Every finding on record at Garden Care Center

Based on record review, and interviews, the facility did not ensure that there was sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was identified on three (3) (Unit 1, Unit 2 and Unit 3) of three (3) resident units reviewed for the Sufficient Nursing Staffing Task. Specifically, the facility triggered for the low weekend staffing metric on the Centers for Medicare and Medicaid Services Payroll-Based Journal Staffing Data Report for Quarter two, Quarter three, and Quarter four of Fiscal Year 2025. A random sampling of facility nursing staffing assignments did not reflect the staffing numbers as stipulated in the Facility Assessment for Certified Nursing Assistants, Licensed Practical Nurses, and Registered Nurses. The finding is:The Centers for Medicare and Medicaid Services Payroll-Based Journal Staffing Data Report for Fiscal Year 2025, Quarter two (2) (January 1st-March 31), Quarter three (03) (April 1st-June 30th) and Quarter four (04) (July 1st - September 30th) indicated that the facility triggered for the Metric of Low Weekend Staffing based on the facility's submitted staffing data.The Facility Assessment last reviewed on 01/28/2026 documented that the facility has an average daily census of 143 residents and a bed capacity of 150. The Facility Assessment included an average census of 28 for Unit one (01), 59 for Unit two (02) and 56 for Unit three (03). The Facility Assessment documented that the facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for the residents competently during both day-to-day operations and emergencies.The following staffing plan was determined for Unit one (01):-During the Day shift (7:00 AM-3:00 PM), Unit one (01) required one (01) Registered Nurse, one (01) Licensed Practical Nurse, and four (04) Certified Nursing Assistants.-During the Evening shift (3:00 PM-11:00 PM), Unit one (01) required two (02) Registered Nurses, one (01) Licensed Practical Nurse, and four (04) Certified Nursing Assistants.-During the Day shift (7:00 AM-3:00 PM), Unit two (02) required one (01) Registered Nurse, two (02) Licensed Practical Nurses, and seven (07) Certified Nursing Assistants.-During the Evening shift (3:00 PM-11:00 PM), Unit two (02) required two (02) Registered Nurses, two (02) Licensed Practical Nurses, and seven (07) Certified Nursing Assistants.-During the Day shift (7:00 AM-3:00 PM), Unit three (03) required (01) Registered Nurse, two (02) Licensed Practical Nurses, and seven (07) Certified Nursing Assistants.-During the Evening shift (3:00 PM-11:00 PM), Unit three (03) required two (02) Registered Nurses, two (02) Licensed Practical Nurses, and seven (07) Certified Nursing Assistants.A review of the 7:00 AM-3:00 PM shift staffing schedule for Unit one (01) with a bed capacity of 30, indicated the following:-There were only three (03) Certified Nursing Assistants assigned for an average census of 26 residents on 01/04/2025, 03/02/2025, 03/16/2025, 04/13/2025, 05/18/2025, 05/25/2025, 08/17/2025, and 09/14/2025.A review of the 3:00 PM-11:00 PM shift staffing schedule for Unit one (01) indicated the following:-There was one (01) Registered Nurse assigned for an average census of 26 residents on 01/04/2025, 01/19/2025, 01/26/2025, 02/01/2025, 03/30/2025, 04/05/2025, 04/26/2025, 05/11/2025, 05/17/2025, 05/18/2025, 05/25/2025, 06/8/2025, 07/06/2025, 07/19/2025, 08/31/2025, 09/13/2025, 09/14/2025, 09/20/2025, 09/21/2025, and 09/27/2025.-There were only three (03) Certified Nursing Assistants assigned for an average census of 26 residents on 02/01/2025, 03/30/2025, 08/16/2025, 09/13/2025, and 09/21/2025.-There were only two (2) Certified Nursing Assistants assigned to an average census of 26 residents on 05/18/2025 and 08/17/2025.A review of the 7:00 AM-3:00 PM shift staffing schedule for Unit two (02), which had a bed capacity of 60, indicated the following:-There were four (04) Certified Nursing Assistants assigned to 57 residents on 03/30/2025.-There were five (05) Certified Nursing Assistants assigned to 55 residents on 04/13/2025, 05/11/2025, 08/24/2025, and 09/13/2025.-There were six (06) Certified Nursing Assistants assigned to an average of 56 residents on 01/04/2025, 04/26/2025, 05/17/2025, 05/25/2025, 06/08/2025, 06/22/2025, 07/06/2025, 07/27/2025, 08/10/2025, 08/16/2025, 08/23/2025, 08/31/2025, 09/14/2025, 09/21/2025, and 09/27/2025.A review of the 3:00 PM-11:00 PM shift staffing schedule for Unit two (02) indicated the following:-There was one (01) Registered Nurse assigned an average of 56 residents on 01/04/2025, 01/19/2025, 01/26/2025, 02/01/2025, 02/08/2025, 02/15/2025, 03/30/2025, 04/05/2025, 04/26/2025, 05/11/2025, 05/17/2025, 05/18/2025, 05/25/2025, 06/08/2025, 06/22/2025, 06/28/2025, 07/06/2025, 07/19/2025, 08/31/2025, 09/13/2025, 09/14/2025, 09/20/2025, 09/21/2025, and 09/27/2025.-There were six (06) Certified Nursing Assistants assigned to an average of 56 residents on 01/19/2025, 02/08/2025, 03/16/2025, 03/30/2025, 05/18/2025, 05/25/2025, 06/08/2025, 06/22/2025, 07/06/2025, 07/27/2025, 08/17/2025, 08/31/2025, and 09/14/2025.-There were five (05) Certified Nursing Assistants assigned to 53 residents on 09/13/2025.-There was one (01) Licensed Practical Nurse assigned to 59 residents on 07/27/2025.A review of the 7:00 AM-3:00 PM shift staffing schedule for Unit three (03), which had a bed capacity of 60, indicated the following:-There were four (04) Certified Nursing Assistants assigned to 54 residents on 01/04/2025. -There were five (05) Certified Nursing Assistants assigned to 56 residents on 09/27/2025.-There were six (06) Certified Nursing Assistants assigned to an average of 55 residents on 01/26/2025, 02/15/2025, 03/02/2025, 04/13/2025, 05/11/2025, 05/25/2025, 06/22/2025, 07/19/2025, 07/27/2025, 08/10/2025, 08/17/2025, 08/23/2025, 08/31/2025, 09/13/2025, 09/20/2025, and 09/21/2025.A review of the 3:00 PM-11:00 PM shift staffing schedule for Unit three (03) indicated the following:-There was one (01) Registered Nurse assigned an average of 54 residents on 01/04/2025, 01/19/2025, 01/26/2025, 02/01/2025, 02/08/2025, 03/30/2025, 04/05/2025, 04/26/2025, 05/11/2025, 05/17/2025, 05/18/2025, 06/08/2025, 06/22/2025, 06/28/2025, 07/06/2025, 07/19/2025, 08/31/2025, 09/13/2025, 09/14/2025, 09/20/2025, 09/21/2025, and 09/27/2025.-There was one (01) Licensed Practical Nurse was assigned to 52 residents on 01/19/2025.-There were five (05) Certified Nursing Assistants assigned to 56 residents on 09/13/2025.-There were six (06) Certified Nursing Assistants assigned to an average of 54 residents on 01/19/2025, 01/26/2025, 02/08/2025, 02/15/2025, 03/16/2025, 05/18/2025, 06/08/2025, 06/22/2025, 07/06/2025, 07/26/2025, 07/27/2025, 08/31/2025, 09/14/2025, and 09/27/2025. During an interview on 02/26/2026 at 11:14 AM, the Staffing Coordinator stated the facility had numerous unscheduled nursing staff absences in the last few quarters. The Staffing Coordinator stated that since the new Administrator started in June 2025, they hired new nursing staff specifically for the weekends. The new full-time nursing staff must cover weekends. The Staffing coordinator stated the facility uses agency staff for Certified Nursing Assistants and Nurses but is not successful in covering the call outs and staff absences. During an interview on 02/27/2026 at 2:39 PM, the Administrator stated that when they started in June 2025, they had identified that the facility had staffing challenges. The Administrator stated that the last few quarters had the same staffing plan for each unit on every shift. The Administrator stated they started to hold meetings with the staffing coordinator to monitor staffing closely, changed the scheduling application the facility was previously utilizing to track staff call outs. The changes made regarding the staffing improvement were not noticeable until after November 2025.During an interview on 03/02/2026 at 12:36 PM, the Director of Nursing Services stated that the facility had staffing challenges in the past few quarters, and they are currently working their improvement plan to address nursing staff shortage.10 NYCRR 415.13(a)(1)(i-iii)

Based on observation, record review, and interviews, the facility did not ensure that it established and maintained an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This was identified for one (1) (Resident #124) of five (5) residents observed during medication administration. Specifically, during the medication pass observation on 02/26/2026, Licensed Practical Nurse #1 did not perform hand hygiene and administered the eye drops while wearing the same gloves they had used to administer the oral medications and respiratory treatment to the resident. The finding is:The facility policy titled Eye Drop Administration, dated 8/2025, documented eye medications will be administered in a safe and effective manner. The first step in the procedure is to put on examination gloves. The policy did not indicate to wash hands first. The policy states with a gloved finger, gently pull down the lower eyelid to form a pouch and instill the eye drops.Resident #124 was admitted with diagnoses including diabetes mellitus, pneumonia, and anxiety disorder. The 02/10/2026 Annual Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact.During the medication pass observation on 02/26/2026 at 8:55 AM, Licensed Practical Nurse #1 prepared the following medications as per physician's order, at the medication cart, outside Resident #124's room: Losartan 100 milligram tablet, give one tablet at 9:00 AM daily (for hypertension).Glimeperide 4 milligram tablet, give one tablet at 9:00 AM daily (for diabetes).Primidone 50 milligram tablet, give one tablet three times a day (for convulsions).Duloxetine 60 milligram capsule, give one capsule two times a day (for depression).Arnuity Ellipta 200 milligram/actuation powder, one puff, for inhalation at 9:00 AM daily (for asthma).Liquid Protein Supplement (LPS) sugar free 30 milliliter supplement at 9:00 AM daily.Tears Lubricant 0.5% eye drops, instill one drop in each eye every 12 hours.Licensed Practical Nurse #1 prepped the medications at the cart by pouring the Liquid Protein Supplement in a cup, putting the tablets and capsule in a cup, and taking the plastic bag containing the Arnuity Ellipta inhaler out of the drawer. Licensed Practical Nurse #1 then sanitized their hands with a hand sanitizer, put on a pair of gloves, and brought all the medications into the room at the resident's bedside. The resident was repeatedly coughing and complained about coughing too much. The nurse responded that they would provide respiratory treatment now. While wearing the gloves, Licensed Practical Nurse #1 handed the medication cup containing tablets and the capsule to the resident. The resident swallowed the medications and handed the cup back to the nurse. The nurse provided a cup of water to the resident. The nurse then handed the Liquid Protein Supplement cup to the resident. The resident drank the Liquid Protein Supplement and handed the cup back to the nurse. The nurse then took the Arnuity Ellipta inhaler device out of the plastic bag, handed it to the resident, who took one puff of the medication, handed the device back to the nurse, and the nurse then put the inhaler device back in the plastic bag. Wearing the same gloves that were used to administer all the other medications, Licensed Practical Nurse #1 administered eye drops in each eye by pulling down the resident's lower eye lids.During an interview on 02/26/2026 at 12:30 PM, Licensed Practical Nurse #1 stated they were nervous during the medication pass observation and that is why they wore gloves. Licensed Practical Nurse #1 stated they should have removed the gloves and sanitized their hands before administering the eye drops. During an interview on 02/27/2026 at 2:20 PM, the Registered Nurse Infection Preventionist stated Licensed Practical Nurse #1 should have removed their gloves, washed their hands, and put on clean gloves before administering the eye drops. During an interview on 03/02/2026 at 12:20 PM, the Director of Nursing Services stated Licensed Practical Nurse #1 put on the gloves too early. They should have put on the gloves for the eye drops only. The Director of Nursing Services stated the nurse should have removed the old gloves, sanitized their hands, and then put on new gloves before administering the eye drops. 10NYCRR 415.19(b)(4)

Based on observation and interviews, the facility did not ensure that all drugs and biologicals were stored in locked compartments. This was identified for one (1) of three (3) medication storage rooms observed during the Medication Storage task. Specifically, two medication cabinets, inside the central supply room, containing over the counter medication supply were left unlocked. The central supply room door lock was malfunctioning causing the door to remain unlocked.The finding is:The facility policy and procedure for Labeling and Storage of Drugs and Biologicals, last reviewed/revised on July 2025 documented that over-the-counter medications maintained in Central Supply shall be secured to prevent unauthorized access. The room shall remain locked when unattended. Access is limited to authorized personnel, including nursing administration and designated staff. During an observation and interview with the facility Assistant Administrator on 03/02/2026 at 01:53 PM, the central supply room located on the facility's basement floor was inspected. The basement included a resident rehabilitation gym, resident hair salon, and the central supply room. Upon entry, the central supply room door was closed but not locked. The Assistant Administrator, who was responsible for central supply, stated that there were two (2) cabinets where over-the-counter medications were stored. A tan-colored freestanding two- door steel cabinet was observed on the right side of the room. The cabinet was labeled emergency supply cabinet. Two strips of white tape were taped on the cabinet doors above the two keyed swing handles. The cabinet door was not locked. Medications stored inside the cabinet included but were not limited to over-the-counter antacids and painkillers. Another same model cabinet was located on the left side of the room. The door to the second cabinet was also not locked. Medications were stored inside the cabinet included but were not limited to over-the-counter multivitamins, vitamins and mineral supplements, stool softeners, antacids and painkillers. The Assistant stated the cabinets remain unlocked because the central supply room door is locked at all times and only limited staff have access to the supply room.During an interview on 03/02/2026 at 02:13 PM, Maintenance Staff #1 stated they were called to check the central supply room door. Maintenance Staff #1 stated that the central supply room door has a slam shut lock which automatically locks the door upon closing. Maintenance Staff #1 stated that after inspecting the door they found out that the door did not automatically lock upon closing and required repair.During an interview on 03/03/2026 at 01:44 PM, the Director of Nursing Services stated the two medication cabinets in the central supply room should be locked. The Director of Nursing Services stated that the central supply room door should also be locked at all times. The Director of Nursing Services stated the basement was not off-limits to residents as the residents visited the rehabilitation gym and the hair salon in the basement.10 NYCRR 415.18(e)(1-4)

