Every finding on record at Fort Hudson Nursing Center Inc

51742 Based on observation, record review, and interviews during the recertification, the facility did not ensure provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, the facility's minimum staffing levels of Certified Nursing Aides and Licensed Practical Nurses were not met every day on multiple shifts and multiple units, from 12/01/2024 - 12/05/2024. In addition, record review indicated resident grievances related to staffing shortages, there were observations of delayed call light responses times, and resident complaints of low staffing. This is evidenced by: Based on the facility assessment, dated 8/28/2024, the following was the current staffing plan, presented as the number of Full Time Employees by position by shift. 6 AM-2 PM (days) 2 PM-10 PM(evenings) 10 PM-6 AM (nights) Registered Nurse 11 2 1 Licensed Practical Nurse 10 10 5 Certified Nursing Assistant 23 20 10 Review of the facility daily staffing guidelines dated 12/01/2024, the following were missing from the evening shift: A-wing was missing 1.375 Certified Nurse Aides, 1 Licensed Practical Nurse B-wing was missing 1 Certified Nurse Aide, 1 Licensed Practical Nurses D-wing was missing 1.5 Certified Nurse Aides, 1.5 Licensed Practical Nurse G-wing was missing 0.5 Certified Nurse Aide, 1 Licensed Practical Nurses S-wing (secure) was missing 2.125 Certified Nurse Aides, 1 Licensed Practical Nurse Review of the facility daily staffing guidelines dated 12/01/2024, the following were missing from the night shift: B-wing was missing 1 Certified Nurse Aide D-wing was missing 1 Certified Nurse Aide, 0.5 Licensed Practical Nurse Review of the facility daily staffing guidelines dated 12/02/2024, the following were missing from the day shift: A-wing was missing 1 Certified Nurse Aide B-wing was missing 1 Licensed Practical Nurses D-wing was missing 2 Certified Nurse Aides G-wing was missing 1 Certified Nurse Aides, 1 Licensed Practical Nurses S-wing (secure wing) was missing 2.5 Certified Nurse Aides Review of the facility daily staffing guidelines dated 12/02/2024, the following were missing from staff from the evening shifts: A-wing was missing 2 Licensed Practical Nurses B-wing was missing 1 Certified Nurse Aide, 2 Licensed Practical Nurses D-wing was missing 2.25 Certified Nurse Aides, 2 Licensed Practical Nurses G-wing was missing 1.5 Certified Nurse Aides, 1 Licensed Practical Nurse S-wing was missing 3 Certified Nurse Aides, 1 Licensed Practical Nurse Review of the facility daily staffing guidelines, dated 12/02/2024, documented the following were missing from the night shifts: B-wing was missing 0.5 Certified Nurse Aides D-wing was missing 0.1876 Certified Nurse Aides, 1 Licensed Practical Nurse G-wing was missing 0.5 Certified Nurse Aide S-wing was missing 1.5 Certified Nurse Aides From 10:00 PM - 11:00 PM there was not a Registered Nurse working at the facility. Review of the facility daily staffing guidelines, dated 12/03/2024, documented the following were missing from the day shifts: A-wing was missing 2 Certified Nurse Aides B-wing was missing 1.5 Certified Nurse Aides, 1 Licensed Practical Nurse D-wing was missing 2.5 Certified Nurse Aides G-wing was missing 2 Certified Nurse Aides S-wing was missing 1.5 certified Nurse Aides Review of the facility daily staffing guidelines, dated 12/03/2024, documented the following were missing from the evening shifts: A-wing was missing 0.5 certified nurse aides, 1.5 Licensed Practical Nurses B-wing was missing 1 Certified Nurse Aide, 1 Licensed Practical Nurse D-wing was missing 2 Certified Nurse Aides, 1.5 Licensed Practical Nurses G-wing was missing 2 Certified Nurse Aides, 1 Licensed Practical Nurse S-wing was missing 1.5 certified nurse aides, 0.5 licensed Practical Nurse Review of the facility daily staffing guidelines, dated 12/03/2024, documented the following were missing from the night shifts: A-wing was missing 1 Certified Nurse Aide B-wing was missing 0.5 Certified Nurse Aide D-wing was missing 0.5 Certified Nurse Aides Review of the facility daily staffing guidelines, dated 12/04/2024, documented the following were missing from the day shifts: A-wing was missing 2.5 Certified Nurse Aides B-wing was missing 1 Certified Nurse Aide D-wing was missing 1.5 Certified Nurse Aides G-wing was missing 1 Certified Nurse Aide, 1 Licensed Practical Nurse S-wing was missing 3 certified nurse aides, 0.5 Licensed Practical Nurse Review of the facility daily staffing guidelines, dated 12/04/2024, documented the following were missing from the evening shifts: A-wing was missing 0.5 Certified Nurse Aide, 1.5 Licensed Practical Nurses B-wing was missing 1.5 Certified Nurse Aide, 2 Licensed Practical Nurses D-wing was missing 2 Certified Nurse Aides G-wing was missing 0.5 Certified Nurse Aide, 1 Licensed Practical Nurse S-wing was missing 1.5 certified nurse aides, 2 Licensed Practical Nurses Review of the facility daily staffing guidelines, dated 12/04/2024, documented the following were missing from the night shifts: A-wing was missing 1 Certified Nurse Aide B-wing was missing 1 Certified Nurse Aide D-wing was missing 0.5 Certified Nurse Aide G-wing was missing 0.5 Certified Nurse Aide S-wing was missing 1 Certified Nurse Aide Review of the facility daily staffing guidelines, dated 12/05/2024, documented the following were missing from the day shifts: A-wing was missing 2.5 Certified Nurse Aides, 1.5 Licensed Practical Nurses, 1 Registered Nurse B-wing was missing 1.5 Certified Nurse Aides D-wing was missing 0.5 Certified Nurse Aides G-wing was missing 2.5 Certified Nurse Aides, 1.5 Licensed Practical Nurses S-wing was missing 2.5 certified nurse aides, 1 Registered Nurse Review of the facility daily staffing guidelines, dated 12/05/2024, documented the following were missing from the evening shifts: A-wing was missing 1.5 certified nurse aides, 2 Licensed Practical Nurses B-wing was missing 2 Licensed Practical Nurses D-wing was missing 2.5 Certified Nurse Aides, 1 Licensed Practical Nurse G-wing was missing 2.5 Certified Nurse Aides, 2 Licensed Practical Nurses S-wing was missing 1.5 certified nurse aides, 1 Licensed Practical Nurse Review of the facility daily staffing guidelines, dated 12/05/2024, documented the following were missing from the night shifts: A-wing was missing 0.5 Licensed Practical Nurses G-wing was missing 1 Certified Nurse Aides Review of the facility grievance sheets documented 10 grievances related to staffing levels between 02/2024 - 09/2024. A grievance dated 2/05/2024 regarded poor care from a Certified Nurse Aide with the facility response of, there was only 1 Certified Nurse Aide on the unit between 2 PM - 4 PM. .A grievance dated 2/14/2024 regarded toileting with the facility response of, staffing was minimal. A grievance dated 2/12/2024 - 02/13/2024 regarded long wait for assistance with the facility response of, .is waiting a long time for BR [bathroom], as is every other resident. A grievance dated 2/13/2024 regarded a 2.5- hour call light wait by a resident that led to incontinence with the facility response of, 2 Certified Nursing Assistants and 1 Licensed Practical Nurse, looking at adding 2 agency Certified Nursing Assistants. A grievance dated 6/25/2024 regarded a resident asking to use the restroom and staff saying no with the facility response of, because that means not helping others that are needing help at that time. A grievance dated 8/11/2024 regarded a resident who waited over 30 minutes and had an accident with the facility response of, this was right after supper. A grievance dated 8/26/2024 regarded a resident being left by the nursing station without staff interaction with the facility response of social worker decided to have resident out in the lobby watching TV with other residents to promote social interaction. A grievance dated 9/19/2024 regarded a resident not being toileted and the facility response of the family member attempted to assist the resident with toileting at 1:00 PM and 2:00 PM. A grievance dated 9/25/2024 regarded a resident that wished to go back to bed after care at 5:00 - 6:00 AM and a Certified Nurse Aide told the resident they had to stay up because there were 22 other residents who needed assistance. A grievance dated 10/06/2024 regarded a resident engaging a call light without a timely response to the point that the resident used the waste bin to urinate with a facility response of, only 1 Certified Nursing Assistant and 1 Licensed Practical Nurse from 2200 [10:00 PM] - 0600 [6:00 AM]. During an observation in the G wing on 12/02/2024 at 12:01 PM, a call light was active in room [ROOM NUMBER] and was answered at 12:23 PM for a response time of 22 minutes. During an observation on the G wing on 12/02/2024 at 1:01 PM a call light was on in room [ROOM NUMBER] and was answered at 1:23 PM for a response time of 22 minutes. During an observation on the G wing on 12/03/2024 at 11:38 AM, a call light was on in room [ROOM NUMBER] and was answered at 11:52 AM for a response time of 14 minutes. During an observation on the G wing on 12/04/2024 at 7:30 AM, a call light was on in room [ROOM NUMBER] and was answered at 8:23 AM for a response time of 53 minutes. During an observation in the D wing on 12/05/2024 at 6:05 AM, a foul odor was noted by room [ROOM NUMBER] and a separate foul odor beyond room [ROOM NUMBER]. During an observation on the D wing on 12/05/2024 at 6:32 AM, a strong urine smell was still noted when first entered the unit by room [ROOM NUMBER], and a separate urine smell by room [ROOM NUMBER] was still present. During an observation on the D wing on 12/05/2024 at 6:55 AM the foul odor by room [ROOM NUMBER] and separate odor on other side of 24 were still present. During an observation on 12/05/2024 at 6:13 AM, the call light G wing room [ROOM NUMBER] was engaged and it was still on at 6:53 AM for a 40- minute call light time. During an observation on 12/05/2024 at 6:16 AM, there was an odor of urine outside of room G-18. During an observation on 12/05/2024 at 6:27 AM on the S Wing, there were 3 residents in recliners in the television room with no staff around, and at 6:48 AM 2 of the same residents were in the same place in the television room. At 6:46 AM, 2 residents were in recliners in the living room area with the lights off and no staff present. During an observation on 12/05/2024 at 7:00 AM on A Wing, the call light was engaged in room [ROOM NUMBER] and remained on until 7:46 AM for a 46- minute call light response time. During an observation on 12/05/2024 at 7:00 AM on A Wing, 6 residents in geri chairs were lined up in the hall by lower numbered rooms with 1 resident calling for help from the chair, and 3 residents in geri chairs were across the nurses' station area in the hall; 1 resident had an electronic device, and the rest had no music, television, or staff interaction in the hall. At 7:30 AM the same residents were in the same positions in the hallway around the nurses' station. During an interview on 12/02/2024 at 12:01 PM, Resident #35 stated the facility needed more help and the roommate had waited over 30 minutes for help after engaging the call light. During an interview on 12/02/2024 at 12:08 PM, Resident #334 stated they screamed until their throat hurt after their call light wait was on too long and the resident wet themselves and then staff tell the resident to stop shouting. On 12/03/2024 at 11:30 AM during a resident council meeting, several residents stated that multiple times residents had waited for a long period of time for staff to answer the call lights. In addition, it was stated that sometimes staff were too busy to help residents eat. Everyone stated that there was not enough staff to help and take care of daily needs. During an interview on 12/03/2024 at 12:35 PM, Resident #21 stated the facility was short on staff and sometimes the resident had to wait for a long time to get help, easily over an hour on average. The wait time was the most around mealtimes because staff were with other residents. During an interview on 12/05/2024 at 6:13 AM, Licensed Practical Nurse #5 stated there was only one Certified Nurse Aide for the second half of the night shift. During an interview on 12/06/2024 at 11:48 AM, Registered Nurse #3 stated that it was difficult when all shifts were not filled; they stated that staff from other units would sometimes cover but those filler staff did not know the residents as well, so it took longer to provide care when it was not the staff assigned to the unit. During an interview on 12/06/2024 at 12:00 PM, Licensed Practical Nurse #6 stated that they had experienced understaffing on several units, and it tended to slow down care of the residents when the staff were stretched too thin. During an interview on 12/06/2024 at 1:12 PM, Assistant Director of Nursing #1 stated that call lights were answered as quick as possible, and it was unrealistic to expect a light to be answered in a specific time frame. They stated that 36 of 40 residents on Unit A required a mechanical lift to get out of bed and that was why residents were lined up along the nurse's station, there was nowhere else to put the residents first thing in the morning. They also stated it was acceptable for a call light to be engaged for over 50 minutes on this unit in the morning and at different times on different units call light times of over 30 minutes was expected. 10 New York Code Rules and Regulations 415.13(a)(1)(i-iii)

Based on observations, record review, and interviews during the recertification survey, the facility did not ensure that each resident received accommodated resident choices, intolerances, and preferences. This was identified for one (Resident #82) of 35 residents reviewed. Specifically, Resident #82 had a dietician recommendation, signed by the physician, to discontinue a collagen supplement. For 35 days after the recommendation, the collagen was still ordered. This is evidenced by: The Policy titled Pressure Injury (PI)/ and Wound Care dated 11/15/2024 documented the facility was to ensure that the residents would receive wound care consistent with resident needs, goals, and recognized standards of practice. The procedure was that the nurse manager or designated registered nurse, dietician, physical therapist, and other interdisciplinary team members as needed would evaluate resident's clinical condition and pressure ulcer risk factors. The interdisciplinary team would define and implement interventions as appropriate. The facility would maintain a system to assure that the procedure for monitoring and documentation were implemented consistently throughout the facility. Resident #82 was admitted with diagnoses including hypertension and a fracture of the femur (broken leg). The Minimum Data Set (an assessment tool) dated 10/04/2024 documented Resident #82 could understand others and be understood by others, and was cognitively intact. The Comprehensive Care Plan titled, Eating initiated on 10/30/2024, documented Resident #82 received a collagen supplement, revised on 11/04/2024, documented the resident had the collagen supplement discontinued. A physician's order dated 10/01/2024 documented an order for collagen supplement 60 cubic centimeters daily. The medication administration record for November 2024 documented that Resident #82 had the 60 cubic centimeter collagen supplement administered each day all month. The medication administration record for December 2024 documented the 60 cubic centimeter collagen supplement continued to be administered up until the 5th of December 2024. The progress note dated 11/04/2024 documented Resident #82 would like to discontinue the collagen supplement, the provider was agreeable, and Registered Nurse unit manager #2 was notified and the care plan was updated. The progress note dated 12/04/2024 documented requested discontinue collagen supplement at last follow up. The order was still in place, Registered Nurse unit manager #2 was notified. On 12/05/2024 a 7:33 AM, Resident #82 was observed in their room on precautions and in no apparent distress. During an interview on 12/05/2024 at 8:08 AM, Registered Nurse unit manager #2 stated that new orders were processed by them and put in the electronic medical record, then placed in the paper medical record. They confirmed that the order was in the paper record and not processed in the electronic record for the administration record. Registered nurse unit manager #2 stated that they missed this one and would take care of it right away. During an interview on 12/05/2024 at 10:07 AM, Director of Nursing #1 stated they would expect the signed dietary recommendation signed by the provider to be followed and discontinued as ordered. 10 New York Codes, Rules, and Regulations 415.14(d)(4)

