find out, he was concerned and ordered an MRI. He was not made aware when the pressure ulcer worsened and expected to be. He stated nursing should have tracked the ulcer and not doing so could have contributed to the wound worsening. On 02/26/18 at 03:15 PM, NP #9 stated in an interview she first became aware of the resident's pressure ulcer on 02/15/18 when she was asked to look at the ulcer because it had worsened. When she saw the ulcer it was unstageable, it had a moderate amount of drainage and treatment with Santyl was appropriate. She stated staff not tracking the ulcer contributed to it getting worse and if tracked appropriately, it could have been prevented. 10 NYCRR 415.12(c)(1,2)