Based on observations, record review, and interviews during the Recertification Survey initiated on 8/26/2024 and completed on 8/30/2024 the facility did not ensure that each resident with Pressure Ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing. This was identified for three (Resident #38, Resident #5, and Resident #82) of eight residents reviewed for Pressure Ulcers. Specifically, 1) Resident #38 had multiple pressure ulcers and had a physician's order to use a low-air loss mattress for pressure relief. During multiple observations, the adjustable weight setting for the air mattress, which is meant to correspond to the resident's weight, was not set accurately. 2) Resident #5 had a history of Moisture Associated Skin Damage to the left buttock. Resident #5 had an order for a low-air loss mattress. During multiple observations, the adjustable weight setting for the air mattress was not set accurately. 3) Resident # 82 had Moisture Associated Skin Damage to the sacrum area. Resident #82 had an order for a low-air loss mattress. During several observations, the adjustable weight setting for the air mattress was not set accurately. The findings are: The facility's policy titled Pressure Injury Management and Prevention revised on 5/2024, documented it is the policy of the facility to have in place all necessary interventions to prevent the development of pressure ulcers and to facilitate healing of any existing pressure ulcers acquired before admission, readmission, or hospital return. Residents at risk for pressure injuries will have a preventative plan implemented and specific preventative care interventions may include pressure-relieving mattresses. The facility's policy titled Air Mattress revised on 1/01/2024 documented that air mattresses should be used as a tool to help with alleviating pressure. The use of an air mattress is an adjunct to proper turning and positioning with other pressure-relieving devices or interventions. The air mattress should be checked daily for proper functioning by staff and any issues will be reported to the unit nurse. The nursing staff will then set up the mattress according to the manufacturer's instructions. The operation manual for the low-air mattress documented instructions that included adjusting the internal pressure of the air mattress according to the patient's weight by using the weight button on the control panel of the power unit. 1) Resident # 38 was admitted with diagnoses including Dementia, Type 2 Diabetes Mellitus, and Pneumonia. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 99, which indicated the resident had severely impaired cognition. The Minimum Data Set documented the resident had three Stage 4 Pressure Ulcers. A Comprehensive Care Plan titled Pressure Ulcer/Injury was initiated on 4/05/2024 with documented interventions that included the use of a pressure relief mattress, turning and positioning the resident every 2 hours and as needed. A Wound Care Physician consultation dated 8/20/2024 documented the resident had a left foot arterial wound measuring 2.5 centimeters in length, 0.8 centimeters in width, and 0.1 centimeters in depth. A left Ischium/buttock Stage 4 Pressure Ulcer (full thickness with an exposed underlying structure) measuring 3.5 centimeters in length, 4.5 centimeters in width, and 2.7 centimeters in depth. A right Ischium/buttock Stage 4 Pressure Ulcer (full thickness with exposed underlying structure) measuring 4.2 centimeters in length, 1.8 centimeters in width, and 2.4 centimeters in depth, with undermining (when the edges of a wound separate from the surrounding tissue creating a pocket underneath the wound surface) measuring 3.1 centimeters. A sacrum Stage 4 Pressure Ulcer (full thickness with exposed underlying structure) measuring 7 centimeters in length, 6.2 centimeters in width, 2.4 centimeters in depth, with undermining measuring 2.4 centimeters. A physician's order dated 7/08/2024 and last renewed on 8/09/2024 documented the use of a low-air loss mattress. A review of the electronic medical record indicated Resident #38's most recent weight was 85 pounds on 8/29/2024. Resident #38 was observed in bed on 8/26/2024 at 10:03 AM. The air mattress weight setting was set at 325 pounds. Resident #38 was observed in bed on 8/26/2024 at 12:19 PM, the air mattress weight setting was set at 325 pounds. Resident #38 was observed in bed on 08/27/24 at 08:50 AM. The air mattress weight setting was set at 325 pounds. Nurse Supervisor #2 was interviewed on 8/28/2024 at 9:16 AM and stated Resident #38 has multiple skin breakdowns and uses the air mattress. The air mattress weight setting should be adjusted to the resident's weight. Nurse Supervisor #2 stated the resident's air mattress weight setting was set at 325 pounds and the resident weighs 85 pounds. The wound care nurse is responsible for ensuring that the air mattress weight setting is accurately set. Nurse Supervisor #2 stated they were only responsible for ensuring that the air mattress was not deflated and was functioning properly. Wound Care Nurse #3 was interviewed on 8/28/2024 at 10:44 AM and stated they check all the air mattresses daily to ensure that the weight setting is set according to the residents' weight. Wound Care Nurse #3 stated Resident #38 weighs 85 pounds, and the air mattress weight setting should not be set at 325 pounds. Certified Nursing Assistant #1 was interviewed on 8/29/2024 at 10:00 AM and stated they are the regularly assigned 7:00 AM-3:00 PM shift Certified Nursing Assistant for Resident #38. Certified Nursing Assistant #1 stated they do not touch the setting on the air mattress and if they identify any concerns with the air mattress, they report them to the unit nurse. Wound Care Physician #2 was interviewed on 8/29/2024 at 11:19 AM and stated the purpose of the air mattress is to relieve pressure from wounds and to prevent further pressure ulcer development. The mattress weight setting should be set according to the resident's weight and the manufacturer's guidelines. If the weight setting for the air mattress is too high or too low, it can cause more pressure injury and impede the healing of the current wounds. The Director of Nursing Services was interviewed on 8/29/2024 at 11:27 AM and stated the air mattress weight setting should be set according to the resident's weight. The nurses are responsible for monitoring the air mattress weight setting when the wound nurse is not in the building. 2) Resident #5 was admitted with diagnoses that included Heart Failure, Major Depressive Disorder, and Dementia. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 99, which indicated the resident had severely impaired cognition. The Minimum Data Set documented that Resident #5 had Moisture Associated Skin Damage. A Comprehensive Care Plan titled Pressure Ulcer/Injury was initiated on 5/12/2023 and last revised on 8/08/2024 documented interventions that included the use of a pressure relief air mattress and encouraging the resident to turn in bed. A physician's order dated 3/18/2024 and renewed on 8/03/2024 documented the use of a low-air loss mattress. A Wound Care Physician's consultation dated 8/20/2024 documented Resident #5 had Moisture Associated Skin Damage to the left buttock that was now healed. A review of the electronic medical record indicated Resident #5's most recent weight was 173 pounds on 8/03/2024. Resident #5 was observed in bed on 8/26/2024 at 9:45 AM. The air mattress weight setting was set at 250 pounds. Resident #5 was observed in bed eating their breakfast on 8/27/2024 at 8:48 AM. The air mattress weight setting was set at 250 pounds. Resident #5 was observed in bed on 8/28/2024 at 9:22 AM. The air mattress weight setting was set at 250 pounds. Nurse Supervisor #2 was interviewed on 8/28/2024 at 09:22 AM and stated Resident #5's air mattress weight setting was set at 250 pounds and currently the resident weighs 173 pounds. The air mattress weight setting should be set according to the resident's weight. The Director of Nursing Services was interviewed on 8/29/2024 at 11:27 AM and stated the air mattress weight setting should be set according to the resident's weight. The nurses are responsible for monitoring the air mattress weight setting when the wound nurse is not in the building. 34798 3) Resident #82 was admitted with diagnoses including Diabetes Mellitus, Non-Alzheimer's Dementia, and Muscle Wasting and Atrophy. The 6/30/2024 Significant Change Minimum Data Set assessment did not have a Brief Interview for Mental Status score due to the resident's severely impaired cognitive skills for daily decision-making. The Minimum Data Set assessment documented the resident was at risk for pressure ulcer development. A Comprehensive Care Plan titled Pressure Ulcer/Skin Integrity Alteration Risk, effective 10/4/2023 and last updated on 7/8/2024, documented an intervention for a low air loss mattress. An update on 7/3/2024 documented that the resident was on comfort care and was at increased risk of skin breakdown. A physician's order dated 10/3/2023 and last updated 8/26/2024 documented the use of a Low Air Loss Mattress. A physician's order dated 4/12/2024 and last updated 8/26/2024 documented under Advanced Directives: Comfort Measures Only. A physician's order dated 8/5/2024 and last updated 8/26/2024 documented cleanse sacral area with soap and water, pat dry, apply zinc oxide (topical wound treatment) and cover with dressing every shift for diagnosis of irritant contact dermatitis due to friction or contact with body fluids. A wound care weekly note dated 8/21/2024 written by Registered Nurse #3 (wound care nurse) documented: sacrum-moisture associated skin damage measuring 5 centimeters in length and 4 centimeters in width; interventions included to apply zinc oxide treatment and offloading with low air loss mattress. Resident #82's weight in the medical record as of 8/2/2024 was 122 pounds. On 8/26/2024 at 9:38 AM Resident #82 was observed in bed. The air mattress weight setting was set at 250 pounds. On 8/28/2024 at 9:08 AM Resident #82 was observed in their wheelchair in their room. The air mattress weight setting was set at 250 pounds. On 8/28/2024 at 9:21 AM Registered Nurse #2 (unit supervisor) observed Resident #82's mattress and confirmed the weight was set at 250 pounds. Registered Nurse #2 checked the resident's weight in the medical record and stated the last recorded weight was 122 pounds. Registered Nurse #2 stated the wound care nurse does daily rounds and is supposed to check the air mattress weight setting and the mattress weight setting is supposed to be set according to the resident's weight. Registered Nurse #2 stated our job as nurses on the unit is to make sure the mattress is not deflated and ensure that the air mattress is functioning properly. It is the wound care nurse's job to ensure the setting is consistent with the resident's weight. Registered Nurse #2 stated they do not check the air mattress weight setting because it has been set by the wound care nurse. Registered Nurse #4, the Clinical Supervisor, was interviewed on 8/28/2024 at 10:31 AM. Registered Nurse #4 stated the wound care nurse orders the air mattress and sets the weight setting on the air mattress based on the resident's weight. Any unit nurse can let the wound care nurse know if the weight setting is not accurate. The unit nurses do environmental checks, so checking the mattress weight setting should be a part of the environmental checks. Registered Nurse #3, the wound care nurse, was interviewed on 8/28/2024 at 10:45 AM. Registered Nurse #3 stated the weight setting on the air mattress should be consistent with the resident's weight and they check the air mattress weight setting on daily rounds, but they have not been in the building for several days. Registered Nurse #3 stated they did not know that there was no protocol for the unit nurses to check the air mattress weight setting in their absence. Physician #2, the wound care consultant, was interviewed on 8/29/2024 at 11:19 AM and stated residents with pressure ulcers should have an air mattress in place to prevent further pressure ulcer development. The purpose of the air mattress is to relieve pressure from wounds and to prevent further pressure ulcers. The mattress should be set according to the resident's weight and the manufacturer's guidelines. If a mattress weight is set too high or too low, it can cause more pressure injury and impede healing of the current wounds. The Director of Nursing Services was interviewed on 8/29/2024 at 11:27 AM and stated the air mattress weight should be set consistent with the resident's weight. The Director of Nursing Services stated the nurses on the unit are responsible for monitoring the mattress when the wound care nurse is not in the building. The nurses are aware that they are responsible for monitoring the settings on the mattress. 10 NYCRR 415.12(c)(1)

Based on observation, record review, and interviews during the Recertification Survey initiated on 8/26/2024 and completed on 8/30/2024, the facility did not ensure that each resident's environment remained as free of accident hazards as possible. This was identified for one (Third Floor) of three units observed during the initial tour. Specifically, a full oxygen E-Cylinder tank (portable oxygen tank) was observed in the third-floor day room that was not secured in a rolling safety stand or a metal rack. The finding is: The facility's policy and procedure titled Oxygen Therapy last revised on 5/2024 documented that safety devices in valves or cylinders shall never be tampered with. Cylinders shall not be chained to portable or movable apparatus such as beds and tables. Even if they are considered empty, cylinders shall never be used as rollers, supports, or for any other purpose other than that for which they are intended by the supplier. Cylinders and containers shall not be dropped, dragged, or rolled. Cylinders shall not be supported by, and neither cylinder nor container shall be placed in proximity of, radiators, steam pipes, or heat ducts. The policy did not include guidance on how to store an oxygen tank in resident units. During an observation on 8/26/2024 at 10:21 AM, a free-standing, unsecured E-cylinder tank was observed in the third-floor unit day room during an activity. The E-cylinder tank gauge needle was at 2,000 PSI (pounds per square inch) indicating that the tank was full. A Recreation Aide was present in the day room during the observation. The Recreation Aide was interviewed on 8/26/2024 at 10:22 AM and stated they did not notice the free-standing E-cylinder tank in the day room. The Recreation Aide stated they would call the nurse if they noticed the E-cylinder tank. Registered Nurse #5, the Unit Supervisor, was interviewed on 8/26/2024 at 10:25 AM and stated they did not know there was a free-standing E-cylinder tank in the day room. Registered Nurse #5 stated the oxygen tank should not be left unsecured and must be placed in a rolling cart or a metal rack to secure the E-cylinder tank. The Director of Maintenance and Housekeeping was interviewed on 8/27/2024 at 2:47 PM and stated the nurses are responsible for the oxygen tanks that are stored on the unit. The Director of Maintenance and Housekeeping stated all oxygen tanks must be secured with a rolling cart or a metal rack. The Director of Maintenance and Housekeeping stated there should not be an unsecured, free-standing E-cylinder tank on the unit. The Director of Maintenance and Housekeeping stated If the tank falls and the tank regulator and valve come off the top of the tank, the tank itself can propel like a rocket. The Director of Maintenance and Housekeeping stated an unsecured E-cylinder tank is an accident hazard. The Director of Nursing Services was interviewed on 8/30/2024 at 9:54 AM and stated the E-cylinder tank should always be secured using a rolling cart or a metal rack. The Director of Nursing Services further stated an unsecured E-cylinder tank is an accident hazard. 10 NYCRR 415.12(h)(1)

Based on observations, record review, and interviews during the Recertification Survey initiated on 8/26/2024 and completed on 8/30/2024, the facility did not ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice. This was identified for two (Resident #5 and Resident #82) of two residents reviewed for Respiratory Care. Specifically, 1) Resident #5 had a physician's order to continuously receive oxygen therapy at 2 liters per minute. The resident was observed receiving an inaccurate amount of oxygen therapy on 8/26/2024, 8/27/2024, and 8/28/2024. 2) Resident #82 had a physician's order to continuously receive oxygen therapy at 2 liters per minute. The resident was observed receiving an inaccurate amount of oxygen therapy on 8/26/2024, 8/27/2024, and 8/28/2024. The findings are: The facility's policy titled Oxygen Therapy revised on 5/2024 documented that oxygen therapy must be ordered by a Physician or Nurse Practitioner and the flow rate of oxygen is to be set at the prescribed liters per minute. 1) Resident #5 was admitted with diagnoses that included Congestive Heart Failure, Major Depressive Disorder, and Dementia. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 99, which indicated the resident had severely impaired cognition. The resident had lower extremity impairment and was dependent on two or more helpers for chair to bed transfer. The Minimum Data Set documented that Resident #5 used oxygen therapy during the look-back period. The Comprehensive Care Plan for Oxygen Therapy last reviewed on 8/08/2024 documented to provide treatments and medications as per Physician orders. A physician's order dated 3/27/2024 last renewed on 8/03/2024 documented to administer 2 liters of oxygen continuously via a nasal cannula. Resident #5 was observed in bed sleeping on 8/26/2024 at 9:45 AM. The resident was receiving oxygen via an oxygen concentrator. The oxygen flow rate was set at 4 liters per minute. Resident #5 was observed in their room in a Geri chair on 8/26/2024 at 12:22 PM. The resident was receiving oxygen via an oxygen concentrator. The oxygen flow rate was set at 4 liters per minute. Resident #5 was observed in bed having breakfast on 8/27/2024 at 8:49 AM. The resident was receiving oxygen via an oxygen concentrator. The oxygen flow rate was set at 4 liters per minute. Resident #5 was observed in bed on 8/28/2024 at 9:24 AM. Nurse Supervisor #2 was also present in the room. The resident was receiving oxygen via an oxygen concentrator. The oxygen flow rate was set at 4 liters per minute. Nurse Supervisor #2 was interviewed on 8/28/2024 at 9:24 AM and stated the resident was supposed to receive continuous oxygen at 2 liters per minute; however, the oxygen flow rate was set at 4 liters per minute. Nurse Supervisor #2 stated only the nursing staff is responsible for changing the oxygen setting on the oxygen concentrator. Nurse Supervisor #2 stated Resident #5 was not able to reach the concentrator from their bed or the Geri chair to change the oxygen setting. The Director of Nursing Services was interviewed on 8/28/2024 at 12:56 PM and stated that the nurses on the unit should monitor the oxygen levels of each resident who is receiving oxygen during their shift. The nurses should regularly assess the resident's oxygen levels, and if an increase is needed, they should obtain an updated order from the Physician. 2) Resident #82 was admitted with diagnoses that included Dementia, Diabetes Mellitus, and Wheezing. The Annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 99, which indicated the resident had severely impaired cognition. The Minimum Data Set documented Resident #82 used oxygen therapy during the look-back period. The Comprehensive Care Plan for Respiratory Care dated 4/01/2024 documented interventions including administering oxygen as per the physician's order. A physician's order dated 6/10/2024 and renewed on 8/26/2024 documented to administer 2 liters of oxygen continuously via a nasal cannula. Resident #82 was observed in bed on 8/26/2024 at 9:38 AM. The resident was receiving oxygen via an oxygen concentrator. The oxygen flow rate was set at 4 liters per minute. Resident #82 was observed in bed on 8/26/2024 at 12:21 PM. The resident was receiving oxygen via an oxygen concentrator. The oxygen flow rate was set at 4 liters per minute. Resident #82 was observed in bed on 8/27/2024 at 8:46 AM having breakfast. The resident was receiving oxygen via an oxygen concentrator. The oxygen flow rate was set at 4 liters per minute. Resident #82 was observed on 8/28/2024 at 9:29 AM in bed. Nurse Supervisor #2 was also present in the room. The resident was receiving oxygen via an oxygen concentrator. The oxygen flow rate was set at 5 liters per minute. Nurse Supervisor #2 was interviewed on 8/28/2024 at 9:29 AM and stated Resident #82 has a physician's order to administer oxygen at 2 liters per minute. Nurse Supervisor #2 acknowledged that the resident was receiving oxygen at 5 liters per minute. Nurse Supervisor #2 stated only the nurses are responsible for changing the oxygen setting on the oxygen concentrator. The nurses should be monitoring the oxygen level on each shift and if the resident needs an increase, they should increase oxygen and notify the Physician. Resident #5 was not able to reach the concentrator from their bed or the Geri chair to change the oxygen setting. The Director of Nursing Services was interviewed on 8/28/2024 at 12:56 PM and stated that the nurses on the unit should monitor the oxygen levels of each resident who is receiving oxygen during their shift. The nurses should regularly assess the resident's oxygen levels, and if an increase is needed, they should obtain an updated order from the Physician. 10 NYCRR 415.12 (k)(6)