Based on observation, record review, and interviews during a recertification survey, the facility did not ensure residents could safely self-administer medication when clinically appropriate for 2 (Residents #35 and #168) of 2 residents reviewed for medication administration. Specifically, (a) Resident #35 was observed with their prescribed Albuterol inhaler on their overbed table on 12/02/2024 and 12/04/2024, and (b) Resident #168 was observed changing their empty oxygen tank to a full oxygen tank on 12/03/2024 and setting the flow rate. There was no documented evidence that Resident #'s 35 and 168 were assessed to determine their ability to safely self-administer medications, or for physician orders for self-administration of medications. This is evidenced by: The facility Medication Self-Administration Policy, dated 9/2017, documented that staff and practitioners would assess each resident's mental and physical abilities to determine whether self-administering medications was clinically appropriate for the resident upon request. Self-administered medications were to be stored in a safe and secure place that was not accessible by other residents. Resident #35 Resident #35 was admitted to the facility with diagnoses of Spina Bifida (a condition that occurs when the spine and spinal cord don't form properly), morbid obesity (a disorder that involves having too much body fat), and paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs). The Minimum Data Set (an assessment tool) dated 10/18/2024 documented that the resident was cognitively intact, could be understood, s and understand others. During an observation on 12/02/2024 at 2:21 PM, Resident #35 was observed to have Proventil inhaler (a medication used to prevent and treat wheezing, difficulty breathing, chest tightness, and coughing caused by lung diseases such as asthma and chronic obstructive pulmonary disease) on their overbed table. A review of Resident #35's medical record did not include documentation that the resident was assessed for their ability to self-administer their medications. A review of Resident #35's medical record did not include documentation from the resident's physician that the resident could self-administer their medications. A review of Resident #35's care plan did not include documentation the resident could self-administer their medications. A review of the physician orders for Resident #35 dated 10/25/2024 documented Proventil Inhalation to be taken every 4 hours as needed for shortness of breath or wheezing. May keep at bedside and self-administer. The medication orders further documented do not leave medications on Resident #35 table, please wait and observe resident taking it every shift for medication safety. During an interview on 12/05/2024 at 2:13 PM, Licensed Practical Nurse #1 stated that the resident could not self-administer medication. They stated that the resident was to be observed taking their medications and they had always left the inhaler at her bedside as the order stated it could be. When asked to review the medications orders they acknowledged that the Medication Administration Record stated that medications should not be left at the resident's bedside. They stated the order was for resident's administration of pill medications as they had a history of hoarding and hiding their medications. In asking Licensed Practical Nurse #1 if the resident's inhaler was a medication they stated that it was and probably should not be left at the bedside per the specific order. When asked if the resident had a specific order allowing them to self-administer medications they stated the resident did not have an order and should have orders for self-administration of the inhaler. During an interview on 12/05/2024 at 2:40 PM, Registered Nurse #1 stated Resident #35 did not have an order for self-administration of medications. They stated that they believed there was an assessment done for the resident to be able to self-administer their medications. When asked to review the medications orders they acknowledged that the Medication Administration Record stated that medications should not be left at the resident's bedside. They stated that the order was for resident's administration of pill medications as they had a history of hoarding and hiding their medications. During an interview on 12/06/2024 at 10:02 AM, Assistant Director of Nursing #1 stated for a resident to self-administer medications, there should be a care plan in place and an assessment completed to demonstrate feedback had occurred and the resident could safely administer medications on their own. They stated that they were not sure of the policy off the top of her head and would have to review it to determine what it stated. They stated that the resident did not have a self-administration assessment done. Resident #168 Resident #168 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (a common lung disease that makes it difficult to breathe), end-stage renal disease (a terminal illness that occurs when the kidneys can no longer function properly), and chronic systolic heart failure (a condition that occurs over time and prevents the heart from pumping enough blood). The Minimum Data Set, dated dated dated [DATE] documented that the resident was cognitively intact, could be understood, and understand others. During an observation on 12/03/2024 at 10:23 AM, Resident #168 was observed to have an empty oxygen tank in the basket of their motorized scooter. The resident had an additional oxygen tank in the basket and proceeded to change their oxygen tubing from the empty tank to the full one and set the flow rate on their own. A review of Resident #168's medical record did not include documentation that the resident was assessed for their ability to self-administer their medications. A review of Resident #168's medical record did not include documentation from the resident's physician that the resident could self-administer their medications. A review of Resident #168's care plan did not include documentation the resident could self-administer their medications. During an interview on 12/05/2024 at 12:22 PM, Certified Nurse Aide #1 stated that the residents were not allowed to self-regulate or change their oxygen tanks. They stated that it was the job of the nurses to change the tanks of residents if they were empty and adjust the oxygen flow rate. They stated that to check the amount of oxygen in the system they have to lift the bottle up and the gauge would read the correct amount of oxygen that was in the tank. Certified Nurse Aide #1 stated that if the tank was empty then they would notify the nursing staff that it would need to be changed. They stated that they were unable to get the tanks as they were locked up in the medication room. During an interview on 12/05/2024 at 2:13 PM, Licensed Practical Nurse #1 stated that residents were not allowed to change their own tanks when they were empty or adjust their flow rates. They stated that the responsibility of changing tanks and adjusting the flow rates lay solely on the nurses of the unit. They stated that oxygen is a medication, and residents should be assessed to self-administer and self-regulate just like any other medication. They stated that they were unsure if the resident had an assessment done as they were not a resident on their assignment. During an interview on 12/05/2024 at 2:40 PM, Registered Nurse #1 stated that residents were not to change their own tank and that the nursing staff should be doing it as oxygen is considered a medication. They stated that residents should not be setting their own flow rate unless there was an order for them to do so. Resident #161 did not have an order for self-administration of medications. They stated that they believed there was an assessment done for the resident to be able to self-administer their medications. During an interview on 12/06/2024 at 10:02 AM, Assistant Director of Nursing #1 stated that for a resident to self-administer medications, there should be a care plan in place and an assessment completed to demonstrate feedback has occurred and the resident can safely administer medications on their own. They stated that they were not sure of the policy off the top of her head and would have to review it to determine what it stated. They stated that the resident did not have a self-administration assessment done. 10 New York Codes, Rules, and Regulations 415.3(e)(1)(vi)

Based on observations, record review, and interviews conducted during a recertification survey, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 1 (Residents #334) of 35 residents reviewed. Specifically, Resident #334 received oxygen that was not noted in the care plan. This is evidenced by: The Policy titled Care Planning dated 09/21/2017, documented the purpose of the policy was to have a written plan for staff to follow to provide care to a resident of the facility. Upon admission the 48-hour care plan would be developed and reviewed with the resident and/or the health care proxy within 48 hours. The care plan would be completed by the first care plan meeting within 14 days of admission. The care plan will be added to as new issues arise and when recognized plans have been resolved. Resident #334 was admitted to the facility with the diagnoses of hypertension, paroxysmal atrial fibrillation (irregular heartbeat), and supraventricular tachycardia (a faster than normal heart rate beginning above the heart's two lower chambers). The Minimum Data Set (an assessment tool) dated 11/28/2024 documented the resident could understand and be understood by others; resident was cognitively intact. Resident #334 used oxygen at 2 liters per minute continuously at the facility. The Comprehensive Care Plan dated 11/21/2024, did not have documented evidence of Resident #334's use of oxygen and nebulizer. The electronic health record documented an order on 11/25/2024 for oxygen at 2 liters per minute continuously, Ipratropium-Albuterol inhalation solution via nebulizer four times a day and every 6 hours as needed. The progress note dated 11/21/2024 documented Resident #334 arrived at the facility with oxygen in place at 2 liters per minute via nasal cannula. On 12/04/2024 at 8:39 AM, Resident #334 was observed with oxygen in place at 2 liters per minute. During an interview on 12/06/2024 at 9:24 AM, Licensed Practical Nurse #3 stated the registered nurse unit managers would update the care plans. They would receive some orders and process them into the electronic health record and call to pharmacy when needed but the registered nurse would update the care plan. During an interview on 12/06/2024 at 9:59 AM, Assistant Director of Nursing #1 confirmed there was no care plan for oxygen for Resident #334, stated they would expect the oxygen to be on the care plan. 10 New York Codes, Rules, and Regulations 415.11(c)(2) (i-iii)

Based on records review and interviews during the recertification survey, the facility did not ensure each resident's drug/medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for 2 (Residents #59 and #86) of 6 residents reviewed for unnecessary medications. Specifically, for Residents #59 and #86, as-needed psychotropic medication orders did not include stop dates. This is evidenced by: The policy and procedure titled Psychotropic Medication Use, dated 6/2024, stated as needed orders for psychotropic medications would be time limited. Resident #59 Resident #59 was admitted to the facility with diagnoses of dementia, anxiety disorder and depression. The Minimum Data Set, dated dated dated [DATE] documented the resident was usually able to be understood and could usually understand others; the resident was severely cognitively impaired. Resident #59 had an order for lorazepam (a sedative), 0.5 milligrams by mouth every 6 hours as needed for agitation, which was ordered 11/12/2024 and started 11/13/2024, and there was no end date for the order. Resident #59's Medication Administration Record dated 11/2024 and 12/2024 documented that the as needed lorazepam was administered on the following dates and times: 11/15/2024, 5:40 PM 11/16/2024, 11:45 AM 11/21/2024, 10:59 AM 11/23/2024, 10:38 AM 11/25/2024, 1:47 PM 11/30/2024, 10:16 AM 12/3/2024, 10:44 AM 51742 Resident #86 Resident #86 was admitted to the facility with diagnoses of dementia, anxiety disorder, and depression. The Minimum Data Set (an assessment tool) dated 10/04/2024 documented the resident was able to be understood, could understand others, and was severely cognitively impaired. Resident #86 had an order for Risperidone oral tablet (an antipsychotic) 0.5 milligram every 4 hours as needed for agitation/anxiety. The order start date was documented as 12/04/2024. There was no end date documented; the end date was documented as indefinite. A Medication Regimen Review was completed on 12/03/2024. The pharmacy consultant recommended an end date be applied to the Risperidone order. Nurse Practitioner #1 documented disagreement with the recommendation and no end date was added to the order. During an interview on 12/06/2024 at 12:49 PM, Nurse Practitioner #1 stated there was a fear that if the medication had an end date, it might not be renewed. They understood that it was a Centers for Medicare and Medicaid requirement that psychotropic medications given on an as needed basis had an end date in the order. 10 New York Codes, Rules, and Regulations 415.18 (c)(2)