Based on observation, record review, and interviews during the Recertification Survey initiated on 8/26/2024 and completed on 8/30/2024 the facility did not ensure that it maintained an infection prevention and control program designed to help prevent the development and transmission of infectious diseases. This was identified for one (Resident #67) of three residents reviewed for tube feeding. Specifically, Resident #67 had a physician's order for Enhanced Barrier Precautions for the use of a gastrostomy tube (feeding tube inserted through the stomach for artificial feeding). During an observation, Registered Nurse Supervisor #2 was observed entering Resident #67's room without the use of Personal Protective Equipment (gown and gloves) and disconnected the tube feeding from the gastrostomy tube. The finding is: The facility policy titled Enhanced Barrier Precautions dated 5/06/2024 documented that Enhanced Barrier Precautions are indicated for residents with central lines, urinary catheters, feeding tubes, and tracheostomies. The Enhanced Barrier Precautions are employed when performing high-contact resident care activities such as device care or feeding tube use. Resident #67 was admitted with diagnoses including Type 2 Diabetes Mellitus, Cerebral Infarction (disrupted blood flow to the brain), and Dementia. The Annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 8, indicating the resident had moderate cognitive impairment. The Minimum Data Set documented the resident utilized tube feeding. A physician's order dated 5/14/2024 and last renewed on 8/26/2024 documented Enhanced Barrier Precautions due to gastronomy tube. A Comprehensive Care Plan dated 5/14/2024 for Enhanced Barrier Precautions had interventions including the use of a gown and gloves when in contact with the gastronomy tube. Nurse Supervisor #2 was observed going into Resident #67's room on 8/26/2024 at 10:00 AM to respond to the tube feeding pump alarm. There was a sign at the door and above the resident's bed indicating the resident was on Enhanced Barrier Precautions. The sign read Everyone must clean hands before entering and leaving the room. Staff must wear gown and gloves for high-contact resident care. The sign had a list of device care including a feeding tube with directions to wear a gown and gloves when providing care. Nurse Supervisor #2 did not don (put on) a gown or gloves when they turned off the feeding pump and disconnected the tube feeding from the resident's gastronomy tube. Nurse Supervisor #2 was interviewed on 8/26/2024 at 10:05 AM and stated Resident #67 is on Enhanced Barrier Precautions for the use of a gastronomy tube. The staff needs to wear Personal Protective Equipment when coming in contact with the gastronomy tube. Nurse Supervisor #2 further stated they should have put on Personal Protective Equipment to disconnect the tube feed; however, they were nervous and wanted to promptly respond to the alarm. The Assistant Director of Nursing Services, the Infection Preventionist, was interviewed on 8/28/2024 at 1:45 PM and stated nursing staff are expected to use gowns and gloves when providing care to a resident with a feeding tube. A resident with a feeding tube is placed on Enhanced Barrier Precautions because the feeding tube can harbor organisms that can transfer to staff and then to other residents. Nurse Supervisor #2 should have put on a gown and gloves when they disconnected the tubing from the resident's gastronomy tube. The Director of Nursing Services was interviewed on 8/30/2024 at 9:52 AM and stated nursing staff should wear Personal Protective Equipment while caring for residents who are on Enhanced Barrier Precautions. 10 NYCRR 415.19 (a)(1-3)

Based on record review and interviews conducted during a Recertification Survey initiated on 8/26/2024 and completed on 8/30/2024, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice. This was identified for one (Resident #1) of five residents reviewed for Unnecessary Medications. Specifically, Resident #1 with a diagnosis of Diabetes Mellitus had a physician's order to monitor the resident's blood glucose level as per the facility's protocol. The facility policy indicated reporting the findings to the Physician if the blood glucose levels were less than 100 milligrams/Deciliter or greater than 300 milligrams /Deciliter. Resident #1's blood glucose levels were less than 100 milligrams/Deciliter or greater than 300 milligrams /Deciliter on 27 occasions in July 2024 and on 13 occasions in August 2024 and the resident's Physician was not notified as per the facility protocol. Additionally, the insulin injection sites were not documented in the resident's medical record on 50 occasions in July 2024 and 70 occasions in August 2024. The finding is: The facility's policy titled Fingerstick Blood Glucose Level Monitoring, last revised May 2024, documented that glucose and fingerstick results with blood sugar levels of less than 100 milligrams/Deciliter or greater than 300 milligrams/Deciliter will be reported to the Primary Care Physician/Nurse Practitioner. The facility's policy titled Medication Administration, last revised May 2024, documented that when giving insulin, site rotation should be charted in the Medication Administration Record. Resident #1 was admitted with diagnoses of Diabetes Mellitus with Diabetic Polyneuropathy (nerve involvement), Hypertension, and Peripheral Autonomic Neuropathy. The Admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The Minimum Data Set documented Resident #1 received insulin injections. The physician's order dated 7/5/2024 documented to administer 4 units of Novolog 100 unit/milliliter insulin subcutaneously three times a day and to monitor blood sugar levels as per protocol. The physician's order dated 7/5/2024 documented to administer 18 units of Lantus Solostar 100 unit/ milliliter subcutaneously once daily at bedtime and to monitor blood sugar levels as per protocol. The Comprehensive Care Plan (CCP) for Diabetes Mellitus dated 7/8/2024 documented interventions to administer antidiabetic medication as ordered, to monitor blood glucose/fingerstick levels as ordered, and to monitor for signs and symptoms of Hypoglycemia (low blood glucose) or Hyperglycemia (high blood glucose). The July 2024 Medication Administration Record documented the resident's blood sugar levels greater than 300 milligrams /Deciliter on 7/9/2024 at 5:03 PM; 7/13/2024 at 5:00 PM; 7/16/2024 at 8:28 AM and 12:07 PM; 7/17/2024 at 9:38 AM; 7/18/2024 at 10:00 PM; 7/19/2024 at 5:07 AM; 7/20/2024 at 12:41 PM; 7/21/2024 at 4:37 PM and 9:10 PM; 7/22/2024 at 8:36 AM, 12:40 PM, and 5:16 PM; 7/23/2024 at 5:11 PM and 9:45 PM, 12:33 PM, 4:33 PM and 8:59 PM; 7/25/2024 at 7:30 AM and 5:00 PM; 7/26/2024 at 11:30 AM; 7/27/2024 at 5:04 PM; 7/28/2024 at 12:18 PM and 5:03 PM; 7/29/2024 at 5:04 PM and 8:55 PM; and on 7/31/2024 at 9:09 PM. There was no documentation in the medical record that the resident's Physician was notified of the elevated blood glucose levels as per the facility's protocols. The July 2024 Medication Administration Record review also revealed that the insulin injection administration site was not documented for 50 out of 100 occasions. The August 2024 Medication Administration Record documented the blood sugar levels were either less than 100 milligrams /Deciliter or greater than 300 milligrams /Deciliter on 8/3/2024 at 7:30 AM, 11:30 AM, and 8:39 PM; 8/4/2024 at 12:35 PM, 5:00 PM, and 8:34 PM; 8/5/2024 at 12:57 PM; 8/6/2024 at 9:31 AM; 8/16/2024 at 11:30 AM; 8/19/2024 at 12:50 PM; 8/24/2024 at 9:51 AM; 8/25/2024 at 9:24 AM; 8/26/2024 at 9:45 PM. There was no documentation in the medical record that the resident's Physician was notified of these blood glucose levels. The August 2024 Medication Administration Record review also revealed that the insulin injection administration site was not documented for 68 out of 106 occasions. Licensed Practical Nurse #2 was interviewed on 8/28/2024 at 2:02 PM and stated they were the regularly assigned medication nurse on Resident #1's unit during the 7:00 AM- 3:00 PM shift. Licensed Practical Nurse #2 stated they were familiar with Resident #1 and would consider the resident's blood sugar level out of range if the blood glucose level was below 70 milligrams /Deciliter and greater than 255 milligrams /Deciliter. Licensed Practical Nurse #2 stated they would notify the unit manager if the resident's blood sugar level was out of range. Licensed Practical Nurse #2 stated Resident #1's physician's orders did not include the blood glucose parameters to indicate when a Physician should be notified and they did not know the facility protocol. Licensed Practical Nurse #2 stated that the insulin injection site should be rotated and documented to prevent insulin from being administered repeatedly at the same location. Licensed Practical Nurse #2 stated that repeated injection administration at the same site may potentially cause swelling and bruising to the area. Licensed Practical Nurse #2 did not know why they did not document the insulin injection sites after they administered the insulin to the resident. Registered Nurse #5, the unit manager, was interviewed on 8/28/2024 at 2:32 PM and stated nurses should notify their supervisor each time when a resident's blood sugar level is below 100 milligrams /Deciliter and greater than 300 milligrams /Deciliter as per the facility's protocol. Registered Nurse #5 stated they were never notified of Resident #1's unstable blood sugar results and thought the resident's blood sugar was under control. Registered Nurse #5 stated nurses should document the injection site after each insulin administration and the site should be rotated. Licensed Practical Nurse #3 was interviewed on 8/28/2024 at 3:31 PM and stated they were the regularly assigned 3:00 PM-11:00 PM medication nurse. Licensed Practical Nurse #3 stated when Resident #1's blood sugar level exceeded 300 milligrams /Deciliter, they did not inform the Physician because Resident #1's physician's order did not have parameters. Licensed Practical Nurse #3 stated they were not aware of the facility protocol regarding when to report the blood glucose levels to a medical provider. Physician #3 was interviewed on 8/30/2024 at 11:04 AM and stated they expected the nursing staff to follow the facility protocol and notify the Physician when the blood glucose levels are outside the established parameters so they can monitor the effectiveness of the resident's current diabetes management and re-adjust the resident's medication dose as necessary. The Director of Nursing Services was interviewed on 8/30/2024 at 11:23 AM and stated nursing staff should follow the facility protocol and notify the Physician each time the resident's blood sugar is below 100 milligrams /Deciliter or higher than 300 milligrams /Deciliter unless otherwise specified by the Physician. The Director of Nursing Services stated insulin injection site should be rotated and nurses should document the injection site each time insulin was administered. The Director of Nursing Services stated that repeated injections at the same site can cause swelling and redness and affect the absorption of insulin. 10NYCRR 415.12

Based on record review and interviews during the Recertification Survey initiated on 8/26/2024 and completed on 8/30/2024, the facility did not ensure that a Pre-Admission Screening and Resident Review (PASARR) was completed for each resident prior to their admission to the facility to determine that the individual requires the level of services provided by the nursing facility and whether the individual requires specialized services. This was identified for one (Resident #29) of 26 residents reviewed for Pre-Admission Screening and Resident Review (PASARR). Specifically, Resident #29 was admitted to the facility in October 2023. There was no documented evidence that a Level 1 Pre-Admission Screening and Resident Review (PASARR) was completed prior to Resident #29's admission. The finding is: The facility's policy and procedure titled Pre-Admission Screening and Resident Review (PASSR) last revised on 6/26/2024 documented that the admission coordinator will ensure a screen is completed before admission for all new admissions. Resident #29 was admitted to the facility on [DATE] with diagnoses of Major Depressive Disorder, Diabetes Mellitus, and Myalgia (muscle pain). The Admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderately impaired cognition. The assessment's Pre-Admission Screening and Resident Review (PASARR) section documented that Resident #29 was not currently considered by the State level II Pre-admission Screening and Resident Review (PASARR) process to have a serious mental illness, intellectual disability, or other related conditions. The facility failed to provide documented evidence that a Pre-Admission Screening and Resident Review (PASARR) form was completed and reviewed prior to Resident #29's admission. The Director of Admissions was interviewed on 8/29/2024 at 11:15 AM and stated they were not employed at the facility in October 2023. The Director of Admissions stated that the admission department is responsible for reviewing and ensuring that the resident's admission documents from the sending facility include a Pre-Admission Screening and Resident Review (PASARR) form. The Director of Admissions stated that if a screen form was not included or was incomplete, they would reach out to the case worker from the sending facility to obtain a completed copy of the screen form. The Director of Social Work was interviewed on 8/29/2024 at 11:32 AM and stated that Resident #29's Pre-Admission Screening and Resident Review (PASARR) form was not found. The Director of Social Work stated that the admission staff who admitted Resident #29 should have ensured that a Pre-Admission Screening and Resident Review (PASARR) form was completed for Resident #29 by the sending facility, prior to their admission. The Director of Social Work stated that the Pre-Admission Screening and Resident Review (PASARR) form was also reviewed by the Social Worker prior to the resident's admission because if a Level II referral was recommended, the Social Work Department is responsible for obtaining recommended services such as psychiatric evaluation assessment and ensuring that the facility can provide the services. The Administrator was interviewed on 8/29/2024 at 2:42 PM and stated that Resident #29's Pre-Admission Screening and Resident Review (PASARR) form was not found and they were not able to obtain the copy from the sending facility. The Administrator stated that the admission department is expected to review and ensure that each resident has a completed Pre-Admission Screening and Resident Review prior to their admission to the facility. The Administrator stated that the Pre-Admission Screening and Resident Review (PASARR) form is essential to determine whether the facility can offer a safe placement and provide appropriate services to the resident. 10 NYCRR 415.11(e)