Based on observation, record review, and interviews during the recertification survey, the facility did not maintain medical records in accordance with accepted professional standards and practices that were accurately documented and completed for 3 (Residents #21, 144. and #171) of 35 residents reviewed. Specifically, (a.) for Resident #21, the facility incontinence care provided was not documented; (b.) for Residents #144 and #171 the care provided by Certified Nurse Aides were not consistently documented, including the amount of meals consumed, consumption of supplements, and nourishment for bedtime snacks. This is evidenced by: A review of policy titled Documentation for Certified Nursing Assistants dated 11/22/2010 documented all documentation of care delivered to a resident by a Certified Nursing Assistant would be done using the Point Click Care (PCC) kiosks. The policy stated care should be entered as close as possible after the care had been rendered and staff was to enter information at the kiosk at various times during their tour of duty, not waiting until the end of a shift. The policy also documented all documentation was to be completed accurately prior to the completion of the Certified Nursing Aide's tour of duty. Resident #21 Resident #21 was admitted to the facility on [DATE] with a diagnoses of unspecified dementia, mild, without behavioral disturbance, paroxysmal atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and muscle wasting and atrophy. The Minimum Data Set (an assessment tool) dated 10/18/2024, documented the resident was able to make themself understood and had the ability to understand others. Resident #21 had a moderate cognitive impairment for activities of daily living. A review of Resident #21's Minimum Data Set, dated dated dated [DATE] indicated for Resident #21, a trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) had been attempted and was currently being used to manage the resident's urinary continence. Resident #21 was listed as being frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding) for urinary continence. A review of Resident #21's care plan initiated 08/17/23 with focus, Resident #21 has bladder incontinence related to impaired mobility listed an intervention as, Check me every 2-4 hours and as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN and after incontinence episodes. A review of task log for Resident #21 listed task as, Individualized toileting schedule: toilet before meals, then walk to D-wing dining room. Must wake up and take to toilet during the overnight shift even if already incontinent. This task log indicated Resident #21 was checked to see if they voided on the following dates at the following times: 11/08/2024: Documented care was performed at 1:04 AM; 10:18 AM, 1:41 PM, 8:54 PM, 8:54 PM (8:54 PM was listed twice). 11/09/2024: Documented care was performed at 2:15 AM, 4:56 AM, and 10:00 AM. 11/10/2024: Documented care was performed at 7:00 AM and 8:00 PM. 11/11/2024: Documented care was performed at 9:06 PM and 9:06 PM (9:06 PM was listed twice). 11/12/2024: Documented care was performed at 1:24 AM, 7:24 PM and 7:24 PM (7:24 PM was listed twice). 11/13/2024: Documented care was performed at 1:34 PM. 11/14/2024: Documented care was performed at 12:00 PM. 11/15/2024: Documented care was performed at 8:00 AM, 12:00 PM, 9:45 PM, 9:45 PM (9:45 PM was listed twice). 11/16/2024: Documented care was performed at 10:42 AM, 1:49 PM, 7:32 PM, 7:32 PM (7:32 PM was listed twice). 11/17/2024: Documented care was performed at 10:43 AM, 1:46 PM, 7:13 PM, 7:13 PM (7:13 PM was listed twice). 11/18/2024: Documented care was performed at 11:23 PM. 11/19/2024: Documented care was performed at 5:54 AM. 11/20/2024: Documented care was performed at 4:12 AM. 11/21/2024: Documented care was performed at 3:42 PM. 11/22/2024: Documented care was performed at 9:02 PM. 11/23/2024: Documented care was performed at 1:32 AM, 11:01 AM, 12:00 PM. 8:43 PM, and 8:44 PM. 11/24/2024: Did not document care was performed. 11/25/2024: Documented care was performed at 3:22 AM, 4:08 PM, 7:01 PM. 11/26/2024 through 11/29/2024: Resident #21 was unavailable for voiding review due to being hospitalized and out of the facility. 11/30/2024: Documented care was performed at 5:00 PM and 8:00 PM. 12/01/2024 Documented care was performed at 1:49 AM, 9:38 PM and 9:38 PM (9:38 PM was listed twice). 12/02/2024: Documented care was performed at 1:28 AM, 8:00 AM, 12:00 PM, 8:05 PM, and 8:05 PM (8:05 PM was listed twice). 12/03/2024: Documented no care was performed. 12/04/2024: Documented care was performed at 10:56 AM, 1:49 PM, 9:42 PM, and 9:42 PM (9:42 PM was listed twice). 12/05/2024: Documented care was provided 7:47 PM and 7:47 PM (7:47 PM was listed twice). During an interview on 12/05/24 at 1:32 PM, Certified Nurse Aide #1 stated they used a peri wash, wipe the resident from front to back, and clean Resident #21 every time they go to the bathroom. Certified Nurse Aide #1 stated they documented the toileting of Resident #21 on the kiosk. Certified Nurse Aide #1 stated they tried to document services provided when they occurred, but t was not always possible, and they may document the services provided at the end of their shift. During an interview on 12/05/24 at 11:57 AM, Licensed Practical Nurse #1 stated that after the Certified Nurse Aides provided care relating to toileting/continence for Resident #21, they should document they provided care. Licensed Practical Nurse #1 stated they would expect to see a check on the report every 4 hours for Resident #21. During an interview on 12/05/24 at 2:40 PM, Registered Nurse #1 stated they did not know if there was a place for Certified Nurse Aides to document they had provided care for a resident. When Registered Nurse #1 was shown the task log mentioned above, they stated they never saw it before and would have to look into it further. During an interview on 12/06/24 at 10:02 AM, Assistant Director of Nursing #1stated if a resident was care planned to be checked and changed for toileting, there should be a task for it to allow Certified Nurse Aides to document the care provided. The Certified Nurse Aides documented tasks on the kiosk when care was performed, but they may wait to document that care was performed because they may not have a chance to document when they performed the actual care. If a resident was to be checked/changed every 4 hours, it should be documented that it occurred every 4 hours. When the Assistant Director of Nursing was shown the above referenced task log, they stated, There is a documentation issue. Resident #144 Resident #144 was admitted with diagnoses of Alzheimer's disease, anxiety disorder, and severe protein-calorie malnutrition. The Minimum Data Set (an assessment tool) dated 10/11/2024 documented the resident was understood, was able to be understood, and severely cognitively impaired. Resident #144's comprehensive care plan documented the resident was at nutritional risk. The documented interventions included: offer a bedtime snack nightly and provide health shakes three times a day. The Point of Care Response History for Supplement consumed - health shake three times a day? (11/5/2024-12/5/2024) documented incomplete or missing documentation for the following dates: 11/7/2024: two health shakes documented at 8:30 AM and 12:00 PM 11/8/2024: no health shakes documented. 11/11/2024: one health shake documented at 8:48 PM 11/12/2024: no health shakes documented. 11/14/2024L two health shakes documented at 8:30 AM and 12:00 PM 11/15/2024: one health shake documented at 9:04 PM 11/18/2024: one health shake documented at 8:30 AM and 12:00 PM 11/19/2024: no health shakes documented. 11/20/2024: two health shakes documented at 11:05 AM and 7:30 PM 11/21/2024: one health shakes documented at 6:32 PM 11/22/2024: one health shake documented at 8:48 PM 11/23/2024: two health shakes documented, both at 1:53 PM 11/24/2024: two health shakes documented at 12:00 PM and 9:39 PM 11/25/2024: one health shakes documented at 8:37 PM 11/26/2024: two health shakes documented at 1:45 PM and 8:25 PM 11/27/2024: one health shake documented at 9:42 PM 11/28/2024: no health shake documented. 11/29/2024: one health shake documented at 9:33 PM 12/1/2024: one health shake documented at 8:29 PM 12/3/2024: one health shake documented at 9:29 PM 12/4/2024: one health shakes documented at 9:31 PM 12/5/2024: two health shakes documented at 1:31 PM and 1:32 PM The Point of Care Response History for what percentage of the meal was eaten? (11/5/2024-12/5/2024) documented incomplete or missing documentation for the following dates: 11/8/2024: no meals documented. 11/11/2024: one meal documented at 6:21 PM 11/12/2024: no meal documented. 11/14/2024: two meals documented at 8:30 AM and 12:00 PM 11/15/2024: one meal documented at 9:04 PM 11/18/2024: two meals documented at 8:30 AM and 12:00 PM 11/19/2024: no meals documented. 11/20/2024: two meals documented at 11:05 AM and 7:30 PM 11/21/2024: one meal documented at 6:32 PM 11/23/2024: one meal documented at 1:53 PM 11/24/2024: two meals documented at 12:00 PM and 9:19 PM 11/25/2024: no meals documented. 11/26/2024: one meal documented at 8:24 PM 11/27/2024: one meal documented at 9:42 PM 11/28/2024: no meals documented. 11/29/2024: one meal documented at 9:33 PM 12/1/2024: one meal documented at 8:29 PM 12/3/2024: one meal documented at 9:29 PM 12/4/2024: one meal documented at 9:24 PM Point of Care Response History for offer nourishing snack: task completed (11/5/2024-12/5/2024) documented missing documentation for the following dates: 11/14/2024 11/18/2024 11/19/2024 11/20/2024 11/23/2024 11/28/2024 12/02/2024 12/05/2024 During an interview on 12/5/2024 at 12:16 PM, Licensed Practical Nurse #4 stated the registered nurses checked for documentation completion. During an interview on 12/5/2024 at 12:23 PM, Registered Nurse #3 stated the licensed practical nurses were to check the electronic medical record dashboard for the completion of certified nurse aide tasks before the certified nurse aides leave at the end of the shift. Resident #171 Resident #171 was admitted with diagnoses that included dysphagia (trouble swallowing), difficulty walking, and muscle wasting and atrophy (muscle loss). The Minimum Data Set (an assessment tool) dated 9/26/2024 documented the resident was able to be understood and could understand others; the resident was severely cognitively impaired. It further documented that the resident was totally dependent on assistance to eat, toilet, and lower body dressing. On 06/26/2024, the resident weighed 151.4 pounds. On 12/02/2024, the resident weighed 130.8 pounds which is a -13.61 % Loss in 6 months. Resident #171's care plan documented that the resident had a potential for weight loss, initiated 9/13/2024, and the intervention was to monitor and record food intake at each meal if applicable (also initiated 9/13/2024). Resident #171's amount of food eaten from 11/4/2024 - 12/2/2024, printed 12/3/2024, was missing meal documentation as follows: 11/4/2024 - 1 meal documented at 5:00 PM 11/5/2024 - 1 meal documented at 5:00 PM 11/6/2024 - 1 meal documented at 6:18 PM 11/7/2024 - 1 meal documented at 7:36 PM 11/8/2024 - all 3 meals documented. 11/9/2024 - 1 meal documented at 5:00 PM 11/10/2024 - all 3 meals documented. 11/11/2024 - all 3 meals documented. 11/12/2024 - 2 meals documented at 10:39 AM and 1:45 PM 11/13/2024 - 1 meal documented at 5:00 PM 11/14/2024 - 1 meal documented at 7:03 PM 11/15/2024 - 2 meals documented at 8:30 AM and 12:00 PM 11/16/2024 - all 3 meals documented. 11/17/2024 - 1 meal documented at 8:33 PM 11/18/2024 - all 3 meals documented 11/19/2024 - 1 meal documented at 9:53 PM 11/20/2024 - 1 meal documented at 9:37 PM 11/21/2024 - 1 meal documented at 9:38 PM 11/22/2024 - 2 meals documented at 8:30 AM and 12:00 PM 11/23/2024 - 1 meal documented at 9:45 PM 11/24/2024 - 1 meal documented at 5:00 PM 11/25/2024 - 1 meal documented at 9:08 PM 11/26/2024 - all 3 meals documented. 11/27/2024 - 1 meal documented at 5:00 PM 11/28/2024 - 1 meal documented at 9:16 AM 11/29/2024 - 1 meal documented at 9:27 PM 11/30/2024 - 1 meal documented at 9:41 PM 12/1/2024 - all 3 meals documented. 12/2/2024 - all 3 meals documented. During an interview on 12/5/2024 at 12:25 PM, Certified Nurse Aide #2 stated all care was to be documented after it was given. This included meals, supplements, and snack consumptions. They stated if the task read for a supplement to be given three times a day, it should be documented that it was given three times a day. During an interview on 12/6/2024 at 10:00 AM, Assistant Director of Nursing #1 stated that documentation should be completed as ordered. They stated the amount of meals consumed should be documented with each meal. The licensed practical nurses were able to access the dashboard in the electronic medical record to check if documentation was completed with the expectation that it was completed. 10 New York Codes, Rules, and Regulations 483.70 (h)(2)(ii)

Based on observation, manufacturer directions review, and staff interview during the recertification survey, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the concentration of quaternary ammonium compound chemical sanitizing rinse (QAC) was less than that required by the manufacturer, shelving and sections of the floor were not in good repair, and equipment and floors required cleaning. This is evidenced as follows. The kitchen was inspected on 12/08/2021 at 9:39 AM. The concentration of QAC used to sanitize food contact equipment at the 3-compartment sink was found to be less than 150 parts per million (ppm) when measured at 70 degrees Fahrenheit (F), and the concentration of QAC used to sanitize food contact equipment at the preparation sink was found to be less than 150 ppm when measured at 71 F. The manufacturer's label directions stated the concentration is to be between 150 ppm and 400 ppm when the solution is measured between 65 F and 75 F. The tabletop mixer, can opener and holder, floor behind cooking line, cooking line utensil drawers, and several unit kitchenettes required cleaning. The shelving far right of the cooking stoves were chipped and had exposed raw wood. Several floor tiles in the cooking line area were broken and had missing grout. The Multi Services Director stated in an interview on 12/08/2021 at 11:59 AM, that the floor tiles will be repaired, the broken shelving will be replaced with metal counters, the vendor will be contacted about the sanitizing solution concentration, and the soiled equipment and areas will be addressed. The Administrator stated in an interview on 12/08/2021 at 1:18 PM, that the Dietary and Maintenance departments will be contacted to address the issues found in the kitchen. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.90, 14-1.110, 14-1.112, 14-170

Based on record review and interviews during the recertification survey, the facility did not ensure to immediately consult with the resident's physician when there was a need to alter treatment significantly for 1 (Resident #57) of 1 resident reviewed for dental services. Specifically, for Resident #57, the facility did not ensure the physician was notified when a physician ordered medication, [MEDICATION(S)] in [MEDICATION(S)] ([MEDICATION(S)]- a corticosteroid used to reduce swelling and ulcers in the mouth) was not available to be administered. This is evidenced by: Resident #57: Resident #57 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 10/1/2021, documented the resident was cognitively intact, could understand others and could make self understood. The Policy and Procedure (P&P) titled Medication Administration and Treatment Documentation last revised 3/29/2012, documented when a medication was not available to call the pharmacy to check on delivery and note in the resident progress notes who was spoken with and to alert the physician and obtain an order to give the medication when the medication arrives from the pharmacy, or hold, etc. A dental note dated 12/2/2021, documented the resident had what appeared to be an aphthous lesion (canker sore- painful sore in the mouth that can make it hard to eat and talk) distal (refers to sites located away from a specific area) to upper dentures on the right side of the soft palate. The note documented the dentist ordered [MEDICATION(S)] in [MEDICATION(S)] and would follow up in 2 weeks. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the December 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . MAR notes documented: -12/3/2021 at 11:04 AM, [MEDICATION(S)] order; Medication not available yet. -12/3/2021 at 2:00 PM, [MEDICATION(S)] order: not available. -12/4/2021 at 12:10 PM, [MEDICATION(S)] order; not available from Pharmacy. -12/4/2021 at 12:12 PM, [MEDICATION(S)] order; not available from pharmacy. Pharmacy called. -12/5/2021 at 2:11 PM, [MEDICATION(S)] order; not received from pharmacy. -12/5/2021 at 7:21 PM, Drug not available. -12/6/2021 at 2:09 PM, [MEDICATION(S)] order; not available. -12/6/2021 at 2:10 PM, [MEDICATION(S)] order; Not available, pharmacy called. A review of progress notes dated 12/2/2021 to 12/8/2021, did not include documentation the physician was notified that [MEDICATION(S)] in [MEDICATION(S)] 0.1% was not available to administer. During an interview on 12/10/2021 at 10:47 AM, Licensed Practical Nurse (LPN) #1 stated the resident had mouth pain and an oral medication had been ordered for the resident's mouth, but they had a hard time getting it from pharmacy. LPN #1 stated it finally arrived from pharmacy on Monday, 12/6/2021. LPN #1 stated an oral medication that was not available would not be something they would bother the on-call provider with and stated they called pharmacy to check to see where the medication was. LPN #1 stated they never applied the oral paste because it came after their shift on 12/6. During an interview on 12/10/2021 at 10:59 AM, Registered Nurse (RN) #1 stated the resident had mouth pain and it started around 12/2/2021. The Dentist saw the resident on 12/2/2021 and ordered [MEDICATION(S)] ordered for 5 days. RN #1 stated they were never made aware the medication did not come to the facility and was not aware of a pharmacy issue. If the medication was not available and the resident was having mouth pain, the nurses should have documented the oral paste was not applied, notified the RN, and contacted the pharmacy. The RN stated they would have called the dentist, but the nurses could call the on-call provider to ask for an alternative treatment. RN #1 stated if the medication was not here in the facility or not available, it could not be administered, and so it should be marked that way on the MAR. During an interview on 12/10/2021 at 2:15 PM, Pharmacist #1 stated the oral medication was delivered to the facility on [DATE] at 9:29 PM and on 12/6/2021 at 1:09 PM. There were no notes that documented there was an issue with this medication. The Pharmacist stated it was ordered to be applied for 5 days so the facility may have had to re-order it if they used it all within the 5 days. During an interview on 12/10/2021 at 2:59 PM, LPN #2 stated they were aware the resident saw the dentist and they did not receive the medication from the pharmacy on 12/2/2021. LPN #2 received the medication from Pharmacy on 12/6/2021. During an interview on 12/13/2021 at 10:10 AM, the Director of Nursing (DON) stated the process the nurses should follow was to search for the medication, if they could not find it, and then they would enter a note in the MAR. The nurses should call the pharmacy and document they called the pharmacy. The nurses should also alert the physician to get an order to hold the medication or to get an order to do something in place of that. The DON stated the nurses would notify the physician so they knew what to do because the physician may order something else, or they may hold the medication until it comes from pharmacy. The DON stated the responsibility fell to the nurses to report up if a medication was not available. 10 NYCRR 415.3 (e)(2)(ii)(b)