Based on record review and interview conducted during an abbreviated survey (NY00320341), the facility failed to protect one of three residents reviewed for Accidents (Resident #1). Specifically, Certified Nurse Assistant #1 (CNA #1) failed to follow the plan of care which required two people to assist for toileting and bed mobility. CNA #1 proceeded to provide incontinet care (in the bed) alone causing Resident #1's head to strike the bedside table resulting in a laceration. The laceration required Resident #1 to be transfer to the hospital and six sutures. This was evidenced by: Resident #1 Minimum Data Set (MDS) dated [DATE] documented resident is rarely/never understood. MDS documented resident requires extensive assistance of two person for bed mobility, transfer, and toilet use. The MDS further documented the resident had limitation in range of motion in both upper and lower extremities. The policy and procedure titled Activities of Daily Living dated 1/2023 documented the Resident will have their needs met based on the facility assessment. Resident #1's nursing instruction date 7/1/23 to 7/31/23 documented resident is extensive assistance of 2 persons for bed mobility and toilet use. Review of the CNA accountability record for the month of June and July documented signatures indicating task was completed as extensive assistance of two persons. A comprehensive care plan titled NSG-ADL (nursing-activities of daily living) function documented the focus as Activities of Daily Living (ADL) deficit secondary to cognitive deficit, contractures, hemiplegia. The goal is to be clean dry and well-groomed x 90 day. The interventions include anticipate resident's needs, attend resident unhurried, encourage and assist with turn and positioning. A progress note dated 7/17/23 documented by the Licensed Practical Nurse #1 (LPN) in charge on the unit documented the resident was observed with laceration to the mid upper forehead. Documented resident remained alert and responsive in stable condition, and the supervisor was notified. A nursing supervisor progress note dated 7/17/23 documented the Registered Nurse #1 (RN) responded to the unit to observe laceration to forehead as per CNA while giving care the resident was turned and hit her head toward the dresser. Progress notes further documented Resident #1 left the facility in stable condition via stretcher to the hospital. The facility investigative summary documented probable evidence of abuse neglect or mistreatment as there is reason to believe the assigned CNA failed to review and follow the plan of care for the resident. Statements provided by assigned CNA documented while giving incontinent care, Resident #1 sustained a laceration to her forehead from contact with the bedside table. The hospital discharge papers dated 7/19/23 documented principal discharge diagnosis superficial laceration. Resident #1 required 6 sutures and computed axial tomography scans (CT scan) of the head which showed old strokes and no signs of new stroke or bleeding. Multiple attempts to reach CNA #1 was unsuccessful. During an interview conducted with CNA #2 on 8/29/23 at 10:00 AM CNA #2 stated that they are responsible to check the resident care summary prior to caring for residents. CNA #2 stated the care summary will provides the resident's ADL needs and anything that needs to be done for the resident and how many people are needed to do it. CNA #2 further stated if staff is unable to follow the plan of care, they must notify a supervisor and they will reassess the resident. An interview was conducted with the Director of Nursing (DON) on 11/1/23 at 3:45 PM who stated that all inservices and competencies were completed by 8/25/23. During previous interviews the DON stated CNAs should follow the residents plan of care. The residents plan of care is in the kiosk, and all have access. The DON stated based on the investigation the assigned CNA was terminated, other residents she cared for were interviewed and no other concerns were identified. The DON further stated that all staff was reeducated, and competencies completed related to following the directions on the CNA instructions, documenting and transfers. Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance on 8/25/23 and was in substantial compliance for this specific regulatory requirement at the time of this survey: -Completed a full house audit to determine what residents required 2-person care. -Completed competencies with 100% of CNA 's including Hoyer lift (a mechanical lift used to assist in the transfer). -Completed -Completed reeducation with 100% of CNA staff about following the residents plan of care. -Developed and implemented an audit tool to ensure staff are following plan of care -All Staff was reeducated on the policy and procedure for abuse neglect and mistreatment. 10 NYCRR 415.12(h)(1)

Based on record review and interviews during the Recertification Survey and Abbreviated Survey (NY00297184) initiated on 1/5/2023 and completed on 1/13/2023, the facility staff did not effectively implement interventions to prevent an avoidable accident. This was identified for 1 (Resident #47) of five residents reviewed for Accidents. Specifically, Resident #47 required two-person assistance for bed mobility as per the resident's assessments and care plans. On 6/8/2022, the assigned Certified Nursing Assistant (CNA) #2 provided incontinent care to Resident #47 independently and did not seek assistance from another staff member. Resident #47 rolled out of the bed and fell to the floor and sustained a Hematoma (pool of mostly clotted blood that forms in an organ, tissue, or body space) to the frontal lobe, and Ecchymotic (bruise) areas to the left eye, nose, and face. Subsequently, Resident #47 was transferred to the hospital and was diagnosed with orbital and pelvic fractures. This resulted in actual harm to Resident #47 that is not Immediate Jeopardy. The finding is: The facility's policy titled CNA Accountability and Assignment Record, dated 10/2021, documented that a CNA provide activities of daily living (ADL) care to all residents according to the plan of care as reflected in their accountability record. This plan of care is given to each CNA, and the CNA signs for all the care provided to the resident for a particular time/day the care is provided. It is the responsibility of the CNA to read the resident's accountability record at the beginning of each shift prior to giving care. Resident #47 was admitted with diagnoses including Diabetes Mellitus, Cerebrovascular Accident, and Hemiplegia (paralysis of one side of the body). The 5/22/2022 Annual Minimum Data Set (MDS) assessment documented no Brief Interview for Mental Status (BIMS) score as the resident had severely impaired cognitive skills for daily decision making. The MDS documented that the resident required total assistance of two staff members for bed mobility and for toilet use. The resident was always incontinent of the bladder and frequently incontinent of bowel. A Rehabilitation (Rehab) Department screen dated 5/23/2022 documented Resident #47 required total assistance of two staff members for bed mobility and required a Hoyer (Mechanical) lift for transfers. The Resident Nursing Instructions (CNA care instructions), from the Electronic Medical Record (EMR), documented two-person physical assistance for bed mobility effective 6/23/2017. A Comprehensive Care Plan (CCP) titled Activities of Daily Living (ADL) Function, effective 7/17/2017 and reviewed on 6/7/2022 prior to the accident, documented the resident is dependent in care needs. Requires total assistance to complete ADLs. A nursing progress note dated 6/8/2022 at 7:14 AM, written by Registered Nurse (RN) #5 (who was the 11 PM-7 AM nursing Supervisor), documented that RN #5 was called by the charge nurse at 6:56 AM to assess Resident #47 who had rolled off the bed onto the floor during morning care. RN #5 observed the resident on the floor lying on their back on the right side of the bed with fresh blood oozing from their nose. A full body assessment was conducted. The resident was noted with a Hematoma to the frontal lobe measuring 3-centimeter (cm) x 3 cm; Ecchymotic area to the left eye, nose, and face measuring 4 cm x 4 cm. No change in level of consciousness was noted. Resident #47 was assisted back to bed with a Hoyer lift. The physician was immediately made aware, and an order was received to transfer the resident to the hospital. The Occurrence Report (Accident/Incident (A/I) Report) dated 6/8/2022 at 6:56 AM documented a nurse (LPN #2) was called to the resident's room and Resident #47 was found lying on the floor. The Supervisor (RN #5) was notified. The resident's Primary Care Physician was contacted, and the resident was transferred to the hospital for further evaluation. A nursing progress note written by the 7 AM- 3 PM RN #1 dated 6/8/2022 at 2:18 PM documented the resident was admitted to the hospital with a diagnosis of pelvic fracture and left orbital fracture. A written statement from CNA #2 (assigned CNA to Resident #47) in the A/I report dated 6/8/2022 documented the CNA was providing incontinence care when they (CNA #2) tried to stop Resident #47 from scratching the resident's back. Resident #47 was rolling and slid from the bed. CNA #2 tried to catch the resident, but the resident slid. Then CNA #2 called the nurse for help. The nurse [LPN #2] responded and called the Supervisor [RN #5] to evaluate the resident who was lying on the floor. The A/I Report included written statements from two other CNAs who worked on the 11 PM-7 AM shift on 6/7/2022-6/8/2022. Both CNAs documented that they were never called by CNA #2 to assist with incontinence care for Resident #47. Review of the Administrative A/I Investigative Summary dated 6/9/2022, signed by the former Director of Nursing Services (DNS), concluded that no abuse, neglect, or mistreatment of Resident #47 occurred related to the fall on 6/8/2022. The incident was a result of a care plan violation. The CNA Accountability Record indicated Resident #47 required two-person assistance for bed mobility and incontinence care. CNA (#2) provided care to the resident by themselves and did not ask any other staff member for help. CNA #2 was taken off the schedule and suspended for five days. Review of the hospital discharge instructions dated 6/17/2022 documented that the resident was admitted on [DATE] with an acute left orbital (eye) fracture, acute fracture of the left superior and inferior pubic rami (pelvis), and the left sacrum (a large triangular bone at the base of the spine). RN #4 (current A/I coordinator) was interviewed on 1/12/2023 at 3:02 PM and stated Resident #47 required two-person assistance for bed mobility, but one aide was doing the care and the resident fell out of bed. RN #4 stated that CNA #2 did not follow the plan of care for Resident #47, which led to Resident #47 falling from their bed. The Rehabilitation Director was interviewed on 1/13/2023 at 9:41 AM and stated the Rehabilitation screen was completed in May 2022 and documented that Resident #47 required total care for Activities of Daily Living (ADLs). The Rehabilitation Director stated Resident #47 required two-person assistance for bed mobility, was transferred with a Hoyer lift, and was non ambulatory. CNA #2 was interviewed on 1/13/2023 at 9:50 AM. CNA #2 stated they (CNA #2) were assigned to care for Resident #47 on 6/8/2022. CNA #2 stated they knew Resident #47 needed the assistance of two people for transfers, but they (CNA #2) just had to change the resident's brief and provided the incontinence care alone for Resident #47 on 6/8/2022. CNA #2 stated they did not ask for help from other staff members because they did not see any other staff members outside the room. CNA #2 stated the resident had a wound on their back and the resident was scratching it and the wound was bleeding. CNA #2 stated while they (CNA #2) had the resident on the resident's side to provide incontinence care, the CNA attempted to try to get the resident to stop scratching the resident's back and the resident rolled out of bed. CNA #2 stated that they reviewed the CNA care instructions for each resident on 6/8/2022; however, they (CNA #2) did not know that Resident #47 needed two-person assistance for bed mobility. RN #5, who was the nursing supervisor for the 11 PM-7 AM shift on 6/8/2022, was interviewed on 1/13/2023 at 10:14 AM. RN #5 stated they responded to Resident #47's fall on 6/8/2022. The Licensed Practical Nurse (LPN) #2 was already in the resident's room. RN #5 stated that Resident #47 required two persons to provide incontinent care, not just for Hoyer transfers. RN #5 stated that CNA #2 was providing care by themselves, and the resident rolled out of bed. RN #5 stated CNA #2 did not call for help and other staff were there to help if needed. RN #5 stated CNA #2 was a new CNA and did not follow Resident #47's plan of care. LPN #2, the unit charge nurse on the 11 PM-7 AM shift, was interviewed on 1/13/2023 at 10:30 AM. LPN #2 stated they (LPN #2) responded to CNA #2's call for help after Resident #47 fell out of bed. LPN #2 stated Resident #47 was a two-person assist for bed mobility and CNA #2 did not call anyone for help when providing incontinence care. Review of CNA #2 Inservice Attendance Record dated 4/4/2022 indicated the CNA received education on the following topics: see accountability record for safe patient handling and transfers and read accountability record before starting care. Physician #2 was interviewed on 1/13/2023 at 10:57 AM and stated that the CNA was supposed to follow the plan of care, but unfortunately accidents happen. The Current Director of Nursing Services (DNS) was interviewed on 1/13/2023 at 11:53 AM and stated when the staff are in a rush, some of them do what they want to do, especially in the morning when there is a lot of rushing. The DNS stated it is not that staff are not aware, they (staff) are supposed to follow the care plan. The DNS stated the CNAs know they are supposed to follow the plan of care or ask a co-worker if they are not sure. The DNS further stated the resident sustained multiple fracture because CNA #2 did not follow the plan of care and ask for help when providing care to the resident. 10 NYCRR 415.12(h)(2)

Based on observation, interview and record review during the Recertification Survey and Abbreviated Survey (NY00306893) initiated on 1/5/2023 and completed on 1/13/2023, the facility did not provide a functional environment for one (Resident #263) of one Resident reviewed for Environment. Specifically, when Resident #263 resided on the second floor in a three bedded room. There was insufficient space in the room to accommodate a Mechanical (Hoyer) lift between Resident #44's bed and Resident #263 bed. Resident #263 was asked to get out of bed exit the room when Resident #44 needed to be transferred in and out of bed with Hoyer lift. The finding is: The facility policy entitled Safety Management Plan dated November 2017 documented that a safe and functional environment of care is essential for delivering high quality of care to all. All staff are responsible for cooperating with all aspects of the Safety Management Program. This includes performing their duties in a safe manner and reporting any and all hazardous conditions. 1 a) Resident #44 has diagnoses including Metatarsal Fractures, Diabetes Mellitus, and Hypertension. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 9 which indicated the resident had moderately impaired cognition. Resident #44 required extensive assistance of two persons for bed mobility and transfer. The Physical Therapy (PT) evaluation dated 11/2/2022 documented that Resident #44 required assistance of two persons via mechanical lift for transfers in and out of bed to the wheelchair. 1 b) Resident #263 has diagnoses of Non-Alzheimer's Dementia, Pneumonia, and Malnutrition. The Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #263 had a Brief Interview for Mental Status (BIMS) score of 9 which indicated the resident had moderately impaired cognition. Resident #263 required extensive assistance of two persons for bed mobility and transfer. The facility census documented that Resident #44 occupied the A bed in the three bedded Room from 11/11/22 to 12/20/22. The census also documented that Resident #263 occupied the C bed in the three room [ROOM NUMBER] from 11/16/22 to 12/22/22. Resident #263's family member was interviewed on 1/10/2023 at 10:10 AM and stated Resident #263 was moved to another unit in a private room after readmission from the hospital on 1/3/2023. Resident #263 had previously resided on the second floor in the three bedded room. The family member stated that the three bedded room was too small for three residents. Whenever the roommate needed to be transferred out of bed with the Hoyer lift, the whole room had to be rearranged. The Certified Nursing Assistant (CNAs) had to move Resident #263's bed to make room for the Hoyer to fit in between the beds. The family member and Resident #263 would have to step out of the room when visiting so that the staff could get to the roommate. The family member stated that they expressed concern to the CNAs and the nurse, but no one did anything about it. The three bedded room was observed on 1/10/2023 at 10:38 AM. The room was L shaped with the A bed located closest to the window. The C bed was parallel to the A bed and was located closest to the room door. The B bed was located on the opposite side of the room. CNA #3 was interviewed on 1/10/2023 at 10:40 AM. CNA #3 stated that they are currently assigned to the three bedded room. CNA #3 stated that it is difficult to get the Hoyer lift into the three bedded room and that whenever they assisted with the Hoyer lift transfer, they had to move the other bed closer to the door. CNA #4, who was dayshift CNA assigned to Resident #263 while the resident was in the three bedded room, was interviewed on 1/11/23 at 9:54 AM and stated that the three bedded room was small. CNA #4 stated that they had to ask Resident #263's family member and Resident #263 to step out of the room whenever they had to get Resident #44 transferred out of bed. Sometimes CNA #4 had to ask Resident #263 to get out of bed so they (CNA #4) can move Resident #263's bed to transfer Resident #44 with the Hoyer lift because the space between the beds is too small to fit the Hoyer lift. The Director of Nursing Services (DNS) was interviewed on 1/12/2023 at 10:25 AM and stated that the resident needs have to be considered when assigning a room. The DNS stated that having a small space for a Hoyer lift is not safe and could cause a resident to fall out of the Hoyer. The DNS stated that the room would have to be re-arranged or a resident who requires a Hoyer lift should be assigned to another room that can fit a Hoyer lift. 10 NYCRR 415.29