Based on observation, record review, and staff interviews during an abbreviated survey (Case #NY 106), the facility did not ensure all alleged violations of abuse were reported to the state agency immediately, but not later than 2 hours after the allegation was made if the events that cause the allegation involved abuse, for 1 (Resident #1) of 2 residents reviewed for abuse, neglect, and mistreatment. Specifically, the facility did not ensure an allegation of physical abuse reported to the facility by Resident #1 on 2/3/2021, was reported to the New York State Department of Health (NYSDOH) within 2 hours after the allegation was made. This is evidenced by: Resident #1: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 12/22/2020, documented the resident had severely impaired cognition, could sometimes understand and was understood by others. The facility's Policy and Procedure (P&P) for Reporting and Investigation of Resident Abuse/Neglect, or Mistreatment revised in 2/2017 documented the facility was to conduct a thorough investigation of all alleged violations including injuries of unknown source and comply with state regulations. An Accident Report Form signed by Registered Nurse Manager (RNM) #1 on 2/4/21, documented that on 2/3/21 at approximately 9:30 AM, Resident #1 was observed sitting in the doorway of his/her room in a wheelchair and had blood coming down his/her face. A staff member called for help and nursing staff on the unit responded. At that time, Resident #1 told the unit staff that a Certified Nursing Assistant (CNA) had squeezed his/her face. The Summary section of the form documented RNM #1 saw no evidence of abuse, neglect or mistreatment. The NYSDOH Complaint Intake dated 2/4/21 at 12:37 PM documented Identity-Protected Reporter (IPR) #1 reported an allegation of abuse by a facility staff member toward Resident #1 that occurred on 2/3/21. A Progress Note dated 2/8/21 at 10:47 AM, written by the Nurse Practitioner (NP) documented Resident #1 had bruising to the inner aspect of both eyes. An untimed Addendum to the NYSDOH Complaint Intake dated 2/5/21 documented Identity-Protected Reporter (IPR) #2 reported an allegation of abuse by a facility staff member toward Resident #1 that occurred on 2/3/21. During an interview on 2/8/21 at 12:20 PM, Licensed Practical Nurse (LPN) #1 stated staff were notified that Resident #1 had blood on his/her face. LPN #1 went to the room and saw blood on the resident's face, hands, and shirt. Resident #1 told the LPN that CNA #1 had grabbed the resident's face. LPN #1 wheeled the resident to the nurse's station and the Registered Nurse Educator assessed the resident. Resident #1 kept saying that CNA #1 had squeezed his/her face. During an interview on 2/8/21 at 11:20 AM, the Director of Nursing (DON) stated Resident #1 told staff that CNA #1 had squeezed his/her cheeks on the morning of 2/3/21. The facility completed an investigation and it was determined no abuse had occurred. The DON stated, I saw no reason to report the incident because we determined no abuse had taken place. There was an injury that we believed was self-inflicted. During an interview on 2/9/21 at 2:20 pm, the Administrator stated the facility should have reported the incident to NYSDOH the day the injury was discovered. After reviewing the reporting manual, it was the opinion of both the DON and the Administrator, this should have been reported immediately. The resident's allegation of abuse by a CNA, with an apparent injury had prompted the facility's investigation but the cause of the injury could be determined. 10 NYCRR 415.4

Based on observations, interviews, and record review during the COVID-19 Focused Infection Control Survey completed on 1/29/2021, the facility failed to 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 COVID-19 on 3 (D, G, and S) of 5 units. Specifically, the facility did not ensure that isolation gowns were discarded after each resident encounter. This is evidenced by: The U.S. Centers for Disease Control and Prevention (CDC) guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 12/14/20, provided that recommended PPE when entering the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection includes an N95 or equivalent or higher-level respirator, gown, gloves, and eye protection. Regarding gowns, the guidance states: Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. The CDC guidance titled, Strategies for Optimizing the Supply of Isolation Gowns updated 1/21/21 provided In general, CDC does not recommend the use of more than one isolation gown at a time by HCP when providing care to patients with suspected or confirmed [CONDITION(S)]-CoV-2 infection. The guidance also provided regarding the re-use of isolation gowns: The risks to HCP and patient safety must be carefully considered before implementing a gown reuse strategy. Disposable gowns generally should NOT be re-used, and reusable gowns should NOT be reused before laundering, because reuse poses risks for possible transmission among HCP and patients that likely outweigh any potential benefits. The New York State Department of Health (NYSDOH) Revised Health Advisory entitled COVID-19 Cases in Nursing Homes and Adult Care Facilities, dated 3/13/20 and updated 7/10/2020, documented that if there are confirmed cases of COVID-19 in a Nursing Home, all residents on affected units should be placed on droplet and contact precautions, regardless of the presence of symptoms and regardless of COVID-19 status. Healthcare Provider (HCP) and other direct care providers should wear gown, gloves, eye protection (goggles or a face shield), and N95 respirators (or equivalent) if the facility has a respiratory program with fit tested staff and N95s. Otherwise, HCP and other direct care providers should wear gown, gloves, eye protection, and facemasks. Facilities may implement extended use of eye protection and facemasks/N95s when moving from resident to resident (i.e. do not change between residents) unless other medical conditions which necessitate droplet precautions are present. However, gloves and gowns must be changed, and hand hygiene must be performed. The facility Policy and Procedure (P&P) titled, Isolation Precautions dated 6/09, revised most recently on 3/19, documented that under droplet precautions, a gown and gloves are worn and that PPE should be used once and discarded in either the trash or used linen receptacle before leaving the room. On 1/28/21, the Hospital Electronic Response Data System (HERDS) report listed the following information: Facility census - 185, COVID- 19 positive residents- 3, and 185 residents on isolation. During an interview on 1/29/21 at 10:00 AM, the Administrator (ADM) stated all residents in the facility were on droplet precautions. During an observation on Unit G on 1/29/21 at 11:00 AM, CNA #3 entered a resident room, donned (applied) a gown from a hook located inside the room next to the door, and assisted the resident using a tablet with a video call. During an observation on Unit D on1/29/21 at 10:45 AM, Licensed Practical Nurse (LPN) #1 placed a new surgical face mask over her N95, donned a washable isolation gown from a hook inside the resident's room, and donned gloves before approaching the resident to administer medication. She then doffed (removed) and disposed of the gloves and surgical mask and then hung up the washable gown on the hook next to the door, inside the resident's room before exiting. During an observation on the S Unit on 1/29/21 at 11:13 AM, 2 washable isolation gowns were observed hanging on unlabeled hooks inside of a resident's room near the door. Open doors of other rooms on the unit revealed washable isolation gowns hanging near the interior next to the doorway of each room. During an interview on 1/29/21 at 10:50 AM, CNA #3 stated that the residents are isolated in their rooms and staff has a gown in each room which is used for both residents in the room. During an interview on 1/29/21 at 10:50 AM, LPN #1 stated that at the beginning of each shift she places a washable gown in each room on a hook and uses the gown when she enters the room during her shift. When leaving the room, the gown is doffed and hung on the hook. During an interview on 1/29/21 at 11:15 AM, CNA #2 stated that there are 2 isolation gowns hung in each room at the beginning of each shift, one is for the CNA and the other is for the LPN. The CNA and LPN decide at the beginning of the shift which hook will be their hook for their respective gowns. The gowns are used when providing care to either resident in the room. At the end of the shift, each person is responsible for removing their gowns from the rooms for laundering. During an interview on 1/29/21 at 11:20 AM, LPN #4 stated that she dons an isolation gown when entering a resident's room. After providing care, the gown is hung on a hook in the room and the same gown is used by the same LPN when re-entering the room. During an interview on 1/29/21 at 12:20 PM, the Infection Preventionist (IP) stated that all units in the facility should have implemented the same contact and droplet transmission-based precautions requiring a gown change with each resident encounter due to the COVID-19 outbreak in the facility. She stated that the facility was reusing gowns in an effort to preserve PPE, however the facility had been informed by NYS DOH Epidemiology that ideally, gowns would be single use. During interviews on 1/29/21 at 10:00 AM and 2:48 PM, the Administrator (ADM) stated they reported three COVID-19 positive residents in the facility yesterday but those residents have since either tested negative or have passed the 14-day quarantine. Those residents were on the B Unit where staff were using disposable isolation gowns for each resident encounter; on Units, D, G, and S, staff were reusing gowns to care for residents. Due to the increased use of PPE during this outbreak, the facility decided as a team that PPE conservation measures were necessary. The ADM stated this was not optimal infection control and they were made aware by epidemiology that using gowns for more than one resident was not acceptable, but the facility needed to make the decision based upon realistic circumstances rather than the ideal. 10 NYCRR 415.19(a)(1);400.2

Based on observation and staff interview during the recertification survey, the facility did not maintain floors and floor coverings in a clean and sanitary manner in accordance with professional standards for food service safety. Floors are to be maintained in good repair and are to be smooth, durable, and not absorbent. Specifically, the floor of the dish machine room and walk in cooler #2 were not maintained in a sanitary manner. This is evidenced as follows. The main kitchen was inspected on 07/09/2019 at 9:39 AM. The floor tiles in the dish room of the main kitchen were not properly grouted, and the floor of the walk-in freezer #2 was covered in a layer of brown debris under the storage racks. The Director of Food Service stated in an interview on 07/09/2019 at 10:15 AM, that the facility just power washed the floors in the dish room and noticed that the floor needed to be re-grouted. Additionally, he stated that the floor in the walk-in cooler will be cleaned. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1, 14-1.110 (b), 14-1.110 (d), 14-1.150 (c) 14-1.170.

Based on interviews, and record reviews during a recertification survey, the facility did not ensure the assessment accurately reflected the resident's status for two (Resident #'s 36 and #125) of thirty-five residents reviewed for accurate resident assessments. Specifically; for Resident #125, the facility did not ensure the accuracy of the Minimum Data Set (MDS) when the reason for the resident's weight loss was documented as intentional rather than unintentional, and for Resident #36, whose medical record did not include a [DIAGNOSES REDACTED]. Resident #36: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident had moderately impaired cognition and was able to make herself understood and understand others. A review of the resident's medical record dated 6/27/14 through 1/29/18, did not include documentation of a [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident had a [DIAGNOSES REDACTED]. During an interview on 07/12/19 at 10:03 AM, the MDS Coordinator stated the MDS dated [DATE] was completed by the previous Nurse Manager who for that unit and she documented the [DIAGNOSES REDACTED]. Resident #125: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident was unable to complete a cognition assessment, had moderately impaired cognition, could usually understand others and could usually make self-understood. The MDS documented the resident had a significant weight loss and was on a physician prescribed weight-loss regimen. The Centers for Medicare & Medicaid Services' RAI 3.0 Instruction Manual documented a weight loss of 5% or more in 30 days or 10% or more in 180 days (6 months) as a result of a physician ordered diet plan or expected weight loss due to loss of fluid with physician orders [REDACTED]. Weight Change Notes documented: 5/10/19 - weight loss of 5.9 percent over the past month and a weight loss of 15.4 percent over the past 6 months. 5/27/19 - weight loss of 7.9 percent over 1 month and a weight loss of 12.8 percent over 6 months. 6/7/19 - weight loss of 5.4 percent over the previous month and a weight loss of 17.4 percent over the past 6 months. The recommendation was to double the amount of the resident's dietary supplement (Two-cal) for a total of 120 ml three times daily. The medical record did not include documentation that the resident's weight loss was expected due to a physician prescribed weight loss regime or due to a loss of fluid with physician orders [REDACTED]. During an interview on 7/12/19 at 11:04 AM, Dietitian #1 stated he completed the MDS dated [DATE]. He made a mistake when he documented the resident was on a physician-prescribed weight-loss regimen. The MDS would indicate the resident had a significant weight loss if he didn't document the resident was on a physician prescribed weight loss regime and that would look bad for the company's published ratings. Dietitian #1 stated he felt a significant portion of the resident's weight loss was initially due to post-operative fluid gain, but the resident was not on a physician's orders [REDACTED]. Dietitian #1 stated the resident was receiving nutritional supplements and was followed closely by the dietary department due to weight loss. During an interview on 7/12/19 at 12:02 PM, the Administrator stated she expected the staff to complete the MDS per the Centers for Medicare & Medicaid Services' RAI 3.0 Instruction Manual. 10NYCRR415.11(b)

Based on medical record review and staff interview during the recent recertification survey, the facility did not ensure that resident and/or their designated representative were fully informed of potential financial liability for rehabilitative services during a non-covered stay. Specifically, the facility did not ensure that residents who remained in the facility and received covered rehabilitative services were provided with the Skilled Nursing Advanced Beneficiary Notice (SNF ABN), Form CMS- or residents who were discharged from the facility were not provided with the Notice to Medicare Provider Non-coverage (NOMNC), form CMS- . This was evident for three (3) out of three (3) sampled residents reviewed for Beneficiary Protection Notification (Residents #'s 93, 162, and #439). This is evidenced by: A policy titled Medicare Notice of Non-Coverage dated (MONTH) (YEAR) documented: Form CMS- (2018) - To be used when Medicare Part A services are determined to no longer be required or if Medicare coverage is not available due to technical reasons (e.g. no qualifying hospital stay or skilled need); Form CMS- - NOMNC - To be used when an individual is determined to be no longer eligible for Medicare A (in conjunction with CMS- ). Resident #93: The resident had a Medicare Part A Skilled Services Episode Start Date of 01/11/19 and a Last covered day Part A Service date of 01/30/19. The resident was admitted to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of Resident #93's medical records on 07/10/19, revealed that the resident remained in the facility and had received rehabilitative services. The resident was not provided the SNF ABN, Form CMS- to inform the resident of their potential financial liability if receiving non-covered rehabilitation services. Resident #162: The resident had a Medicare Part A Skilled Services Episode Start Date of 06/11/19 and a Last covered day Part A Service date of 06/25/19. Review of Resident #162's medical records on 07/10/19, revealed that the resident was not provided the NOMNC form CMS- to inform the resident of their right to an expedited review of service termination. Resident #439: The resident had a Medicare Part A Skilled Services Episode Start Date of 04/09/19 and a Last covered day Part A Service date of 04/23/19. Review of Resident #439's medical records on 07/10/19, revealed that the resident was not provided the NOMNC form CMS- to inform the resident of their right to an expedited review of service termination. During an interview on 07/10/19 at 3:46 PM, the Minimum Data Set (MDS) Coordinator stated that she does not provide the NOMNC form CMS- to residents who had a planned discharge to home. She stated she did not provide the SNF ABN form to Resident #93 because the resident was discharged to the hospital on [DATE], was readmitted to the facility on [DATE] and had not received Medicare Part A services. The MDS Coordinator stated that if this is what is supposed to be done then I'm just going to have to start doing it. During an interview on 7/10/19 at 4:36 PM, the Administrator stated the expectation is that residents and/or their representative would be provided advanced notice of Medicare notice of non-coverage per facility policy which reflects the regulation. 10 NYCRR 415.3(g)

Based on observation, record review and interview conducted during a recertification survey, the facility did not ensure that residents in need of respiratory care, received such care consistent with professional standards for one (1) resident (Residents #37) of one (1) resident reviewed. Specifically, for Resident #37, the facility did not ensure an oxygen tank was replaced when empty. This is evidenced by: The Policy and Procedure for Oxygen Use and Storage, last updated 8/31/17, documented, nurses are to check each shift, or more frequently as appropriate, the oxygen tank to ensure appropriate flow and sufficient oxygen is present in the tank Resident #37: This resident was admitted [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was without impaired cognition, was able to understand others and was able to be understood. The physician's orders [REDACTED]. The Medication Administration Record (MAR) dated (MONTH) 2019, documented the resident received oxygen on 7/1/19 through 7/9/19 day shift at 3 to 3.5 liters per minute via nasal canula. The MAR and Treatment Administration Record (TAR) did not include documentation for when to check or change oxygen levels in the portable oxygen tank. During an observation on 7/9/19 at 2:19 PM, the resident was sitting in his wheelchair in his room with an oxygen tank attached. The gauge on the oxygen tank was pointed to empty, indicating the resident was not receiving oxygen. The resident stated there was no oxygen coming out of the nasal canula. Registered Nurse Unit Manager (RNUM) #1 was asked to observe the oxygen, RNUM #1 stated the tank was empty, then placed the resident on the concentrator in his room and resumed the resident's oxygen administration. During an interview on 7/9/19 at 2:35 PM, RNUM #1 stated that she was not assigned to this resident. The oxygen tanks should be checked regularly to ensure the tank is not empty. RNUM #1 stated the facility protocol is to place the resident on a full oxygen tank when they get out of bed in the morning and change the oxygen tank between 12:00 PM and 1:00 PM. RNUM #1 stated the facility protocol was that the resident be placed on the oxygen concentrator when in his room. RNUM #1 stated she was unsure when the oxygen tank was changed last as the nurse in charge of this resident left at 2:00 PM, and the resident was not yet seen by the oncoming nurse. During an interview on 7/12/19 at 11:56 AM, the Administrator stated portable oxygen tanks are expected to be checked on a regular basis to ensure the resident received oxygen per doctor's orders. The Administrator stated the facility protocol is to place the resident on a full oxygen tank when they get out of bed in the morning and change the oxygen tank between 12:00 PM and 1:00 PM. The Administrator stated the protocol was based on a resident receiving 2 liters per minute of oxygen and the facility had not assessed the change frequency of portable oxygen tanks for residents that received a higher concentration of oxygen therapy. 10NYCRR415.12(k)(6)

Based on record review and interview during the recertification survey, the facility did not ensure a policy was developed for the monthly medication regimen review (MRR) that included time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This is evidenced by: A facility Policy titled Timeliness of Medication Regimen Review (MRR) Reports approved 1/2/19, documented that when the consultant pharmacist identified an irregularity that required immediate or urgent action, the pharmacist would notify the Director of Nursing (DON) and the assigned nurse at the time the irregularity was identified. The policy did not include the timeframe for contacting the physician. During an interview on 7/12/19 at 1:10 PM, the Administrator stated that she thought the policy did addressed the timeframe's. 10NYCRR 415.18(c)(2)

Based on record review and interview, the facility did not ensure a policy regarding use and storage of foods brought to residents by family and other visitors was developed to ensure safe and sanitary storage, handling, and consumption. Specifically, the facility did not ensure facility staff would assist dependent residents in accessing and consuming food brought in by family or visitors. This is evidenced by: A Policy and Procedure titled Food From Outside Sources dated 3/19, did not include documentation of how the facility would assist dependent residents in accessing and consuming food brought in by family or visitors. During an interview on 7/12/19 at 10:18 AM, the Food Service Director (FSD) stated the policy did not include a process or procedure to ensure dependent residents could access and consume foods brought in by family or visitors. 10NYCRR415.14 (h)

Based on record review, and staff interview during an abbreviated survey (Case # NY 083), the facility did not ensure that based on the comprehensive assessment, a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers (PU) and does not develop pressure ulcers for one (Resident #3) of three residents reviewed. Specifically, for Resident #3, the facility did not identify the resident's risk factors for the development of a pressure ulcer from the use of a medical device (knee immobilizer); Additionally, preventative interventions to reduce or remove the risk were not implemented upon the resident's readmission to the facility post hospitalization for a fractured leg. The knee immobilizer was not removed for 10 days from 8/31/17 through 9/11/17 resulting in an avoidable pressure ulcer. This is evidenced by: Resident #3: The resident was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severe cognitive impairment. The Policy and Procedure (P&P) (undated) for Adaptive Medical Devices (sling, braces, splints, immobilizers) documented that medical devices must have a physician order that clearly states what the medical device is used for and when the device should be applied and removed. The Preventative Skin Care P&P dated as revised on 6/2012, documented the facility will maintain a system in which positioning devices (immobilizer) are routinely evaluated for pressure reduction/relief. The hospital Transfer/Discharge Summary dated 8/31/17 at 2:30 pm, documented the resident had a brace and mild swelling to the right lower extremity (RLE). admission orders [REDACTED]. A Nurses Note dated 8/31/17 at 10:54 pm, written by the Registered Nurse Supervisor (RNS), documented a brace was in place to the resident's right lower extremity (RLE). The Nursing Admission/Re-Admission Assessment skin assessment dated [DATE] at 10:55 pm, written by the RNS, did not include whether the skin under the KI had been assessed. A Nurses Note dated 9/1/17 at 2:57 am, written by Licensed Practical Nurse #1 (LPN), documented a leg immobilizer was in place on the right leg. The CNA (certified nursing assistant) Care Card dated 9/1/17, documented the resident had a knee immobilizer. The Comprehensive Care Plan (CCP) dated 10/30/14, documented that the resident has the potential for pressure ulcer development related to immobility. The care plan did not include a documented update to reflect a KI following the resident's readmission to the facility on [DATE]. A Provider Progress Note dated 9/1/17 at 3:33 pm, written by Medical Doctor (MD) #1, documented the resident's RLE was [MEDICAL CONDITION] (swollen) from the injury and surgery. A Provider Illness Visit dated 9/11/17 at 9:09 am, written by the Nurse Practitioner (NP), documented the resident had a KI on, and had a wound on the posterior (back part) lower portion of the right calf right over (the area) where one of the metal stays in the KI was. The ulcer measured 4.0 cm x 3.0 cm and had dry, necrotic (dead) material or slough (dead tissue) at the center. A Skin/Wound Note dated 9/11/17 at 10:08 am, written by the RNUM, documented the resident had a 4 cm x 3 cm area of eschar (dead tissue) on the posterior right calf, with no drainage/odor and consistent with the placement of a bar in the KI. The CCP created and initiated on 9/11/17, for the pressure ulcer on the posterior right calf did not include the KI on the resident's RLE. The CNA Care Card was revised on 9/11/17, did not include directions for the CNAs to provide care for the resident's KI. A Therapy Note dated 9/12/17 at 4:44 pm, written by the Physical Therapist (PT), documented that on 9/11/17, during the resident's therapy session, a red area was observed on the side of the resident's right shin. The KI was loosened to inspect the skin and a huge blackened area due to pressure from brace was found. The area was reported to the RNUM on 9/11/17. A Nurses Note dated 9/12/17 at 12:09 pm, written by RNUM #1, documented she was asked to assess the resident's right heel and right lateral thigh area. The right thigh area had a Stage 2 pressure ulcer that measured 1 cm x 1 cm. The area was consistent with placement of a bar in the KI rubbing against it. The right heel had a 4 cm x 4 cm fluid filled intact blister. An Orthopedic follow-up visit note dated 9/13/17, written by MD #3, documented the resident had a full thickness pressure ulcer on the posterior right leg with dry eschar. The knee immobilizer was discontinued. A Physician's Order Note dated 9/13/17 at 12:34 pm, written by the RNUM, documented the resident returned from an orthopedic appointment with a new order to discontinue the KI. A Nurses Note dated 9/20/17 at 12:22 pm, written by the RNUM, documented the resident had a 4 cm x 3 cm area of eschar on the posterior part of his right calf. The right lateral thigh wound was resolved. A Provider Progress Note dated 9/28/17 at 2:32 pm, written by MD #2, documented an open area with necrotic appearing tissue about 4.0 cm x 6.0 cm on the right lateral calf at the location of where a rod was located on the KI brace. An Orthopedic follow-up visit note dated 10/6/17, written MD #3, documented the resident had a deep pressure ulcer on his right leg, with lateral tendon and muscle exposed. The MD was sending the resident to the hospital to be evaluated by wound care and plastic surgery. Wound culture results from the resident's leg wound dated 10/9/17, documented [MEDICAL CONDITION] resistant Staphylococcus (MRSA) (bacterium with antibiotic resistance). A Plastic Surgery consult dated 10/7/17, written by the plastic surgeon, documented the resident had a stage 4 pressure ulcer to his right lateral lower leg. During an interview on 3/8/18 at 11:41 am with RNUM #1 regarding the resident's 8/31/17 readmission, the resident returned from the hospital with a leg brace following a femur fracture. It was true RNUM #1 did not identify the fact an immobilizer was in place without any orders or directions for care. The care plan and CNA Care Card were not updated, but should have been. RNUM #1 did not recall any CNAs questioning the immobilizer. If they had, RNUM #1 would have checked into it. RNUM #1 was unaware the resident had the KI until 9/11/17, when it was removed and there was a pressure area on the resident's right calf. The resident was seen by the NP. Had they been aware of the rod rubbing the calf area sooner, the pressure ulcer may have been prevented. During an interview on 3/12/18 at 2:27 pm, CNA #1 stated the resident had a KI. CNA #1 provided care by cleaning area around the immobilizer. There were no directions for how to care for the resident's KI, so CNA #1 did not remove it. During an interview on 3/14/18 at 3:18 pm, the RNS stated the resident's readmission skin assessment was completed however, the KI was not removed to inspect the skin under it. During an interview on 3/15/18 at 2:02 pm, MD #2 stated the location of the pressure ulcer on the resident's right calf was consistent with the location of a rod in the immobilizer. During an interview on 3/15/18 at 3:19 pm, the Assistant Director of Nursing stated Nursing, PT and Occupational Therapy (OT) all missed that there was no physician order for [REDACTED]. During an interview on 3/15/18 at 4:07 pm, the Director of Nursing stated RNUM #1 took report from the hospital. The resident returned to the facility on the 3:00 pm-11: pm shift. There were no orders from the hospital for the knee immobilizer. There should have been one obtained for the KI and the surgical wound dressing. The DON would expect the RNUM to check for orders. During an interview on 3/19/18 at 2:10 pm, the NP stated the ulcer was on the bottom of the right calf, right where one of the metal stays in the KI was. The NP would expect staff to open the immobilizer, check the skin, and clean the area. During an interview on 4/18/18 at 4:01 pm, MD #3 stated the resident was treated for [REDACTED]. On the 9/13/17 post-operative visit a severe pressure ulcer on the RLE was found. MD #3 expected that the nurse would have called him to clarify the use and instructions regarding the care of the KI. KIs were used for stability and to protect the surgical wound. Staff would need to check the skin under the KI at least daily. [MEDICAL CONDITION] in the RLE could have increased the risk for the development of the pressure ulcer. The resident's medical record did not include a documented history of [MEDICAL CONDITION] or arterial insufficiency (both conditions that can impair circulation and lead to wounds). The wound was consistent with a pressure ulcer and clinically avoidable if regular repositioning and skin checks had been done. Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement at the time of this survey: - Facility audit of all residents with adaptive devices was conducted to ensure that an active order, care card and care plan were in effect; - The Admission/Re-Entry Checklist use by staff responsible for the admission of residents was revised to include the items required when admitting residents with adaptive devices (MD order, care plan/care card with instruction regarding the care of adaptive devices); - Reeducation of all RNs, PTs and Occupational Therapists (OT) on the facility policy/procedures for adaptive devices; - Auditing of all new/readmitted residents with adaptive devices for compliance with policies/ procedures by RNS on night shift. Audits result forward to QAPI committee on monthly basis for 6 months. NYCRR 415.12(c)(1)