Based on interview and record review during the Recertification Survey and Abbreviated Survey (NY00306893) initiated on 1/5/2023 and completed on 1/13/2023, the facility did not conduct COVID-19 testing individuals with known or suspected exposure to COVID-19. This was identified for one (Resident #263) of one resident reviewed for Infection Control. Specifically, Resident #263 was transferred to the hospital for low blood pressure, low heart rate and low oxygen saturation on 12/22/2022. At the hospital the resident was diagnosed with COVID-19 infection. The facility was notified of the resident's COVID-19 diagnosis by the hospital. The facility did not conduct contact tracing to identify staff that were in close contact with Resident #263 to identify transmission of COVID-19 infection and did not conduct COVID-19 testing. The finding is: The facility policy entitled Long Term Care Facility Testing/Visitation dated 9/23/2022 documented that facilities are required to test residents and staff based on parameters and frequency set forth by the Health and Human Services (HHS) Secretary. Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately (but not earlier than 24 hours after the exposure, if known). If the facility has the ability to identify close contacts of the individual with COVID-19, they could choose to conduct focused testing based on known close contacts. Close Contact refers to someone who has been within 6 feet of a COVID-19 positive person for a cumulative total of 15 minutes or more over a 24-hour period. Resident #263 has diagnoses of Non-Alzheimer's Dementia, Pneumonia, and Malnutrition. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 9 which indicated the resident had moderately impaired cognition. The physician's orders dated 11/10/2022 documented to administer oxygen at a rate of 2 liters per minute as needed via Nasal Cannula. The nursing note dated 12/22/2022 at 2:09 PM documented Resident #263 was hypotensive (low blood pressure), bradycardic (low heart rate) and hypoxic (low oxygen saturation). The resident's oxygen was increased from 2 liters to 4 liters per minute. The Physician was notified and ordered to transfer the resident to the hospital. The nursing progress note written by the Registered Nurse (RN) #2 dated 12/22/2022 at 9:41 PM documented Resident #263 was admitted to the hospital with a diagnosis of COVID-19 infection. The hospital admission note dated 12/22/2022 documented the reason for the resident's admission to the hospital was Hypoxia and COVID-19 infection. The Certified Nursing Assistant (CNA) Accountability Record dated December 2022 documented CNA #4 and CNA #5 provided care for Resident #263 from 12/20/2022 to 12/22/2022. The progress note dated 12/23/2022 at 10:58 AM documented RN #1 performed a Rapid COVID-19 test for Resident #24, who was Resident #263's roommate. Resident #24 was negative for COVID-19 infection. RN #1 was interviewed on 1/10/2023 at 12:20 PM. RN #1 stated that they were assigned to Resident #263 on 12/22/2022 before the resident was transferred to the hospital. RN #1 stated that the night nurse, RN #2, called the hospital on 12/22/2022 and was notified by the hospital that the resident was admitted with COVID-19 infection. RN #2 notified RN #1 of the resident's COVID-19 diagnosis on 12/23/2022. RN #1 stated that after the resident's diagnosis was known to the facility, they (RN #1) were not tested and were not aware if other staff members who provided care to Resident #263 were tested for COVID-19. RN #2 was interviewed on 1/11/2023 at 9:46 AM and stated that they (RN #2) informed the Director of Nursing Services (DNS) on 12/22/2022 at 9:38 PM via a text message that Resident #263 tested positive for COVID-19 infection at the hospital. CNA #4 was interviewed on 1/11/23 at 9:54 AM. CNA #4 was Resident #263's regular CNA during the day shift. CNA #4 stated that they (CNA #4) provided care for Resident #263 the week of 12/19/2022 through 12/22/2022. CNA #4 stated that during the week, Resident #263 had a cough and CNA #4 was told by RN #1 it was just Pneumonia. Resident #263 was not wearing a surgical mask and CNA #4 was wearing a surgical mask when CNA #4 provided care. Resident #263 was not on any precautions. As CNA #4 noticed Resident #263's cough worsened, CNA #4 decided to wear an N95 mask but did not wear eye protection. CNA #4 stated that they spent 30 minutes every morning with Resident #263 to assist with toileting, washing, oral swabbing, washing the dentures and combing the resident's hair. In addition to the 30 minutes spent in the morning, CNA #4 also toileted Resident #263 throughout the day which would take a minimum of 5 minutes on each occasion because they had to stay with Resident #263 during toileting activities and the resident requested to be toileted frequently. CNA #4 did not work on 12/23/2022 and returned to the facility on [DATE]. No one from the facility notified CNA #4 that they had close contact with a positive COVID-19 case and they (CNA #4) were not instructed to get tested for COVID-19. CNA #5 was interviewed on 1/11/23 at 3:20 PM. CNA #5 stated that they were the regularly assigned evening shift CNA for Resident #263. CNA #5 stated that they spent 15-25 minutes providing care to Resident #263 before bedtime each night from 12/20/2022 through 12/22/2022. In addition to the 15-25 minutes of care, CNA #5 would spend about 10 minutes with Resident #263 every 2 hours to provide incontinence care. CNA #5 stated that Resident #263 did not wear a mask. CNA #5 stated that they wore an KN95 mask but did not wear eye protection. CNA #5 stated that Resident #263 was not on any precautions. CNA #5 further stated that the facility did not contact CNA #5 about getting tested for COVID-19. The Administrator was interviewed on 1/11/23 at 3:43 PM. The Administrator stated that they were aware that Resident #263 tested positive for COVID-19 infection in the hospital on 12/22/2022. The Administrator stated that the DNS at that time was the Infection Preventionist. The Administrator stated that staff members who provided care for Resident #263 were not tested because the previous DNS, who was also the Infection Preventionist, did not tell them (Administrator) that the staff had to be tested . 10NYCRR 415.19

Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (NY00290705) initiated on 1/5/2023 and completed on 1/13/2023, the facility did not ensure that the medical care of each resident was supervised by the Physician including monitoring changes in the resident's medical status. This was identified for one (Resident #163) of two residents reviewed for Nutrition. Specifically, Resident #163 had a 14% significant weight loss in one month, identified in December 2021, which was not addressed by their Primary Care Physician (PCP). Resident #163 had an additional 5% significant weight loss in one month, identified in January 2022, and there was no documentation from the PCP addressing the resident's significant weight loss in a timely manner. The finding is: The facility's policy titled, Monthly Weight and Vital Sign Policy and Procedure last reviewed on 1/2021 documented that the Nurse would notify the Physician and Dietitian of any 5 pounds (lbs)/5% weight changes. The facility's policy titled, Unplanned Significant Weight Changes last reviewed on 11/2021 documented that a significant weight loss is defined as a 5% weight loss in one month or more and a 10% loss in 6 months. The policy also documented that the Physician should review the weight loss and based on the resident's diagnosis/prognosis, determine if the weight loss is unavoidable. Resident #163 has diagnoses which include Type 2 Diabetes Mellitus and Hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident had severely impaired cognitive skills for daily decision making. The resident required extensive assistance of one person for eating. The resident's height was 70 inches and they weighed 180 pounds. The MDS documented the resident had loss of liquids/solids from mouth when eating or drinking; was holding food in mouth/cheeks or residual food in mouth after meals; and exhibited coughing or choking during meals or when swallowing medications. The quarterly MDS assessment dated [DATE] documented that the resident had a BIMS score of 3 which indicated the resident had severely impaired cognitive skills for daily decision making. The resident was totally dependent on one person for eating. The resident's height was 70 inches and they now weighed 150 pounds a decrease of 30 lbs since the 11/4/2021 MDS assessment. The MDS documented the resident had loss of liquids/solids from mouth when eating or drinking; was holding food in mouth/cheeks or residual food in mouth after meals; and exhibited coughing or choking during meals or when swallowing medications. The MDS also documented that there was a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and that the resident was not on a physician prescribed weight-loss regimen. The Physician's Order dated 7/30/2021 and last renewed on 1/12/2022 documented Do Not Resuscitate (DNR): Consent on File, Comfort Measures Only, Do Not Intubate (DNI), Do not send to the Hospital (DNH), and a trial period of Intravenous (IV) Fluids. The resident's Weight Monitoring Report documented that on 10/20/2021 the resident weighed 180 lbs and on 12/10/2021 the resident weighed 158 lbs which indicated a 22 lbs or a 14% significant weight loss in two months. The Medical Monthly Progress Note dated 12/22/2021, written by the resident's PCP (Physician #2), documented: Weight 180 lbs - No changes - observe only. The resident's current diet orders dated 12/22/2021 documented Diet: No Concentrated Sweets (NCS), Food Consistency: Ground (No Bread), and Fluid Consistency: Thin Liquids. The Speech Therapy Progress Note dated 1/12/2022 recommended a diet change from ground solids (no bread) and thin liquids to puree solids and nectar thick liquids secondary to a change in the resident's cognitive status. The resident's diet orders dated 1/12/2022 documented Diet: NCS, Food Consistency: Puree, and Fluid Consistency: Nectar Thickened. The resident's Weight Monitoring Report documented that on 1/14/2022 the resident weighed 150 lbs which indicated an additional 8 lb or 5% significant weight loss in one month. The Speech Therapy Progress Note dated 1/14/2022 at 4:26 PM recommended a diet change from nectar thickened liquids to honey thickened liquids due to an increased aspiration risk. Speech Language Pathologist (SLP) observed excessive coughing post swallow of nectar thick liquids. The resident's diet orders dated 1/14/2022 documented Diet: NCS, Food Consistency: Puree, and Fluid Consistency: Honey Thickened. The Medical Monthly Progress Note dated 1/14/2022 at 10:14 PM, written by the resident's PCP (Physician #2), documented: Weight 150 lbs - observe only. There was no further documentation in reference to the resident's weight. The Weight Change/Quarterly Nutrition assessment dated [DATE], written by Registered Dietitian (RD #2), documented that the resident's Current Body Weight (CBW): 150 lbs, Height: 70 inches, Ideal Body Weight Range (IBWr): 149-183 lbs, and the Body Mass Index (BMI): 21.5 (categorized as normal body weight; BMI>20 is desirable given advanced age). The evaluation by RD #2 documented that the resident presented with a weight change of (-30 lbs, -20% loss) x 3 months, and (-30 lbs, -20% loss) x 6 months; weight change (x 3 and 6 months) was clinically significant, unplanned, and undesirable, questioned the accuracy of weighs/weight status and a reweigh for the resident for January was currently pending. The weight loss was likely related to the resident's variable oral (po) intake, mechanically altered diet, disease process, Parkinson's Disease, Dementia, and recent positive COVID-19 diagnosis The Brief Nutrition Note dated 1/17/2022, written by RD #2, documented concerns regarding the resident's weight loss and nutrition status were discussed with the resident's family, food preferences were obtained, and Glucerna shakes (a nutritional supplement) would be provided twice daily to aid in optimizing the resident's intake and weight status. The resident's diet order dated 1/17/2022 documented Supplement: Honey Thickened Glucerna 8 ounces (oz) by mouth twice daily (BID). The Medical Progress Notes dated 1/17/2022, 1/19/2022, 1/21/2022, and 2/7/2022 written by the resident's PCP (Physician #2) documented that they were asked to see patient by staff for f/u (follow-up) eval (evaluation) with no documented evidence addressing the resident's significant weight loss. The Medical Progress note dated 3/6/2022 written by the resident's PCP (Physician #2) documented that the resident's family had taken the resident to the Emergency Department (ED) on 2/9/2022 for an undisclosed reason. The 3rd Floor Registered Nurse (RN #7) Charge Nurse was interviewed on 1/10/2023 at 3:00 PM and stated that monthly weights are started at the end of each month by the 30th or 31st and finished by the 5th of the following month. RN #7 stated that if there is a weight discrepancy, reweights are done by the 10th of the month. RN #7 stated that the weights are written on a weight worksheet, and they (RN #7) would check if they could find the old weight worksheets for 2021 to see why the resident was not weighed for November 2021 and why no reweights had been done to check the accuracy of the weights when the resident had lost 22 lbs between October and December 2021 and another 8 lbs between December 2021 and January 2022. RN #7 was re-interviewed on 1/10/2023 at 4:05 PM and stated that they (RN #7) did not see any documentation in the resident's electronic medical record (EMR), nor were they (RN #7) able to find any weight worksheets to explain why there was no weight taken for the resident in November 2021 and why no reweights were done to address the resident's significant weight loss. RN #7 was re-interviewed again on 1/11/2023 at 10:00 AM and stated that during October, November, and December 2021 the RD would enter the weights into the EMR. RN #7 stated that if there is a discrepancy of more than 2 pounds, they (RN #7) would ask for a reweigh. If a significant weight loss was seen, they (RN #7) would notify the PCP with a phone call and write a progress note in the EMR. RN #7 could not explain why they (RN #7) did not write a progress note regarding the resident's weight loss and notification to the PCP. The facility's current RD (RD #1) was interviewed on 1/11/2023 at 10:45 AM and stated by looking into the resident's EMR, a weight in November was never obtained nor was there a re-weight for the December weight. RD #1 stated there should have been a note written by the RD at that time (RD #2) stating that a reweight was pending and some kind of intervention put into place in December of 2021 when the 22 lb weight loss was seen. RD #1 stated that the resident's family should have been called first to get food preferences and to tell them (the family) if there was a confirmed weight loss and put an intervention in place first while waiting for a reweigh such as giving a Mighty Shake (a high calorie shake) in between meals at 10:30 AM, 2:30 PM, and 8:30 PM. Resident #163's PCP (Physician #2) was interviewed on 1/11/2023 at 1:13 PM and stated that the resident was on Comfort Measures since 7/30/2021 and guessed that was why they (Physician #2) were not too aggressive in treating them (Resident #163) for their weight loss. Physician #2 stated that it was very strange why they (Physician #2) did not acknowledge the resident's significant weight loss in December of 2021 and could not explain why they (Physician #2) would just observe the resident's weight in January 2022 when the resident had lost 20 lbs or 20% of their weight in 3 months. The Medical Director was interviewed on 1/11/2023 at 2:50 PM and stated that when Physician's document weights, they should refer to the weights in the EMR. The Medical Director stated that if a resident has a significant weight loss, it should be documented that it was discussed with family and in this case, that weight loss was expected because they (the resident) were on Comfort Care. The facility's prior RD (RD #2) was interviewed on 1/11/2023 at 3:00 PM and stated that if they (RD #2) had known about the weight or seen the significant weight loss in December 2021, they (RD #2) would have documented. RD #2 stated that they (RD #2) were in charge of putting all of the weights into the EMR. RD #2 stated that Resident #163's weight of 158 lbs in December of 2021 was a 14% weight loss in two months, which was significant. RD #2 could not say why they (RD #2) missed the resident's initial weight loss in November 2021. The Director of Nursing Services (DNS) was interviewed on 1/12/2023 at 10:00 AM and stated that Nursing staff communicates with the PCP when there is a weight loss. The DNS stated that the weight scale should be checked if there was something wrong, maybe the weight scale was not balanced. The DNS stated that a re-weigh for the resident should have been obtained. The DNS stated that the resident should also have been looked at to see how much the resident was eating at meals at the time and the RD should have been notified. The DNS further stated that if there was a change in the resident's weight of plus or minus 5 lbs in a month, the resident should have been reweighed. 10 NYCRR 415.15(b)(1)(i)(ii)

Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (NY00290705) initiated on 1/5/2023 and completed on 1/13/2023, the facility did not ensure that each resident maintained, to the extent possible, acceptable parameters of nutritional and hydration status. This was identified for one (Resident #163) of two residents reviewed for Nutrition. Specifically, Resident #163 had a 14% significant weight loss in one month, identified in December 2021, which was not addressed by the Registered Dietitian (RD) until January 2022. The finding is: The facility's policy titled, Monthly Weight and Vital Sign Policy and Procedure last reviewed on 1/2021 documented that the Nurse would notify the Physician and Dietitian of any 5 pounds (lbs)/5% weight changes. The policy also documented that once weights are completed, they will be given to the Dietitian. The Dietitian will enter the weights into the Electronic Medical Record and document the weight on the monthly weight sheet. The facility's policy titled, Unplanned Significant Weight Changes last reviewed on 11/2021 documented that a significant weight loss is defined as a 5% weight loss in one month or more and a 10% loss in 6 months. The policy also documented that the Dietitian will complete a comprehensive assessment and based on the findings, the Dietitian will determine the need for further interventions. Resident #163 has diagnoses which include Type 2 Diabetes Mellitus and Hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident had severely impaired cognitive skills for daily decision making. The resident required extensive assistance of one person for eating. The resident's height was 70 inches and they weighed 180 pounds. The MDS documented the resident had loss of liquids/solids from mouth when eating or drinking; was holding food in mouth/cheeks or residual food in mouth after meals; and exhibited coughing or choking during meals or when swallowing medications. The quarterly MDS assessment dated [DATE] documented that the resident had a BIMS score of 3 which indicated the resident had severely impaired cognitive skills for daily decision making. The resident was totally dependent on one person for eating. The resident's height was 70 inches and they now weighed 150 pounds, a decrease of 30 lbs since the 11/4/2021 MDS assessment. The MDS documented the resident had loss of liquids/solids from mouth when eating or drinking; was holding food in mouth/cheeks or residual food in mouth after meals; and exhibited coughing or choking during meals or when swallowing medications. The MDS also documented that there was a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and that the resident was not on a physician prescribed weight-loss regimen. The resident's Weight Monitoring Report documented that on 10/20/2021 the resident weighed 180 lbs and on 12/10/2021 the resident weighed 158 lbs which indicated a 22 lbs or a 14% significant weight loss in two months. The resident's current diet orders dated 12/22/2021 documented Diet: No Concentrated Sweets (NCS), Food Consistency: Ground (No Bread), and Fluid Consistency: Thin Liquids. The Speech Therapy Progress Note dated 1/12/2022 recommended a diet change from ground solids (no bread) and thin liquids to puree solids and nectar thick liquids secondary to a change in the resident's cognitive status. The resident's diet orders dated 1/12/2022 documented Diet: NCS, Food Consistency: Puree, and Fluid Consistency: Nectar Thickened. The resident's Weight Monitoring Report documented that on 1/14/2022 the resident weighed 150 lbs which indicated an additional 8 lb or 5% significant weight loss in one month. The Speech Therapy Progress Note dated 1/14/2022 at 4:26 PM recommended a diet change from nectar thickened liquids to honey thickened liquids due to an increased aspiration risk. Speech Language Pathologist (SLP) observed excessive coughing post swallow of nectar thick liquids. The resident's diet orders dated 1/14/2022 documented Diet: NCS, Food Consistency: Puree, and Fluid Consistency: Honey Thickened. The Weight Change/Quarterly Nutrition assessment dated [DATE], written by Registered Dietitian (RD) #2, documented that the resident's Current Body Weight (CBW): 150 lbs, Height: 70 inches, Ideal Body Weight Range (IBWr): 149-183 lbs, and the Body Mass Index (BMI): 21.5 (categorized as normal body weight; BMI>20 is desirable given advanced age). The evaluation by RD #2 documented that the resident presented with a weight change of (-30 lbs, -20% loss) x 3 months, and (-30 lbs, -20% loss) x 6 months; weight change (x 3 and 6 months) was clinically significant, unplanned, and undesirable, questioned the accuracy of weighs/weight status and a reweigh for the resident for January was currently pending. The weight loss was likely related to the resident's variable oral (po) intake, mechanically altered diet, disease process, Parkinson's Disease, Dementia, and recent positive COVID-19 diagnosis. The Brief Nutrition Note dated 1/17/2022, written by RD #2, documented concerns regarding the resident's weight loss and nutrition status were discussed with the resident's family, food preferences were obtained, and Glucerna shakes (a nutritional supplement) would be provided twice daily to aid in optimizing the resident's intake and weight status. The resident's diet order dated 1/17/2022 documented Supplement: Honey Thickened Glucerna 8 ounces (oz) by mouth twice daily (BID). The 3rd Floor Registered Nurse (RN) #7, Charge Nurse, was interviewed on 1/10/2023 at 3:00 PM and stated that monthly weights are started at the end of each month by the 30th or 31st and finished by the 5th of the following month. RN #7 stated that if there is a weight discrepancy, reweights are done by the 10th of the month. RN #7 stated that the weights are written on a weight worksheet, and they (RN #7) would check if they could find the old weight worksheets for 2021 to see why the resident was not weighed for November 2021 and why no reweights had been done to check the accuracy of the weights when the resident had lost 22 lbs between October and December 2021 and another 8 lbs between December 2021 and January 2022. RN #7 was re-interviewed on 1/10/2023 at 4:05 PM and stated that they (RN #7) did not see any documentation in the resident's EMR, nor were they (RN #7) able to find any weight worksheets to explain why there was no weight taken for the resident in November 2021 and why no reweights were done to address the resident's significant weight loss. RN #7 was re-interviewed again on 1/11/2023 at 10:00 AM and stated that during October, November, and December 2021 the RD would enter the weights into the EMR. RN #7 stated that if there is a discrepancy of more than 2 pounds, they (RN #7) would ask for a reweigh. If a significant weight loss was seen, they (RN #7) would notify the Primary Care Physician (PCP) with a phone call and write a progress note in the EMR. RN #7 could not explain why they (RN #7) did not write a progress note regarding the resident's weight loss and notification to the PCP. The facility's current RD (RD #1) was interviewed on 1/11/2023 at 10:45 AM and stated by looking into the resident's EMR, a weight in November 2021 was never obtained nor was there a re-weight for the December 2021 weight. RD #1 stated there should have been a note written by the RD at that time (RD #2) stating that a reweight was pending and some kind of intervention put into place in December of 2021 when the 22 lbs. weight loss was seen. RD #1 stated that the resident's family should have been called first to get food preferences and to tell them (the family) if there was a confirmed weight loss and put an intervention in place first while waiting for a reweigh such as giving a Mighty Shake (a high calorie shake) in between meals at 10:30 AM, 2:30 PM, and 8:30 PM. The facility's previous RD (RD #2) was interviewed on 1/11/2023 at 3:00 PM and stated that if they (RD #2) had known about the weight or seen the significant weight loss in December 2021, they (RD #2) would have documented the findings. RD #2 stated that they (RD #2) were in charge of putting all of the weights into the EMR. RD #2 stated that Resident #163's weight of 158 lbs. in December of 2021 was a 14% weight loss in two months, which was significant. RD #2 could not say why they (RD #2) missed the resident's initial weight loss in November 2021. RD #2 stated that had they (RD #2) seen the resident's weight loss in December 2021, they (RD #2) would have discussed meal preferences with resident's family, initiated a supplement, liberalized their (Resident #163) diet if possible, seen if there was anything they (RD #2) could work on with the speech therapist, and start Resident #163 on weekly weights. The Director of Nursing Services (DNS) was interviewed on 1/12/2023 at 10:00 AM and stated that Nursing staff communicates with the PCP when there is a weight loss. The DNS stated that the weight scale should be checked if there was something wrong, maybe the weight scale was not balanced. The DNS stated that a re-weigh for the resident should have been obtained. The DNS stated that the resident should also have been looked at to see how much the resident was eating at meals at the time and the RD should have been notified. The DNS further stated that if there was a change in the resident's weight of plus or minus 5 lbs. in a month, the resident should have been reweighed. 10 NYCRR 415.12(i)(1)

Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (NY00292723) initiated on 1/5/2023 and completed on 1/13/2023, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (Resident #21) of one resident reviewed for Change of Condition. Specifically, Resident #21 was identified with swelling and pain of the right lower extremity beginning on 3/8/2022. The resident continued to participate in Physical Therapy (PT), standing on both lower extremities, and was performing transfers from once surface to another (bed/chair) on the nursing unit daily. The resident was complaining of pain to the right lower extremity during the PT and during transfers. The resident was evaluated by the Physician on 3/8/2022, 3/10/2022 and 3/15/2022. An x-ray of the right lower extremity and Doppler study were ordered on 3/15/2022, seven days after the pain and swelling was first identified. The x-ray results identified a fracture of the right tibia. The finding is: Resident #21 was admitted with diagnoses including Non-Alzheimer's Dementia, Depression, and Muscle Weakness. The 3/10/2022 Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident had severely impaired cognitive decision-making skills. The MDS documented the resident required extensive assistance of two staff members for bed mobility and transfers, was non ambulatory and had no falls. The MDS indicated the resident utilizes wheelchair for locomotion when out of bed. A wound care nursing note dated 3/1/2022 at 12:14 PM documented Resident #21 was seen and examined by the wound care/vascular Physician (MD) for bilateral lower extremity discoloration and dry scabs to bilateral lateral feet. Both lower extremities were examined and noted with Varicose veins, chronic Venous Insufficiency and discolorations at the ankle and dorsum (top) of both feet. There were spider reticular veins and dark dry scabs covering the lateral feet. No open wounds. Dorsalis pedis pulses positive, no cellulitis, no peripheral arterial disease. The feet and toes were warm with no leg edema present. Impression: chronic venous insufficiency, varicose veins and changes of chronic venous insufficiency with healing superficial skin ulcers. Treatment in progress with dry protective dressing and Ace wraps to bilateral lower extremities. A Rehabilitation-Physical Therapy (PT) progress note dated 3/4/2022 documented Resident #21 stood with a rolling walker and one person assistance full weight bearing on both lower extremities. The resident had no pain. A nursing progress note written by Registered Nurse (RN) #1 on 3/8/2022 at 8:32 AM documented Resident #21 was alert and responsive and complained of pain in the right foot. Upon examination right foot had edema, was warm to touch, and very tender. Pedal pulses were present and equal bilaterally. Physician notified and ordered Motrin 400 milligram (mg) as a onetime dose and stat (immediate) laboratory blood work. A Physician note (Physician #1) dated 3/8/2022 at 4:39 PM documented Resident #21 had left foot redness, pain, and swelling. The resident had no history of trauma. The resident had been evaluated by a vascular surgeon on 3/2/2022 with no clinical evidence of peripheral arterial disease. Ace wrap and dry protective dressing ordered for daytime for both lower extremities. Further work-up and prescription as per clinical course. A nursing progress note dated 3/9/2022 at 6:18 AM documented the laboratory blood work results were received and reviewed with the Physician with no new orders obtained. A PT discharge summary dated 3/10/2022 documented Resident #21 stood full weight bearing on both lower extremities for 20 seconds; however, now required maximum assistance of two staff members. The resident was complaining of right lower leg and right foot pain. The discharge summary recommended for the resident to get out of bed daily to the wheelchair, begin Restorative Nursing Program for active assistive range of motion to bilateral upper and lower extremities and a standing program. A nursing note dated 3/10/2022 at 7:53 AM documented Resident #21 was discharged from Occupational Therapy (OT)/PT. Recommendations were to provide a Restorative Nursing Program for Transfers/Standing Program, 20 seconds with extensive assistance of 2 persons using handrails, 6 days per week. A nursing note written by RN #1 dated 3/10/2022 at 2:06 PM documented the resident was alert and responsive. The resident's right foot remains swollen and tender to touch. The Physician was notified and ordered Tylenol 650 mg every 6 hours as needed for pain and to elevate the foot while in bed. A nursing note written by RN #1 dated 3/11/2022 at 2:15 PM documented the resident's right foot remains swollen and tender to touch. Orders were in place for Tylenol 650 mg every 6 hours as needed for pain and to elevate the foot while in bed. Physician #1's note dated 3/11/2022 at 3:55 PM documented the resident continues with right foot pain episodically. The resident was discussed with the RN and was given Tylenol with good results. The assessment/plan for the right foot included Osteo Arthritis (OA). Further adjustments as per clinical course. A nursing note written by the wound RN on 3/15/2022 at 12:02 PM documented Resident #21 was seen and examined by the wound care physician for evaluation of right lower extremity pain and tenderness. The Right ankle and right distal leg were identified with tenderness and warmth compared to the left leg. A nursing note written by RN #1 on 3/15/2022 at 12:41 PM documented resident alert and responsive. Seen today by Wound Care/Vascular Physician. Suggested ordering a right lower extremity Venous Doppler and Physician (#1) was in agreement. A STAT (immediate) portable x-ray was ordered and to be completed today. Physician #1's note dated 3/15/2022 at 3:22 PM documented the resident continues with right foot pain, no history of trauma, diffuse tenderness to the dorsal aspect of the right foot and lateral malleolar area. The plan for the right foot pain was to check x-rays and a Doppler study was already ordered by the vascular surgeon. A nursing note dated 3/15/2022 at 7:56 PM documented the x-ray and venous Doppler results were received and Physician #1 was made aware. X-ray of the right ankle revealed an acute nondisplaced spiral distal tibial fracture. A new order was obtained to transfer the resident to the hospital. A Rehabilitation evaluation dated 3/16/2022, upon the resident's return from the hospital, documented that the resident had a cast in place to the right lower extremity, was non-weight bearing to right lower extremity, and was to follow up with the Orthopedic Surgeon in one week. RN #1 (unit supervisor) was interviewed on 1/10/2023 at 12:20 PM and stated the x-ray was not considered initially because there was no trauma, like an accident or fall, and the pain was treated as arthritic pain. RN #1 stated when the pain persisted the x-ray was ordered. RN #1 stated when the resident was transferred out of bed, the resident would complain about pain to the CNA, and even when the resident was being moved in bed the resident would complain of pain to the CNA. RN #1 stated the CNA reported the pain to me (RN #1) and RN #1 reported it to the doctor. RN #1 stated on 3/15/2022 the wound care physician and the Primary Care Physician discussed Resident #21 and decided to order an x-ray. RN #1 further stated as far as they (RN #1) know transfers were not stopped when the resident complained about pain because there was no Physician's order for non-weight bearing. Review of the CNA Accountability record from 3/8/2022-3/15/2022 revealed that the resident was transferred from bed to chair and chair to bed daily with extensive assistance of two persons. Physician #1 was interviewed on 1/10/2023 at 1:22 PM and stated that an x-ray was not initially ordered because there was not a high index of suspicion of a fracture because there were no falls or accidents, and the suspicion of a fracture was remote. Physician #1 stated in the setting of trauma, an x-ray would be done, but in the absence of trauma, things were done to determine if there was something else going on like a clot, which is more significant. Physician #1 stated an order for an x-ray was made when an evaluation was made with the wound care physician on 3/15/2022. The physician acknowledged that a fracture may have been a result of routine transfers. The current Director of Nursing Services (DNS) was interviewed on 1/10/2023 at 2:20 PM and stated an x-ray should have been ordered initially to rule out a fracture. The DNS stated they (DNS) would have fought with the doctor for an x-ray order because we are all clinicians. The DNS stated transfer status is based on what the Rehabilitation Department (Rehab) assessment indicates, and Rehabilitation did not say to stop transfers after the resident was discharged from therapy. Physician #1 was reinterviewed on 1/11/2023 at 8:23 AM and was asked if a clot was a concern, why was the venous Doppler ordered on 3/15/2022 instead of 3/8/2022 when the pain and swelling started. Physician #1 stated a venous Doppler was not ordered sooner because maybe the pain and swelling were not as accentuated, but as time progressed and the pain and swelling did not resolve, or the pain worsened, that is when the venous Doppler was ordered. The Rehabilitation Director was interviewed on 1/11/2023 at 9:59 AM and stated the 3/10/2022 PT discharge note documented pain in the right lower leg. The Rehabilitation Director stated we did not know what was going on because there was no x-ray and the resident was still able to stand with extensive assist of two persons. The PT note documented that the resident stood for 20 seconds with maximum assistance of two persons. The Rehabilitation Director stated if we notice pain, we report it to nurse and nurse tells the doctor and that Rehabilitation Department does not communicate with the doctor. The Rehabilitation Director stated the pain was probably the reason why therapy was discontinued because the resident's status was not improving, and the resident reached maximum potential. The resident was placed on active assistive range of motion because the resident's pain was inconsistent, and the PT wanted to keep the resident active. The Rehabilitation Director stated we just inform the nurse about the pain by phone call; we do not say what is needed or recommended like an x-ray. Certified Nursing Assistant (CNA) #1 was interviewed on 1/11/2023 at 10:41 AM and stated they (CNA #1) were the one who reported to the nurse that the resident had pain in the right leg CNA #1 stated the resident would wince if you tried to move or touch the resident. CNA # 1 stated we just transferred the resident by having the resident step on the floor and pivot but did not do a standing program. CNA #1 could not recall if the resident complained of pain during the transfer process. PT #1 (treating therapist) and Rehabilitation Director were interviewed concurrently on 1/12/2023 at 10:30 AM. PT #1 stated the resident was not performing that well because of the pain in the right lower leg and kept on refusing to participate. PT #1 stated we did not know what was going on with the right leg. PT #1 stated the resident's pain was not consistent and they (PT #1) had documented in the therapy notes before discharge that the resident had pain. PT #1 stated they (PT #1) recommended a nursing rehab program after discharge because they (PT #1) did not want the resident to stop activities. PT #1 stated that nursing was aware of the pain in the right leg. PT #1 stated they (PT #1) did speak to a nurse on the unit regarding the resident's pain, but PT #1 did not document the conversation and did not remember who the nurse was. PT #1 stated that as long as the resident was able to tolerate the program and there was nothing excruciating, they (PT #1) did not recommend an x-ray to the nurse. 10NYCRR 415.12