Based on record review and staff interview during an abbreviated (Case # NY 083), the facility did not ensure that at the time each resident is admitted , the facility had physician orders for the resident's immediate care for 1 resident (Resident #3) of three residents reviewed. Specifically, for Resident #3's readmission to the facility following surgery for [REDACTED]. This is evidenced by: Resident #3: The resident was admitted to the facility on [DATE], and readmitted on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severe cognitive impairment. The Adaptive Medical Devices Policy and Procedure (undated), defined Medical Devices to include slings and immobilizers. All medical devices need an accompanying physician order that clearly stated what the device was to be used for, and when it was to be on or off. The hospital Transfer/Discharge Summary dated 8/31/17 at 2:30 pm, documented the resident had a brace to right lower extremity. The hospital General Discharge Orders and Instructions, dated 8/31/17 at 5:00 pm, documented a sling to right upper extremity (RUE) and a dry sterile dressing to the right hip daily. The admission orders [REDACTED]. A Physician's Order Note dated 9/1/17 at 10:22 am, written by RNUM #1, documented the Medical Doctor (MD) assessed the resident and reviewed the chart for readmission. No new orders were received. A Provider Illness Visit dated 9/11/17 at 9:09 am, written by the Nurse Practitioner (NP), documented the resident was wearing a KI, and noted a wound on the the lower portion of the back part of the resident's right leg. The wound (position) was located right over where one of the metal stays in the KI was. The upper portion of the right hip incision was slightly reddened around it and it had some purulent discharge (pus) that was to be cultured. The resident was started on an antibiotic. A Nurses Note dated 9/12/17 at 12:09 pm, written by RNUM #1, documented the RNUM assessed the resident's right heel and right lateral thigh area. The right thigh area had an open area consistent with the placement of a bar in the KI rubbing against it. The right heel had a fluid filled intact blister. The Orthopedic follow-up visit note dated 9/13/17, by MD #3 documented the resident had a deep pressure ulcer on the back of the right leg with dry, black skin. The KI was discontinued. The resident had some redness at the top of the surgical wound on the RLE and was on an antibiotic. Continue monitoring the [MEDICAL CONDITION] (the infection at the surgical wound site) and the prescribed antibiotic. During an interview on 3/8/18 at 11:41 am, RNUM #1 stated the resident had returned from the hospital on [DATE] with a leg brace following a femur fracture. RNUM #1 stated she usually looks at hospital records to have them ready for the MD. Nothing stood out about the KI. RNUM #1 did not catch the fact that the resident had an immobilizer in place, without orders or directions for care. RNUM #1 stated that another RN did the admission and she had not double checked the orders. Audits were done at night by the RNS. During an interview on 3/14/18 at 1:53 pm, RNUM #2 stated that upon admission or readmission of a resident from the hospital, the hospitals discharge summary, history and physical, consults, and labs were reviewed. RNUM #1 would look for any big questions. MD orders were needed for KI, slings, splints, etc. Orders need to have directions for the removal to provide care, and the frequency to be removed. She stated the 11:00 pm-7:00 am RNS did audits for admissions/readmission to check for completeness of orders and documentation. The results were provided to the RNUM and Director of Nursing (DON). During an interview on 3/15/17 at 2:29 pm, RNUM #1 stated there should have been an order for [REDACTED].#1 stated I missed it. RNUM #1 did not always review discharge orders from a facility because the RNS should be doing it, and again, the night RNS did audits. During an interview on 3/15/18 at 3:19 pm, the Assistant Director of Nursing (ADON) stated Nursing, PT and Occupational Therapy (OT) all missed that there was no order for the KI, the sling, or the dressing for the surgical wound. During an interview on 3/15/18 at 4:07 pm, the DON stated RNUM #1 took report from the hospital. The DON would expect the RNUM to check for orders. During an interview on 5/2/18 at 10:40 am, the Medical Director stated the facility should obtain as many records as possible from a transferring facility to reconcile care and medications. The MD writes the initial admission orders [REDACTED]. Frequently, the MD needs to get specific MD orders from the surgeons for resident post-operative care. The RN should have called the surgeon to clarify the orders, and once clarification was received, call the facility MD. Somebody should have clarified with the hospital. Many pieces for the resident's care were missed that led to the outcome. Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance related to MD order for adaptive devices and was in substantial compliance at the time of this survey: - Facility audit of all residents with adaptive devices was conducted to ensure that an active order, care card and care plan were in effect; - The Admission/Re-Entry Checklist use by staff responsible for the admission of residents was revised to include the items required when admitting residents with adaptive devices (MD order, care plan/care card with instruction regarding the care of adaptive devices); - Reeducation of all RNs, PTs and Occupational Therapists (OT) on the facility policy/procedures for adaptive devices; - Auditing of all new/readmitted residents with adaptive devices for compliance with policies/ procedures by RNS on night shift. Audits result forward to QAPI committee on monthly basis for 6 months. 10 NYCRR 415.11

Based on record review, and staff interview during an abbreviated survey (Case #NY 083), the facility did not ensure that based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice to maintain the highest practicable physical well-being for one (Resident #3) of three residents reviewed. Specifically, upon Resident #3's readmission to the facility post hospitalization , the facility did not identify that the resident had a surgical wound, a knee immobilizer, and an arm sling. This resulted in a lack of treatment and care for the resident's surgical wound, knee immobilzer (KI) for repair of leg fracture and arm sling for fractured arm from 9/1/17-9/11/17. This is evidenced by: Resident #3: The resident was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severe cognitive impairment. The Admission Policy and Procedure (P&P) revised on 6/15/12, documented the Registered Nurse (RN) would initiate an assessment that included the skin, pressure ulcer risk, pain, and cognition within 4 hours after the resident arrived at the facility. A care plan should be implemented based on the assessment findings. The policy and procedure (P&P), for Pressure Ulcer and Wound Care Policy (undated), documented the facility would ensure residents received wound care consistent with their needs and recognized standards of practice to promote optimal healing of wounds or prevent deterioration. The resident would be assessed weekly by a Registered Nurse (RN) and the assessment findings documented. The Adaptive Medical Devices P&P (undated), documented that medical devices included slings, braces, and immobilizers. The Comprehensive Care Plan (CCP) and/or Certified Nursing Assistant (CNA) Care Card should address the care of, maintenance for, and measures to prevent excessive pressure on body sites related to the medical device. The hospital General Discharge Orders and Instructions dated 8/31/17 at 5:00 pm, documented instructions to apply a dry sterile dressing to the right hip daily and that the resident had an arm sling. The admission orders [REDACTED]. An Admission Note dated 8/31/17 at 10:35 pm, written by the Registered Nurse Supervisor (RNS), documented the resident's right arm was in a sling, and the dressing to the right lower extremity (RLE) from the hip, to just below knee was dry and intact. Review of the medical record did not include a CCP for the resident's arm sling, surgical wound and knee immobilizer or a care plan following the discovery of an infection at the surgical site. Review of the resident's CCPs did not include a care plan for the resident's arm fracture with sling, surgical wound and KI. The CNA care card did not include instructions for the CNAs to follow to provide care for the resident's fractured arm and sling and immobilizer. A Provider Illness Visit dated 9/11/17 at 9:09 am, written by the Nurse Practitioner (NP), documented that the upper portion of the right hip incision was slightly reddened and had some purulent discharge (pus). A wound culture was ordered and the resident was started on an antibiotic. A Wound Tracking flowsheet was initiated on 9/11/17. The column on the flowsheet for surgical wound checks were blank. There were no other wound tracking flowsheets in the medical record. An orthopedic follow-up visit note dated 9/13/18, written by MD #3, documented to continue monitoring the [MEDICAL CONDITION] (skin infection) and the antibiotic for treatment of [REDACTED]. During an interview on 3/8/18 at 11:41 am, the RNUM #1 stated she did not double check orders when another RN did the readmission. The night RNS did audits for readmissions to ensure assessments, orders, etc. were complete. During an interview on 3/12/18 at 2:27 pm, CNA #1 stated approximately 10 days after the resident's return from the hospital, greenish-yellow drainage was noted on the pillow under the resident's right leg and the drainage was reported to the Licensed Practical Nurse (LPN) #2. During an interview on 3/15/17 at 2:29 pm, RNUM #1 stated there should have been an order for [REDACTED]. She did not always review discharge orders from a facility because the RNS should be doing it, and again, the night RNS did audits. During an interview on 3/15/18 at 4:07 pm, the Director of Nursing (DON) stated she expected that RNUM #1 would have reviewed the hospital discharge summary and instructions, obtain orders for the resident's care, and start a care plan. During an interview on 5/2/18 at 10:40 am, the Medical Director stated the facility should obtain records from a transferring facility to reconcile care and medications. The MD writes the initial admission orders [REDACTED]. Many pieces for the resident's care were missed that led to the outcome. Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance related to MD order for adaptive devices and was in substantial compliance at the time of this survey: - Facility audit of all residents with adaptive devices was conducted to ensure that an active order, care card and care plan were in effect; - The Admission/Re-Entry Checklist use by staff responsible for the admission of residents was revised to include the items required when admitting residents with adaptive devices (MD order, care plan/care card with instruction regarding the care of adaptive devices); - Reeducation of all RNs, PTs and Occupational Therapists (OT) on the facility policy/procedures for adaptive devices; - Auditing of all new/readmitted residents with adaptive devices for compliance with policies/ procedures by RNS on night shift. Audits result forward to QAPI committee on monthly basis for 6 months. 10 NYCRR 415.12

Based on record review and staff interview during an abbreviated survey (Case # NY 083), the facility did not ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident' goals and preferences for 1 (Resident #3) of 3 residents reviewed. Specifically, for Resident #3, who had severe cognitive impairment, the facility did not assess the resident for pain upon readmission on 8/31/17 post hospitalization for a fractured arm and surgical repair of a fractured leg. Additionally, the facility did not routinely evaluate or monitor for pain or the potential for pain. The Admission Note dated 8/31/17, Evaluations and Plans of treatment for [REDACTED]. This is evidenced by: Resident #3: The resident was admitted to the facility on [DATE], and readmitted on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severe cognitive impairment. The facility's Policy and Procedure for Pain Management (undated) documented that upon readmission a pain assessment will be completed, a care plan will be established when the assessment indicates a need for pain management and pain documentation will include the intensity, location, and level of relief following PRN (as needed) administration. The P&P documented that evaluations for pain staggered across all shifts were to be done weekly and the results documented on the Medication Administration Record (MAR). The Comprehensive Care Plan (CCP) initiated on 4/1/15 for the potential to demonstrate verbally abusive behaviors related to dementia, included an intervention revised on 3/27/17 to assess and anticipate the resident's needs. Evaluate for comfort level and pain. The CCP did not include a revision or update regarding the resident's comfort or pain upon readmission to the facility on [DATE]. The hospital Transfer Discharge Summary dated 8/31/17, documented [MEDICATION NAME] (Tylenol) 325 mg, 2 tablets every 4 hours as needed for mild pain or headache and [MEDICATION NAME] (narcotic pain medication), 5 mg every 4-6 hours as needed for moderate to severe pain. The admission orders [REDACTED]. The Admission Note dated 8/31/17 at 10:35 pm, written by the Registered Nurse Supervisor (RNS), documented the resident was readmitted to the facility at 7:15 pm and had discomfort only on movement. Review of the CCP's in the medical record did not include a care plan for pain or the potential for pain. The Medication Administration Record (MAR) dated 8/31/17, documented physician orders [REDACTED]. The MAR did not include documentation that as needed Tylenol was given. The Admission/Re-Admission Assessment form dated 8/31/17 at 10:55 pm, written by the Registered Nurse Supervisor (RNS), included a Section for completion of an assessment for pain. The pain assessment section was blank. The Medication Administration Record (MAR) dated 8/1/17-8/31/17 documented weekly pain evaluations staggered between the three shifts. The Occupational Therapy (OT) Evaluation and Plan of Treatment dated 9/1/17 at 5:14 pm, written by the OT, documented the resident had mild pain at rest, severe pain to the right arm when touched and right leg pain when the OT moved it. The pain assessment method used was based on the resident's behaviors and having cried out that it hurt. After a change in position the resident would state it was better. It documented the pain limited the resident's functional activities. The OT assessed the resident's ability to be aware of, and feel pain was intact. The Physical Therapy (PT) Evaluation and Plan of Treatment dated 9/1/17 at 5:24, written by the (PT), documented mild pain at rest, and severe pain with movement of the resident's right leg. The pain was described as sharp and quick. The MAR dated 9/1/17 - 9/30/17, documented the resident received 650 mg of [MEDICATION NAME] twice for pain on 9/1/17 at 6:28 am for a pain level of 7 and at 10:46 am for a pain level of 4. The MAR for the above time period did not include documentation that evaluations for pain staggered across all shifts were done. The Pain Assessment Interview section of the MDS dated [DATE], for the Indicators of Pain or Possible Pain for the past 5 days (9/2/17-9/7/17), documented the resident had vocal complaints of pain. A Nurses Note dated 9/21/18 at 4:31 pm, written by Licensed Practical Nurse (LPN) #3, documented the resident did not have pain on the weekly pain evaluation for the evening shift. During an interview on 4/30/18 at 11:41 am, the Physical Therapist (PT) stated the resident had behaviors, and pain could have made them worse. The resident's inability to fully cooperate with therapy could have been related to pain. During an interview on 3/14/18 at 1:53 pm, RNUM #2 stated pain assessments should be completed and documented when a resident is readmitted . Residents pain should be assessed every shift for seven days. During an interview on 3/15/18 at 3:19 pm, the Assistant Director of Nursing (ADON) stated a pain assessment was supposed to be done when a resident was readmitted . During an interview on 4/30/18 at 11:47 am, Registered Nurse Unit Manager (RNUM) #1 stated pain assessments were completed upon residents' admissions, readmissions, and quarterly. RNUM #1 stated she did not know why a pain assessment was not done when the resident was readmitted . The RNUM stated it was the responsibility of the RNUM to ensure admission/readmission assessments were completed. A pain assessment was to be done 48-72 hours after the resident arrived at the facility. Upon admission, residents were supposed to have pain assessments every shift for 7 days. There should have been a care plan for pain. During an interview on 5/1/18 at 10:32 am, the Director of Nursing (DON) stated a pain evaluation should be done at the time a resident is admitted or readmitted to the facility. She stated there should have been a Potential for Pain care plan implemented. During an interview on 5/2/18 at 10:40 am, the Medical Director stated pain could be difficult to assess in residents with dementia. Staff should be aware of changes in a resident's behaviors. During a phone interview on 5/2/18 at 2:01 pm, the DON stated the standing orders for pain evaluations was in the order section of the electronic medical record. The nurse must click on the box for the weekly pain evaluations. They must also click on the option for pain evaluations to be done every 4 hours for seven days for admissions and readmissions. The evaluations for a seven-day timeframe were done to establish a baseline for the residents' pain levels. The RNUM forgot to pull up the template to access the orders for the pain evaluations. 10 NYCRR 415.12