Based on record review and interviews during the Recertification Survey initiated on 1/05/2023 and completed on 1/13/2023, the facility must develop and implement a Comprehensive Person- Centered Care Plan (CCP) for each resident that includes measurable objective and time frames to meet a residents medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. This was identified for one (Resident #54) of one resident reviewed for Communication and Sensory: Hearing/Vision. Specifically, Resident #54 utilized bilateral hearing aids. There was no CCP developed for the use of the hearing aids. The finding is: The facility Policy and Procedure for Comprehensive Care Plan dated 6/2017 documented that each resident must have an individualized interdisciplinary plan of care in place. Within 48 hours, there must be a baseline care plan in place. Within 21 days of admission, the Interdisciplinary Team will develop and implement the Comprehensive Care Plan. All care plans are then reviewed and revised quarterly, annually, and as needed. The facility's Resident Care Policy and Procedure for Hearing Aids dated 3/2015, documented residents with hearing aids will be assisted by the staff in application and maintenance of their devices. Resident #54 was admitted with diagnoses including Hypertension, Hyperlipidemia, and Anxiety Disorder. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. The MDS documented the resident had adequate hearing and utilized hearing aids or other hearing appliances. The Physician's order dated 8/31/2022 and last renewed on 1/6/2023 documented to apply hearing aids in the morning and remove before bedtime. The resident may keep the hearing aids at their bed side. Resident #54 was observed on 1/13/2023 at 10:55 AM lying in bed. Resident #54 was not wearing their hearing aids. Resident #54 had difficulty hearing, and voices had to be raised for them to hear. A hearing aid was observed on the resident's nightstand. Resident #54 stated they keep their hearing aids at their bedside. The Resident stated they have two hearing aids, and the second hearing aid is located in their nightstand. Resident #54 stated they charge their hearing aids in their room across from the bed with a Universal Serial Bus (USB) cord. The resident was observed to get out of their bed and placed one of the hearing aids on the USB charger. Resident #54 further stated they charge one hearing aid at a time and while one hearing aid is charging they utilize the other hearing aid. Review of the Comprehensive Care Plan on 1/13/2023 revealed that there was no CCP developed for hearing deficit, use of hearing aids, or communication deficit. The Treatment Administration Record (TAR) for January 2023, documented the hearing aids were applied and removed by the nurse from 1/1/2023 to 1/13/2023. Registered Nurse (RN) #1 Supervisor was interviewed on 1/13/2023 at 12:13 PM and stated they did not develop any care plans for Resident #54. The former Director of Nursing Services was responsible for developing CCPs. RN #1 further stated the CCP for hearing loss and use of the hearing aids was not in place for Resident #54. The current DNS was interviewed on 1/13/2023 at 1:07 PM and stated there should be a care plan developed for Resident #54's hearing and hearing aid use. The DNS stated they did not see a care plan for communication, hearing, or hearing aids in Resident #54's electronic medical record and that there should be one. 10NYCRR 415.11(c)(1)

Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (NY00292723) initiated on 1/5/2023 and completed on 1/13/2023, the facility did not ensure that all alleged violations were thoroughly investigated for one (Resident #21) of one resident reviewed for Change of Condition. Specifically, Resident #21 was identified with swelling and pain of the right lower extremity beginning on 3/8/2022. An x-ray of the right lower extremity was not ordered until 3/15/2022, upon which a fracture of the right tibia was identified. The accident and incident (A/I) investigation dated 3/18/2022 concluded that no abuse, neglect, or mistreatment had occurred; however, interviews with staff only went back to 3/14/2022, and not to when the pain and swelling initially started on 3/8/2022. The finding is: Resident #21 was admitted with diagnoses including Non-Alzheimer's Dementia, Depression, and Muscle Weakness. The 3/10/2022 Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident had severely impaired cognitive decision-making skills. The MDS documented the resident required extensive assistance of two staff members for bed mobility and transfers, was non-ambulatory and had no falls. The MDS indicated the resident utilizes wheelchair for locomotion when out of bed. A nursing progress note written by Registered Nurse (RN) #1 on 3/8/2022 at 8:32 AM documented Resident #21 was alert and responsive and complained of pain in the right foot. Upon examination right foot had edema, was warm to touch, and very tender. Pedal pulses were present and equal bilaterally. Physician notified and ordered Motrin 400 milligram (mg) as a onetime dose and stat (immediate) laboratory blood work. A nursing progress note dated 3/9/2022 at 6:18 AM documented the laboratory blood work results were received and reviewed with the Physician with no new orders were obtained. A nursing note written by RN #1 dated 3/10/2022 at 2:06 PM documented the resident was alert and responsive. The resident's right foot remains swollen and tender to touch. Blood work was completed and was within normal limits. The Physician notified and ordered Tylenol 650 mg every 6 hours as needed for pain and to elevate the foot while in bed. A nursing note written by RN #1 dated 3/11/2022 at 2:15 PM documented the resident's right foot remains swollen and tender to touch. Orders were in place for Tylenol 650 mg every 6 hours as needed for pain and to elevate the foot while in bed. A nursing note written by the wound RN on 3/15/2022 at 12:02 PM documented Resident #21 was seen and examined by the wound care physician for evaluation of right lower extremity pain and tenderness. The Right ankle and right distal leg were identified with tenderness and warmth compared to the left leg. A nursing note written by RN #1 on 3/15/2022 at 12:41 PM documented resident alert and responsive. Seen today by Wound Care/Vascular Physician. Suggested ordering a right lower extremity Venous Doppler and Physician (#1) was in agreement. A STAT Portable x-ray was ordered and to be completed today. A nursing note dated 3/15/2022 at 7:56 PM documented the x-ray and venous Doppler results were received and Physician #1 was made aware. X-ray of the right ankle revealed an acute nondisplaced spiral distal tibial fracture. A new order was obtained to transfer the resident to the hospital. This fracture was reported to the New York State Department of Health on 3/16/2022 as an injury of unknown origin (NY00292723). Review of the A/I report dated 3/18/2022, and signed by the former Director of Nursing Services (DNS), documented the investigation was completed. The facility concluded that no abuse, neglect, or mistreatment regarding this resident occurred. There was no care plan violation. Review of the A/I report revealed that the interviews with staff went back to 3/14/2022, not to when the swelling and pain were first identified on 3/8/2022. Registered Nurse (RN) #4 was interviewed on 1/10/2923 at 12:49 PM and stated they are the wound care nurse, and they currently perform the accident investigations for the facility. RN #4 stated they (RN #4) were not doing the accident and incident investigations in March 2022 when the incident related to Resident #21 occurred. RN #4 stated they (RN #4) did not know why the investigation did not go back to 3/8/2022 when the pain and swelling were first identified. RN #4 further stated it was the former DNS's error for not going back to 3/8/2022. The current DNS was interviewed on 1/10/2023 at 2:20 PM and stated the investigation should have included interviews with staff going back to 48 hours before 3/8/2022 when the pain and swelling were first identified. 10NYCRR 415.4(b)

Based on record review and staff interviews during the Recertification Survey initiated on 1/5/2023 and completed on 1/13/2023 the facility did not ensure for influenza vaccine that each resident's medical record indicated either the resident received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. This was identified for one (Resident #104) of five residents reviewed for influenza vaccine; and for Pneumococcal vaccine the facility did not ensure that each resident's medical record indicated either the resident received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal for two (Resident #104 and #99) of five residents reviewed for pneumococcal vaccine. The findings are: The facility's policy dated 12/2021, titled Influenza Vaccination (seasonal flu), documented all new admissions will be assessed for the need for this vaccine as part of the admission medical work-up; and documentation of the vaccine will be noted in the medication administration record, 24-hour report, nurses notes and resident's immunization record. The facility's undated policy titled Immunization Specific to Pneumococcal Vaccines documented that on admission, annually, and with significant change the nursing department will review the resident's pneumococcal vaccination history; and each resident will have an immunization care plan, and this will be updated accordingly, and each resident will have all immunizations listed in the electronic medical record. 1a) Resident #104 was admitted on [DATE] with diagnoses including Diabetes Mellitus, Non-Alzheimer's Dementia, and Hypertension. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 9, indicating the resident had moderate cognitive impairment. The MDS assessment documented the influenza vaccine was not administered in the facility and was not offered in the facility. The pneumococcal vaccine was not up to date and the vaccine was not offered in the facility. Review of the nursing admission assessment dated [DATE] revealed documented that the resident/representative were not educated regarding the influenza and pneumococcal vaccines and did not receive an opportunity to consent or decline the vaccines. Licensed Practical Nurse (LPN) #1, unit charge nurse, was interviewed on 1/6/2023 at 1:05 PM. LPN #1 reviewed Resident #104's medical record and stated there was no documentation of whether the resident received the influenza vaccine. LPN #1 stated they (LPN #1) were not sure if the vaccine was offered, and that Resident #104 may have received the influenza vaccine before admission. A nursing progress note, written by Registered Nurse (RN) #1, dated 1/9/2023 at 8:29 AM documented they (RN #1) spoke to the resident's family regarding the 2022 flu shot. The family member stated the vaccine was declined upon admission because the resident was previously vaccinated by their (Resident #104) primary care physician in community. The progress note indicated that the flu shot was administered on 9/24/2022. RN #1, unit supervisor, was interviewed on 1/9/2023 at 9:05 AM. RN #1 stated whoever did the admission failed to put the vaccination status in the admission note and assessment. 1b) Review of a vaccination history document provided by a community physician for Resident #104 revealed that the resident received the pneumococcal vaccine on 10/26/2015. A nursing progress note written by RN #3 dated 1/9/2023 at 11:56 AM documented the writer spoke to the resident's family member and the family member agreed that Resident #104 can get the pneumococcal vaccine in the facility as the last pneumococcal vaccination was given on 10/26/2015. The facility physician was made aware and ordered the pneumococcal vaccine on 1/9/2023. RN #2, who was the evening RN supervisor/ admission nurse, was interviewed on 1/13/2023 at 8:27 AM. RN #2 stated the resident spoke Italian and RN #2 had left a message with the family regarding the vaccines. RN #2 stated admissions usually come in late in the day, so follow up the next day regarding vaccine status is usually needed. RN #2 stated Social Work is supposed to follow up. 2.) Resident #99 was admitted on [DATE] with diagnoses including Hypertension, Adult Failure to Thrive, and Wedge Compression Fracture of Lumbar Vertebra. The admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS assessment documented the pneumococcal vaccine was not up to date and the vaccine was not offered in the facility. The nursing admission assessment dated [DATE] revealed no documentation for the pneumococcal vaccine. There was no documentation in the medical record that the resident was offered and or received the pneumococcal vaccine. Registered Nurse (RN) #3 (unit supervisor) was interviewed on 1/9/2023 at 2:31 PM and stated there was nothing in the medical record regarding the status of the pneumococcal vaccine for Resident #99, so we just asked the resident today (1/9/2023) and the resident declined the vaccine. RN #1, the admission nurse, was interviewed on 1/12/2023 at 1:35 PM and stated there was no determination of the resident's pneumococcal vaccination status upon admission. RN #1 further stated sometimes the information is not available at admission and it has to be followed up. The current DNS was interviewed on 1/13/2023 at 2:09 PM and stated they (DNS) thought the former DNS followed up the resident vaccine status after an admission. The DNS stated going forward the RN supervisors will be responsible to follow up on the residents' vaccination status. 10 NYCRR 415.19(a)(3)

Based on interviews and record review during an abbreviated survey (Complaint #NY 662), the facility did not ensure that the resident had the right to be free from physical restraints imposed for purposes of discipline or convenience for one (Resident #1) of three residents reviewed for restraints. Specifically, Resident #1 had a nightgown tied around the waist restraining the resident for approximately four and a half hours and restricting the resident from rising from the wheelchair. The finding is: The facility's policy titled Restraint revised 10/14/2020 documented that the facility will promote and encourage a restraint free environment for all residents. Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached to or adjacent to the resident's body that the individual cannot easily remove which restricts freedom of movement or normal access to one's body. Convenience is defined as any action taken by the facility to control a resident's behavior or manage a resident's behavior with a lesser amount of effort by the facility and not in the resident's best interests. The personnel file of Certified Nurse's Aide (CNA) #1 was reviewed. CNA #1 received in-service on Abuse Prevention and Reporting for Residents and Employees on 9/10/2019, Resident's Rights and Needs of Elderly and Dementia and Behavior Monitoring on 10/11/2019 and Preventing Recognizing and Repotting Abuse on 8/7/2020. CNA#1 was terminated on 11/5/2020 for elderly abuse. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS-an assessment tool) dated 10/23/2020 documented the resident with Brief Interview for Mental Status (BIMS) score of 3 indicating severely impaired cognition. The resident required extensive assistance of one person for transfers. The Comprehensive Care Plan( CCP) titled Behavior/Dementia, [CONDITION(S)], Confusion dated 10/22/2020 documented the resident requires behavioral supervision and tries to get up and walk unassisted. Interventions included monitor changes in behavior and mental status, reapproach when agitated, administer medications as ordered, provide emotional support and reassurance, set limits when appropriate and history of falls and was moved closer to nursing unit for close observation. The Nurse's Progress Notes (NPN) dated 10/21/2020 documented the resident was attempting to ambulate unassisted several times, redirected and it was effective. Resident was transferred to another room, closer to nursing station for close supervision. The NPN dated 10/22/2020, 10/23/2020, 10/24/2020 and 10/25/2020 documented the resident attempting to ambulate unassisted, redirected with positive effect. On 10/25/2020, 10/26/2020, 1027/2020 the resident continues to ambulate unassisted, and the resident was placed in high visible area. The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Wandering in the nighttime often with redirection by staff. The NPN dated 10/29/2020 at 3:14 AM documented that at 2:25 AM the resident was getting up and trying to wheel their self, agitated and aggressive behavior towards the staff. The resident was redirected and offered snacks, ate well and resting in wheelchair in their room. No complaints of pain and no acute distress was noted. All needs anticipated and met by staff and frequent toileting done. The NPN dated 10/29/2020 at 6:41 PM by the Director of Nursing (DON) documented the resident was noted with a restraint device on their body this morning and the device was removed immediately. A body check was done by RN with no visible injury noted. The MD, SW and next of kin were notified. Resident was confused and unable to state what happened. The CNA Accountability Record (CNAAR) dated 10/1/2020 to 10/31/2020 documented the resident was on fall precautions, on falling star program, to be kept at the nursing station, keep ADL items within reach, bed in low position and locked, anticipate need and keep call bell within reach and staff to answer promptly. The facility's investigative summary dated 11/2/2020 documented the resident with multiple episodes of getting up unassisted especially at night. On 10/29/2020 around 10 AM the Registered Nurse (RN) asked the DON to check the resident. The resident was sitting in a wheelchair with a night gown loosely tied around the waist and secured to the back of the wheelchair with a knot. The resident was confused and unable to state what happened. A full body check was done, and no visible injuries noted to the resident. The incident was reported to the Police and Department of Health. The investigative summary also documented as per CNA statement, CNA #1 admitted that they tied the resident with a night gown because the resident was constantly getting up from their bed and wheelchair and did not want the resident to fall. CNA#1 also stated they had to complete their assignment and had to take the resident with them. CNA #1stated they did not tell the charge nurse or the supervisor what they did. The CNA claimed the night gown was applied at 5:30 AM. The facility concluded the accused CNA failed to follow the plan of care for the resident and did not follow the policy and procedure of the facility. The dayshift CNA #2 was interviewed on 10/19/2021 at 1:59 PM and stated they (CNA#2) was assigned to the resident on 10/29/2020. CNA #2 stated the night shift dressed the resident and the resident was taken out of bed. At 7 AM the resident was sitting in a wheelchair with RN #2, The resident was not agitated at that time. CNA #2 handed the breakfast to RN #2. RN #2 left for morning meeting and the LPN was taking the resident with them between 9 AM to 9:45 AM while doing medication pass for monitoring. The rehab staff came for the resident's therapy at approximately 9:45 AM and asked CNA #2 to untie the resident. CNA #2 saw the resident had a white blanket draping over the back of the wheelchair and over the resident's shoulders. The rehab staff were getting ready to walk the resident and removed the blanket and saw the resident was tied. CNA#2 observed the night gown wrapped around the resident's waist and tied around the back of the wheelchair. The resident's body was tied to the wheelchair preventing the resident to from moving or rising from the wheelchair and the resident was unable to untie their self. CNA #2 reported to the LPN and RN #1 who informed the DON. RN #2 and DON untied the resident. CNA #2 did not notice the resident was tied when they came in because the blanket was covering the tie. The dayshift Licensed Practical Nurse (LPN) was interviewed via phone on 10/19/2021 at 2:45 PM. The LPN stated on 10/29/2020 CNA #2 asked the LPN to check the resident and the LPN saw the resident was tied around their waist to the wheelchair using a night gown. The LPN informed the charge nurse (RN#2). The LPN stated when they came at 7 AM, the resident was sitting quietly and there was a sheet covering the wheelchair and LPN did not see the knot. The night shift RN #1 was interviewed via phone on 10/19/2021at 2:59 PM. RN#1 stated on 10/29/2020 the resident was a little aggressive and agitated. CNA #1 placed the resident in bed at 12:30 AM and resident was trying to get up at around 2 PM. CNA #1 took the resident out of bed and sat and monitored the resident in their room. At 6:45 AM CNA #1 placed the resident at the nursing station. The resident was dressed, and RN #1 did not notice sheet hanging on Resident's wheelchair or gown being tied. RN #1 left the unit at 7:15 AM. RN #1 stated CNA #1 did not report anything to them or did not ask for their help. The Certified Occupational Therapy Assistant (COTA) was interviewed on 10/19/2021 at 3:13 PM and Physical Therapy Assistant (PTA) was interviewed via phone on 10/19/2021 at 4:15 PM. They stated on 10/29/2020 at approximately 10 AM they went to see the resident for rehab and as they were about to walk the resident, they noticed the resident was tied to the chair. They stated a night gown was used to tie the resident under their armrest to the back of the wheelchair. The COTA stated they noticed a blanket was around the wheelchair covering the tie. The PTA saw the tie and they did not touch it and reported to CNA #2 and CNA #2 then reported to the charge nurse. They stated there was a little room where the resident can move around but prevents them from getting up. The tie was behind the wheelchair and the resident would not be able to untie their self. CNA #1 was interviewed via phone on 10/19/2021 at 3:22 PM. (CNA #1) stated they were assigned to the resident on 10/29/2020 and the only CNA on the floor with 16-18 residents to take care of. CNA #1 stated they had to restrain the resident not to harm the resident but to prevent from falling. CNA #1 stated they placed the resident in the wheelchair and restrained the resident using a night gown. CNA #1 loosely tied the resident around their waist and around the back of the wheelchair. CNA #1 stated the resident could move around but could not get up CNA #1stated the facility does not condone restraints CNA #1 stated they dressed the resident around 5 AM to 5:30 AM then applied the restraint to the resident. CNA #1 stated they did not release the restraint from 5:30 AM until they went home. CNA #1 stated there is no other way CNA #1 could provide care to other residents without the resident trying to get up and prevent them from falling. CNA #1 stated it was not on the resident's plan of care to tie the resident. The DON was interviewed on 10/19/2021 at 4:29 PM and stated on 10/29/2020 RN #2 asked the DON to check the resident. The LPN, CNA #2, rehab staff and RN were standing around the resident. The DON stated there was a sheet at the back of the wheelchair covering the knot, the night gown was tied around their waist at the back of wheelchair and resident's sweater was covering the gown. The DON removed the blanket and untied the knot. The DON stated CNA #1 admitted they tied the resident because the resident kept getting up and CNA #1 had to take care of other patients and did not want them to fall. The DON also stated CNA #1 was the only CNA and they had 6 residents not 16 or 18 residents and there was also an RN on the unit and the RNS. CNA #1 stated to DON they tied the resident around 5:30 AM and did not release the resident at 7AM. DON stated the resident was tied loosely but the resident did not know how to untie their self and the tie prevented the resident from getting up. The facility concluded CNA #1 should not tie the resident because tying a resident is a restraint and it prevented the resident from getting up. CNA #1 should ask for assistance from RN and RNS, instead chose to tie the resident and covered it with sweater and sheet. The night shift Registered Nurse Supervisor (RNS) was interviewed via phone on 10/20/2021 at 9:29 AM. The RNS stated on 10/29/2020 CNA #1 was assigned to rehab floor with 6 residents on the unit. The RNS made rounds at 3 AM the resident was observed sitting in wheelchair in front of their room with CNA #1 sitting. The resident was not agitated and not aggressive. The resident was talking and touching CNA #1. The RNS did not notice the resident trying to get up and offered a snack and juice to the resident. At 5:00 AM the RNS observed CNA #1 providing care to the resident, the resident was dressed and in wheelchair at the nurse's station. RNS stated they did not notice any sheet hanging and or a gown tied to the resident. If staff needs to provide care to other residents, RNS stated they would help with monitoring the resident. CNA #1 had only 6 residents and did not request help from RNS. 415.4(b)(1)(i)

F333 Based on record review and interview during an abbreviated survey, the facility did not ensure that each resident's drug regimen was free of any significant medication error. Specifically, one resident (Resident #1) of three residents reviewed for medications, the physician's orders [REDACTED]. The physician's orders [REDACTED]. [MEDICATION NAME] was administered daily to Resident #1 for a total of 7 doses. The resident was noted with nausea, vomiting and elevated temperature. She was subsequently sent out to the hospital and admitted with [DIAGNOSES REDACTED]. This resulted in actual harm that is not Immediate Jeopardy. Complaint ID Number: NY 685 The findings are: Resident #1 was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The hospital patient discharge instructions record dated 02/15/12 documented [MEDICATION NAME] 10 mg po. The facility's physician order [REDACTED]. The Medication Administration Record (MAR) documented that [MEDICATION NAME] 10 mg po q pm was administered to the resident at 6:00 PM from 02/16/12 - 02/22/12 for a total of 7 daily doses. The Interdisciplinary progress notes (IDPN) dated 02/21/12 documented that the resident was seen by the Attending Physician for an oral lesion. On 02/23/12 at 1:00 AM the IDPN documented that the resident was found in bed in a lying position, had vomited a yellow liquid two times with a temperature of 101.2. The physician was made aware and ordered the resident transferred to the hospital for evaluation, where she was admitted . A facility investigation dated 03/21/12 documented that on Monday, March 19, 2012, the hospital's Medical Director contacted the facility administrator and inquired if the facility was aware there was a problem with the medication [MEDICATION NAME] and requested that the facility's Medical Director contact him. The Administrator expressed no knowledge of any issue and an investigation was initiated. The facility's undated policy and procedure related to Medication order transcription documented that the prescriber is responsible for initiating a complete order, including name of drug, strength, route of administration, and frequency. The nurse picking up the original order would transcribe the complete order, including name of medication, strength, route of administration, and frequency onto MAR (for new medication orders); and shall clarify any medication order which appears illegible, potentially inaccurate, or inappropriate for any reason, and document such clarification on the medical record. Review of hospital discharge summary dated 03/23/12 documented that the resident was admitted with profound [MEDICAL CONDITION] with [DIAGNOSES REDACTED]. After a hematologic consult it was found that [MEDICATION NAME] 10mg was administered to the resident daily resulting in significant neutropenic bone marrow response. Resident #1 required ventilation and ultimately, a [MEDICAL CONDITION] for airway management. The resident was discharged to rehabilitation following extubation. PDR.net (Physician Desk Reference-drug information source) documented that [MEDICATION NAME] should be administered once per week for [MEDICAL CONDITION] Arthritis. Toxicity may be related in frequency and severity to dose/frequency of administration; reduce dose or d/c therapy and take corrective measures when toxicity occurs. Leukopenia, Nausea/vomiting, chills, fever, and decreased resistance to infection are adverse reactions to the medication. During an interview with the Director of Nursing (DON) on 03/23/12 at 9:02 AM, she stated (concerning [MEDICATION NAME]) that the Registered Nurse (RN) misread the hospital transfer summary to the physician, the physician gave the verbal order and signed the order the following day. The pharmacy filled the prescription and did not notify the facility of any issues. During an interview with the facility's Medical Director on 03/23/12 at 10:50 AM, he stated that on 03/19/12 the Administrator informed him that the hospital's Medical Director called about Resident #1 and an issue with the medication [MEDICATION NAME]. The Medical Director read Resident #1's record and noted that [MEDICATION NAME] was ordered on a daily basis, "which is not the way it should be given." An interview was conducted with the Float Licensed Practical Nurse (LPN #1) on 03/23/12 at 11:20 AM. He stated that he administered [MEDICATION NAME] to Resident #1 on 02/21/12 as ordered and he was not familiar with the medication. During an interview with the 3:00 PM - 11:00 PM Registered Nurse (RN) charge nurse on 03/23/12 at 3:15 PM, he stated that on 03/19/12 he was made aware by the DON that [MEDICATION NAME] should have been ordered/written once weekly but was written every pm. Prior to 03/19/12, the RN was not aware there was an issue with the medication. He did not know how the medication error occurred. The RN stated that he reads the hospital discharge orders by phone to the physician who orders what is appropriate. The RN also stated that the medication [MEDICATION NAME] is a rare order and he was not familiar with the frequency of medication. During an interview with the 3:00 PM - 11:00 PM LPN #3 charge nurse on 03/23/12 at 3:40 PM, she reviewed the MAR and stated she signed for the [MEDICATION NAME] on 02/17/12, 02/18/12 and 02/22/12. The charge nurse stated that she was not familiar with the medication [MEDICATION NAME] and did not know that it should not be administered daily. An interview was conducted with the 3:00 PM - 11:00 PM LPN #4, on 03/23/12 at 4:10 PM. She stated that she was not familiar with the frequency of the medication; it was her first time administering [MEDICATION NAME]. She did not know it was supposed to be given weekly. She administered the medication on 02/16/12 and 2/19/12. A telephone interview was conducted with the Attending Physician on 03/26/12 at 11:58 AM. He stated that on the night of the resident's admission he gave the orders for the [MEDICATION NAME], came into the facility the next day and signed the order for [MEDICATION NAME] once per day. However, he could not explain why he gave that order or signed for it. He further stated that in this particular case, it should not have been given daily but once per week. The Attending physician stated on 02/22/12 or 02/23/12, he was called because the resident was febrile (temp. 101) and ordered Resident #1's transfer to hospital. He did not know the cause of the fever and at the time did not realize she was leukopenic or that there was an issue with the [MEDICATION NAME]. 415.12(m)(2)

Based on record review and staff interviews during the abbreviated survey, the facility did not ensure that pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals met the needs of each resident. Specifically, the pharmacy dispensed the medication Methotrexate (to treat Rheumatoid Arthritis) 10 milligram (mg) by mouth (po) every (q) day, exceeding the manufacturers specification for one resident (Resident #1) of three residents reviewed for pharmaceutical services. The pharmacy did not inform the facility staff that the dosage ordered by the physician exceeded the manufacturer's specification. Subsequently, Resident #1 was administered 7 doses of Methotrexate by the medication nurses. Resident #1 was transferred and admitted to the hospital with [REDACTED]. This resulted in actual harm that is not Immediate Jeopardy. Complaint ID Number: NY 685 The findings are: Resident #1 was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The pharmaceutical services contract dated July 1, 2009 documented that the pharmacy will provide prescription and non-prescription drugs including intravenous drugs and pharmaceutical supplies as ordered by physicians and other healthcare professionals legally authorized to prescribe such products. The contract documented that the pharmacy would provide drug information to the Facility's licensed professional staff regarding Medications. The facility's physician order [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Interdisciplinary progress notes (IDPN) dated 02/23/12 at 1:00 AM documented that the resident was found in bed in a lying position, vomited a yellow liquid two times with a temperature of 101.2. The physician was made aware and ordered the resident transferred to the hospital for evaluation, where she was admitted . The Pharmacy Medication Occurrence Dispensing Report dated 03/21/12 documented that the medication ordered was Methotrexate 10 mg po q pm, which fell above the recommended daily dose and the facility was not notified of the high dosage. PDR.net (Physician Desk Reference-drug information source) documented that Methotrexate should be administered once per week for Rheumatoid Arthritis. Toxicity may be related in frequency and severity to dose/frequency of administration; reduce dose or d/c therapy and take corrective measures when toxicity occurs. Leukopenia, Nausea/vomiting, chills, fever, and decreased resistance to infection are adverse reactions to the medication. Review of the hospital discharge summary dated 03/23/12 documented that the resident was admitted with profound [DIAGNOSES REDACTED] count with [DIAGNOSES REDACTED]. After a hematologic consult it was found that Methotrexate 10mg was administered to the resident daily resulting in significant neutropenic bone marrow response. Resident #1 required ventilation and ultimately, a tracheostomy for airway management. The resident was discharged to rehabilitation following extubation. During an interview with the Director of Nursing (DON) on 03/23/12 at 9:02 AM, she stated (concerning Methotrexate) that the Registered Nurse (RN) misread the hospital transfer summary to the physician, the physician gave the verbal order and signed the order the following day. The pharmacy filled the prescription and did not notify the facility of any issues. During a telephone interview with the Supervising Pharmacist on 03/23/12 at 4:20 PM she stated that she did investigate the issue with Methotrexate after receiving a call from the Director of Nursing (DON). When the pharmacist was entering the order for Methotrexate 10 mg once per day, the system did trigger an alert that it was a higher dose, which should have prompted the pharmacist to call the facility. However, the pharmacist overrode the system and continued to fill the order and the Methotrexate was dispensed to the facility. The pharmacist could not say why she overrode the system. 415.18 (a)