Based on observation, record review, and interview during standard recertification survey and an abbreviated survey (Case #NY 788), the facility did not provide necessary care and services to attain or maintain the highest practicable physical well being in accordance with the comprehensive assessment and plan of care for five (5) of eight (8) Residents (#'s 201, 8, 68, 73, and #99) reviewed. Specifically, Resident #201 who has a history of, and was care planned for, falls and wandering into other resident's rooms, was found on the floor in a room that was not his own on 12/22/14, assessed by a Registered Nurse (RN) who documented "yells with all movements and if you touch him", however, no further action was taken at that time. On 12/29/14, is noted by the physical therapist to have had less than maximum progress due to pain after his fall on 12/22/14 and that nursing staff were made aware. On 12/29/14, the Nurse Practitioner (NP) conducted a routine review of Resident #1 and noted no falls or significant changes to the resident more recent than a month prior (November). On 1/2/15, nursing staff requested review of the resident's lower left extremity due to increased pain, decline in ambulation and inability to participate fully in physical therapy, the Physician's Assistant (PA) did not examine the resident, however, prescribed additional pain medication noting a complaint of pain in the right lower extremity. On 1/10/15 at 6:30 am, the resident was noted with significant bruising to the lower left extremity, was not thoroughly assessed by an RN, and when the bruising was reported again, almost eight hours later, to the RN on the on-coming shift, the resident was assessed and transferred to the hospital where an x-ray revealed a fractured left femur. For Resident #'s 8, 68, 73 and #99, the facility did not: complete documentation in nursing notes of the presence and location of a [MEDICAL TREATMENT] catheter, did not have a comprehensive care plan in place for presence and location of the [MEDICAL TREATMENT] catheter, and did not have a policy and procedure for care of the resident receiving [MEDICAL TREATMENT] treatment. This resulted in actual harm that is not Immediate Jeopardy for resident #201; and no actual harm for Resident #'s 8, 68, 73 and #99, but had the potential for more than minimal harm that is not Immediate Jeopardy. This evidenced by the following: Resident #201 The resident was admitted to the facility on [DATE] diagnosed with [REDACTED]. Minimum Data Set ((MDS) dated [DATE] assessed the resident with severe cognitive impairment with short and long term memory impairment and severely impaired decision making skills. Comprehensive Care Plan for falls initiated 12/4/13 documented that the resident was at risk for falls due to confusion. Interventions included, the need for a safe environment and for bed and chair alarms. Comprehensive Care Plan initiated 12/13/13 documented that the resident was occasionally aggressive related to inability to understand, unexpected movements and history of wandering and invading space of others. Interventions included; provide with redirection when resident appears to be wandering in others rooms and initiated on 11/17/14, half hour whereabouts checks documented by the LPN. Incident and Accident Report dated 12/22/14 documented that the resident, who resides in room [ROOM NUMBER], was found at 2:15 am on the floor in the middle of room [ROOM NUMBER] (not his room) with the door closed. Root cause analysis documented that two staff were in a room providing patient care and one staff member was at the nurses station checking charts. The form signed by RN #1 documented that there was not evidence of abuse, neglect or mistreatment. In a statement attached, CNA #1 documented that the resident was last seen at 1:30 am and was sitting at the nurses station. In a statement attached, CNA #2 documented that the resident was last seen at 1:00 am sitting in his wheelchair. There is no documented evidence of a statement from the staff member (LPN #3) identified as sitting at the nurses station checking books. Nurses Note dated 12/22/14 at 3:23 pm signed by RN #1 documented that she was called to assess the "resident laying 1/2 on the floor and upper body on mattress on floor. Resident was able to move all extremities. Yells with all movements and if you touch him. Assisted to wheelchair with gait belt and two assists. Returned to room and toileted. Moves legs without complaint when toileted and placed in bed." Nurses Note dated 12/23/14 at 10:14 am, documented a late entry for 12/22/14 that residents family was called at approximately 1:00 pm to notify of fall on overnight. no answer left message on answering machine. Provider Progress note dated 12/29/14 at 7:46 am signed by the NP documented a routine visit for the resident and documented "he had no significant problems of late, he did over a month ago have a contusion of his right knee but he has had no further problems or pain. He has had no further falls. Apparently he had a fall at that time but has been doing well". Physical Therapy Progress Report dated 12/29/14 at 9:21 signed by the therapist documented therapy service dates between 12/13/14 and 12/26/14. The Physical Therapist (PT) documented that the resident's progress and response to treatment lacked maximum improvement due to overall tolerance limited by pain in the lower left extremity after a recent fall on 12/22/14. The PT further documented that the resident was complaining of pain, rubbing the left thigh/knee at rest and during efforts to range or perform therapy to the lower left extremity, the resident would state "no stop that" due to pain, Nursing staff aware. Nurses Note dated 1/2/15 at 11:03 am documented that LPN #1 "spoke to the PT regarding the residents decline over the last week. Resident is complaining of left leg discomfort and is not able to perform the exercise that he was able to prior to his fall last week. Resident is on for the physician's assistant to see today regarding increased left leg discomfort." Nurses Note dated 1/2/15 at 11:13 am signed by LPN #1 documented a conversation with the resident's family member to update on recent complaint of left leg discomfort and overall decline. It is further documented "she has noticed a decline and is agreeable to medication changes regarding pain management." physician's orders [REDACTED]. will add [MEDICATION NAME] ([MEDICATION NAME]) 50 milligrams twice daily." Nurses Note dated 1/10/15 at 6:57 am documented that RN #1 was called to assess left lower leg ecchymosis and [MEDICAL CONDITION] noted. Positive pedal pulse, foot warm to touch. Nurses Note dated 1/10/15 at 10:07 am signed by LPN #2 documented that a certified nurses assistant (CNA) alerted her to a large ecchymotic area on the resident's left leg. LPN #2 documented that she observed a 10 centimeter by 7 centimeter bruise on the inner thigh about 10 centimeters above the knee. Also a 27 centimeter by 5 centimeter area behind the knee, down the calf and a 9 centimeter by 6 centimeter area on the inner ankle. Two plus [MEDICAL CONDITION] in left foot. Knee also swollen and the RN was called to assess. Incident Report dated 1/10/15 documented that a CNA alerted the nurse to bruise on residents left leg. Nurse observed a large ecchymotic area with [MEDICAL CONDITION] from above the knee to the ankle. Statement of prevention was documented as unknown cause at present time. Nurses Note dated 1/10/15 at 3:01 pm signed by RNS #2 documented that she was "called to re-assess the left lower leg which was noted earlier from the morning aide at 6:30 am was seen by 11-7 am supervisor. Upon exam it looks like an anticoagulant bleed into the tissue. I cannot palpate pedal pulses in either foot. will call physician for possible portable Doppler and x-ray." Nurses note dated 1/10/15 at 4:01 pm, documented that an order was received to transfer the resident to the hospital for evaluation. X-ray Report dated 1/10/15 at 6:27 pm documented an inter-trochanteric [MEDICAL CONDITION] femur with medial angulation of the distal fragment. Internal Case Review for the 1/10/15 event was completed on 1/15/15 and documented that it is felt that this could have been a result of a slight crack in the left femur related to a roll out of bed on 12/22/14, that shattered as a result of the stress of ambulating on PT recently. The conclusion is documented that based on information available at this time including interviews, chart review, and resident assessment, there is not sufficient evidence of abuse, neglect or mistreatment. There was no known incident that led to this fracture, the surgeon gave the family the idea that this is a healing fracture and explained that his recent ability to ambulate put stress on a possible crack. During an interview on 1/26/15 at 3:00 pm, the resident's PT stated that prior to the resident's fall on 12/22/14, the resident was walking with a wheeler walker in therapy 100-150 feet. The PT stated that the week following the fall, the resident was limited in his abilities due to pain. The PT stated that she spoke with nursing staff who were aware of the fall and the resident's pain and she was told that the medical provider had been informed of the increase in pain to the left lower extremity. The PT stated that due to the pain, she continued to work with the resident in therapy, however, his therapy was modified as to not cause additional pain. During an interview on 1/28/15 at 11:40 am, LPN #1 stated that she has worked with the resident for some time and that the resident has had right leg pain for some time and was receiving routine Tylenol for pain management. LPN #1 stated that the PT came to her to report that the resident was experiencing left leg discomfort which was new so she reported it to the RNM. LPN #1 stated that she believes that the RNM placed a note in the provider book so that the resident could be seen by one of the medical providers. LPN #1 stated that she believed that NP had reviewed the resident, however, there did not appear to be any changes to the resident's plan of care and she believes that the PT placed the resident back on the provider list for continued left leg pain. LPN #1 stated that she spoke with the resident's family member about his left leg pain, and the family member agreed to a medication change because "she didn't want him in pain." LPN #1 stated that the PA saw the resident as a result of being placed on the provider list and on her way out, the PA came to her and told her that she had ordered [MEDICATION NAME] 50 milligrams for leg discomfort. LPN #1 stated that she had assisted the resident the day before the fracture was discovered and the resident was his normal resistive self, he was toileted and placed back in his chair with his legs up. LPN #1 stated that she was advised that next day that the resident was diagnosed with [REDACTED].#1 stated that she was aware that the resident had a fall on 12/22/14 and "he hadn't been the same since the fall." During an interview on 1/28/15 at 12:00 pm, the PA stated that the resident's last fall was in November and at that time, the resident experienced pain in the right leg as a result and was prescribed Tylenol for pain management. The PA stated on 1/2/15 she was asked to see the resident because staff reported that the resident seemed to be in more pain and the Tylenol wasn't making him comfortable. The PA stated on 1/2/15, she assumed that the staff were referencing pain to the right leg and she ordered [MEDICATION NAME], another pain medication. The PA stated that she did not examine the resident, she did not review the resident's medical record, nor was she aware that the resident had another fall on 12/22/14. The PA stated, "I did not order an x-ray because I did not know that there was another fall and I knew that the increase in pain could not be from the November fall." The PA stated that if she were aware of another fall and a new complaint of pain in a different leg, she would have examined the resident and may have ordered an x-ray at that time. During an interview on 1/28/15 at 12:45 pm, the NP stated that she conducted the review and renewal for the resident on 12/29/14. The NP stated that the purpose of these visits are to determine if a resident is experiencing any new problems. The NP stated that typically she will look to review the resident's progress over the last two months and relies on the nursing staff to give her information about the resident. The NP was asked how she obtained pertinent information about the resident during the 12/29/14 visit and the NP stated that she spoke with the nurses and/or the aides but could not be more specific and stated that she does not keep notes regarding her visits. The NP stated "I guess we do the best that we can to get the whole picture, I can't recall the circumstances or the resident." During an interview on 1/28/15 at 1:50 pm, the Director of Nursing (DON) stated that when she reviewed the Incident Report regarding the resident's fall on 12/22/14, she did not realize that the resident was not in his own room and did not review the nurse's notes regarding the resident's fall, just the incident report that indicated no injury. The DON stated that she relies on the RNS' to identify any possible abuse or neglect when they are called to the incident. Additionally, the DON stated that the NP and PA have responsibilities for review and renewals and for sick visits, and while she was aware that the NP does not utilize the computer system, it is expected that the providers gather the necessary information about residents during these visits. The DON stated that an investigation was initiated after the resident was found on 1/10/15 with significant bruising and a subsequent fracture. The DON stated that the investigation resulted in a look back to the 12/22/14 incident. The investigation revealed that the PA documented the wrong leg in her note of 1/2/15. The DON stated that when she spoke with the PA during the investigation of 1/10/15 and the PA told her she must have charted on the wrong leg but the DON was unaware that the resident was not physically examined by the PA on 1/2/15. The DON reviewed the RN note of 1/10/15 at 6:57 am and stated that it did not appear to be thorough. During an interview with RNS #1 on 1/29/15 at 1:00 pm, stated that she was called to assess the resident after being found on the floor on 12/22/14 at 2:10 am. The RNS #1 stated that she was not very familiar with the resident and could not immediately remember if the resident was found on the floor of his room or someone else's. Upon review of the resident's room number and the room number where he was located on the Incident Report, RNS #1 stated, yes, he may have been in the wrong room and I think he was found on a floor mat. RNS #1 stated that to the best of her recollection, she had not previously had much interaction with the resident, and she was not aware of what the resident's usual pain was like, but when she touched him, he yelled. The RNS #1 stated that she had no further interaction with the resident at that time and believed that the fall incident would be reported to the next shift. RNS #1 stated on 1/10/15 at about 6:50 am, she was called to assess the resident while lying in bed. RNS #1 stated that she observed bruising to the back of the leg with two plus [MEDICAL CONDITION]. The RNS #1 stated that in trying to determine what was going on, she thought, had the resident fallen lately?, was the bruising due to a stand lift transfer or had someone backed him into the bed? RNS #1 stated that when she touched the resident's leg, the resident responded with "ouch" and she was only able to see one bruise. The RNS #1 was asked if the physician was notified, and the RNS #1 stated, "no, we (11-7 shift) don't usually call the physician." The RNS #1 stated that she was concerned so she reported it to the on-coming RNS for follow-up and expected that they would follow through but "I can't speak for them." During an interview on 3/7/15 at 2:00 pm, the Medical Director (MD) stated that falls with fractures are always of concern to him and the entire facility administrative team. The MD stated that the facility is working on finding ways to monitor rather than restrain residents, but this requires more staff or new ways to monitor residents to keep them safe. During an interview on 3/26/15 at 10:15 am, LPN #3 stated she was working on 12/22/14, the night of the resident' s fall. LPN #3 stated that the resident had attempted to get out of bed several times during the evening/night and was placed in a chair at the nurse's station. LPN #3 stated that she was working on books at the nurses station and at some point she heard a faint alarm, looked for the resident and could not locate him and assumed he was about the unit. LPN #3 stated that she went to room [ROOM NUMBER], the door was closed and when she opened it, she observed the resident on the floor. LPN #3 stated that each of the resident's in this room had floor mats and it appeared as though the resident had gotten himself into the room, but was unable to get himself back out, stood up and fell . LPN #3 stated that she does try to check on the resident routinely, however, she was unaware that the resident was care planned for 1/2 hour checks by the LPN as an intervention to his wandering. Resident #73: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident with full cognition, Brief Inventory for Mental Status (BIMS) score of 14, and full ability to understand and be understood. Nurses' notes documented the following: 11/27/14- The resident was seen at the facility for bleeding from the [MEDICAL TREATMENT] site and the charge nurse was holding pressure to the site but bleeding was continuing. The action undertaken was a call was placed to the provider who said apply a pressure bandage to the area. The note further documented under the response area that staff were unable to stop the bleeding and the resident was sent to the emergency room . A call was placed to the hospital at which time facility staff that the resident was admitted to the hospital. 12/4/14- An admission note documented the resident has a dressing to the left arm. No documentation was available to determine presence or location of a [MEDICAL TREATMENT] catheter. 12/4/14 - 03/23/15- No documented evidence of nurses' notes were found to document the presence or location of the [MEDICAL TREATMENT] catheter. The Comprehensive Care Plan (CCP) for the resident with [MEDICAL CONDITION] and requiring [MEDICAL TREATMENT] three days a week originally dated and initiated 2/23/13 documented a revision to the CCP dated 3/24/15. The revision documented do not draw blood or take blood pressure in left arm with port for [MEDICAL TREATMENT]. No other entry in the CCP documented presence or location of the [MEDICAL TREATMENT] catheter prior to 3/24/15. The Resident Care Card dated 3/24/15 (identified by staff to provide information to the CNA's for care of the resident) documented no information on location and presence of the [MEDICAL TREATMENT] catheter. No policy or procedure was available for care of the resident with needs for [MEDICAL TREATMENT]. During interview on 3/24/15 at 10:00 am the Director of Nursing (DON) stated there is no policy and procedure related to [MEDICAL TREATMENT]. The DON also stated she was unaware that the presence and location of the catheter port was not documented anywhere. Resident #8: Resident #8 was admitted to the facility on [DATE] with a readmission date of [DATE] and [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) that had a score of 13 that indicates resident is cognitively intact. physician's orders [REDACTED]. A physician's orders [REDACTED]. Nurses' Notes: Following the 1/2/15 admission Register Nurse's (RN) there was no documented evidence through 3/25/15 that the [MEDICAL TREATMENT] catheter site was being monitored every shift. The Comprehensive Care Plan (CCP) for [MEDICAL TREATMENT] documented the following: The CCP dated 2/25/15 contains an intervention for Licensed Practical Nurses (LPNs) and RNs to "monitor/document/report to MD as needed (PRN) any signs/symptoms of infection to access site: Redness, swelling, warmth or drainage". As apparent in further record review, this was not being documented in any area of the resident's medical record. The Treatment Administration Record (TAR) documented the following: Prior to 3/25/15, the TAR contained no intervention to check the fistula site for signs and symptoms of infection. The TAR was updated on 3/25/15 to initiate the following: "Check fistula site every shift with signs and symptoms of infection every shift". The Resident Care Card (RCC) documented the following: Prior to 3/25/15, the RCC did not provide any direction for the Certified Nursing Assistants (CNAs) to follow regarding the [MEDICAL TREATMENT] fistula. The RCC was updated on 3/25/15 with the following: "Monitor catheter right chest when dressing and undressing." The interview conducted with the Director of Nursing (DON) on 3/24/15 at 10:00 am documented that she stated she was unaware the presence and location of the catheter port was not documented anywhere. Resident #99: Resident #99 was admitted on [DATE] with [DIAGNOSES REDACTED]. MDS dated [DATE] documented a BIMS score of 15, cognitively intact. The Nursing Admission assessment dated [DATE] Section C Skin Integrity documented a right chest implanted port. Physician orders [REDACTED]. The Comprehensive Care Plan (CCP) for [MEDICAL TREATMENT] created 10/14/2014 documented the following intervention: "monitor/document/report to MD as needed (PRN) any signs/symptoms of infection to access site: Redness, swelling, warmth or drainage." The hospital [MEDICAL TREATMENT] Chronic Monitor Sheet (located in the resident's [MEDICAL TREATMENT] communication book) dated 3/23/15 documented purulent drainage was noted. Catheter insertion site red and a triple antibiotic dressing was applied. Blood cultures were drawn x 2 and a culture of the catheter site was obtained. A "sticky note" attached to the Monitor Sheet documented the resident was started on [MEDICATION NAME] 1 Gram [MEDICATION NAME] Grams IV for one week (while at [MEDICAL TREATMENT]). From 12/4/14 - 03/23/15- No nurses' notes were found to document the presence or location of the [MEDICAL TREATMENT] catheter. There was no documented evidence in the progress notes or on the MAR indicated [REDACTED]. Prior to 3/25/15, the RCC did not provide any direction for the CNAs to follow regarding the [MEDICAL TREATMENT] vascular access site. Interview with LPN on 3/24/15 at 9:30 am. LPN #1 reported he usually works nights but was doing a double (night shift 3/23/15 and day shift on 3/24/15). The LPN reported he was unsure where the resident's vascular access was located but stated "may be the right arm." He further reported he would not necessarily check the vascular access site as it was not a task on the TAR. Interview with CNA on 3/24/15 at 10:35 am . CNA reported she was aware the resident had a catheter on her right chest. She reported the information is not on care card but knows this resident as she is a float and often is assigned to her care. The CNA reported the catheter site should not get wet during a shower. Interview with the Registered Nurse Unit Manager (RNUM) on 3/24/15 at 10:40 am. The RNUM reported there should have been an order on the TAR for the nurses to check the catheter site for infection every shift. The RNUM reported this was an oversight and will be corrected. 10 NYCRR 415.12

Based on medical record review, observations and staff interview, the facility did not ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing during the standard recertification survey. Specifically: for 1 (# 7) of 9 residents reviewed the facility did not reassess the resident's risk to develop pressure sores in a timely manner, did not initiate off loading measures for heels for residents identified as high risk to develop pressure sores ,did not initiate off loading measures for a resident who was admitted with bilateral heel pressure sores and did not initiate pressure relieving measures for a resident with a stage 1 pressure sore. Resident #7 developed a pressure sore on the right heel on 12/25/10 and it was not until the left heel developed a pressure that offloading of the left foot was initiated. The development of a black eschar, unstageable pressure sore resulted in actual harm for Resident #7 that is not immediate jeopardy. This is evidenced by: Findings: The facility's policy entitled "Preventive Skin Care" dated 11/07 and most recently revised 2/09 documented "Additional pressure ulcer risk assessments will be completed at least annually and with every significant change. Either the Braden Scale or EQuip Pressure Ulcer Risk Assessment may be used for this." The 2 documents provided by the facility describing the (Posey) heel booties documented the heel booties were indicated for residents at low risk for skin breakdown, and were not recommended for residents who currently have open wounds on the feet, and heel sore prevention was 50%. The National Pressure Ulcer Advisory Panels', Quik reference Guideline for the prevention of pressure sores, dated 2009, documented to ensure heels are free from the surface of the bed. Resident #7 The facility did not assess the resident's risk to develop pressure sores in a timely manner, and did not initiate off loading measures for the resident's heels prior to the development of 2 pressure sores. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident had impaired short and long term memory, moderately impaired cognitive skills for daily decision making, usually understands and is usually understood. This same MDS assessed the resident required extensive assistance of one person for bed mobility, total dependence and support of 2 staff for transfers and was at risk to develop pressure ulcers, however had none at the time. The Short Pressure Ulcer Risk Assessment Tool dated 4/12/10 documented the resident's risk score was "17" which was considered lower risk. The Short Pressure Ulcer Risk Assessment Tool dated 3/9/11 documented the resident's risk score was "37", which was considered very high risk to develop pressure sores. The scale for this tool documented that score of 19 to 23 meant that the resident was at moderate risk for pressure ulcers, that a score of 24 to 27 meant that the resident was at high risk for pressure ulcers, and that a score equal to or greater than 28 meant that the resident at very high risk for pressure ulcers. Additionally, at the top of the tool, the instructions read new admissions with pressure ulcers present were to be categorized as "Very High Risk". The Nursing Notes (NN) dated 8/27/10 at 1:00 pm documented the resident was no longer utilizing the stand lift for transfers. The note documented the resident required assistance of 2 staff with a mechanic lift for transfers, and heel protectors (heel bootie) were to be on at all times as a proactive measure. The note also documented the heel protectors (heel booties) should be removed for care. The NN dated 12/27/10 at 10:56 am and signed by the Registered Nurse Unit Manager (RNUM) documented an area was discovered on the resident's right (R) heel which was examined and determined to be a deep tissue injury (DTI). DTI is described by the National Pressure Ulcer Advisory Panel (NPUAP) as a "purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear." (Pressure Ulcer Stages Revised by NPUAP, February 2007). The "Pressure or Stasis Ulcer Tracking" tool, dated 12/25/10 documented the area measured 2.0 cm X 1.8 cm X 0 cm. The NN also documented the resident had heel booties on at all times and was turned and positioned every 2 hours (Q2h) while in bed, utilizing a wedge for positioning. Skin prep to right heel twice a day (BID) and a " heel up " boot to the right foot were implemented. The NN dated 12/28/10-3/18/11 documented weekly assessments of the resident's R DTI. These NN documented no evidence the facility was utilizing a heels up bootie to off load the resident's left (L) heel. The NN dated 3/24/11 at 2:09 pm and signed by the RNUM, documented the resident was found to have a DTI on her L heel, which measured 2.3 cm X 2.0 cm with no openings noted. This note also documented the resident was receiving skin prep [MEDICATION NAME], a " heels up " boot has been in place, and an air mattress was implemented on 3/24/11. NCP, care card and interview all indicate " heels up " not in use to L heel. The "Resident Care Card" (documented the care a resident required by certified nurse's aides-CNAs) dated 10/21/10, documented the resident required 2 assist and a mechanical lift for transfers, was to have heel protectors (heel bootie) on at all times and utilized a perimeter mattress. The "Resident Care Card" dated 12/27/10 and 3/2/11, documented the resident required 2 assist and a mechanical lift for transfers, was to have heel protectors (heel booties) on at all times, utilized a raised perimeter mattress, and was to have a "heel up" boot to the Right foot. The "Resident Care Card" dated 3/24/11, documented the resident required 2 assist and a mechanical lift for transfers, was to have "heel up" boots to both feet when out of bed (OOB), and utilized an air mattress. The "Resident Care Card" dated 4/4/11, documented the resident required 2 assist and a mechanical lift for transfers, was to have " heel up" boot to both feet when OOB and heel up should be removed when in bed secondary to air mattress. This Care Card also documented the resident must be put back to bed after every meal secondary to skin breakdown and the resident utilized an air mattress. The Nursing Care Plan (NCP) entitled "Ulceration or interference with structural integrity of layers of skin caused by prolonged pressure related to immobility" initiated 12/21/10 documented a heel up bootie to the R foot was initiated on 12/27/10, and on 3/25/11, the NCP was revised and a heel up boot was initiated to both feet when OOB. A surveyor observed the resident 's heels on 4/18/11 at 10:30 am with the assistance of the LPN. The right heel had an area of scaly skin with small scabs, approximately 3/4 " diameter. The left heel had an area of dry black eschar (necrotic tissue) surrounded by approximately 1/8 " of ecchymotic (Purple/maroon) tissue. "Heel up" boots were present on both feet. During interview on 4/19/11 at 10:40 am, the RNUM stated she felt the resident had everything in place to prevent the pressure sores. The RNUM stated if a resident is high risk for skin breakdown, she would initiate heel booties, which she thought were pressure-reducing. The RNUM also stated the facility has always used heel booties and does not use the heels up booties (multi podus) until after the resident has had a skin breakdown. During interview on 4/19/11 at 11:05 am the Assistant Director of Nursing (ADON) stated the heel booties provide some reduction of pressure, however are not for residents at high risk. When asked, the ADON stated resident #7 was not considered a low risk for the development of pressure sores. During interview on 4/20/11 at 9:15 am, the resident's physician stated the facility probably should have used the heels up or off loaded both of the resident's heels as she was considered a high risk. The physician stated " we will have to change that." 10 NYCRR 415.12 (c)(1)