Every finding on record at Glen Island Center for Nursing and Rehabilitation

Based on observation, record review, and interview the facility failed to ensure that residents had the right to formulate advance directives that would be honored. This was evident for two (2) of three (3) residents (Resident #10, #28) reviewed for Advance Directives out of total 38 sampled residents. Specifically, the facility did not ensure Resident #10 and Resident #28's advance directive wishes were accurately reflected in the medical record. The findings included: The facility's policy and procedure titled Advance Directives reviewed 01/21/2026 documented it is the policy of the facility to inform all adult residents of their rights to accept or refuse medical treatment by providing written and/or verbal information on Advance Directives. The individual's wishes on advance directive will be identified and honored by the facility. Resident's Advance Directives will be reviewed upon admission, re-admission from the hospital, quarterly and annually. Advance Directives are also reviewed at the request of the resident/surrogate or at any time during their stay by the social worker. 1) Resident #10 was admitted to the facility with diagnoses including Hypertension, Non-Alzheimer's Dementia and Diabetes Mellitus. The Minimum Data Set, dated [DATE] documented Resident #10 has moderately impaired cognition. The Hospital Patient Review Instrument completed 11/20/2025 documented Resident #10's code status was Do Not Resuscitate and Do Not Intubate. The Physician Orders initiated on 11/22/2025 documented Do Not Resuscitate and Do Not Intubate. The Medical Orders for Life-Sustaining Treatment form documented Resident #10 and/or their representative requested for Cardiopulmonary Resuscitation (to perform chest compressions to restart the heart) and Intubation; the form was signed 11/20/2024. The form was last reviewed by the physician on 12/01/2025. The Social Services Note dated 12/10/2025 documented admission care plan meeting was held with Resident #10's family and the interdisciplinary team. Advance directives were reviewed and family verbalized that Resident #10's prior code was Do Not Resuscitate and Do Not Intubate in the hospital, but that they wished to rescind the hospital advance directive order and requested full code. The Care Plan for Advance Directive for Resident #10 was revised on 12/10/2025 to reflect Full Code (every medical intervention possible to keep alive) status. Review of Resident #10's physician orders from 11/22/2025 to 1/28/2026 revealed there was no documented evidence that resident's advance directive was changed from Do Not Resuscitate, Do Not Intubate to Cardiopulmonary Resuscitation status as per family request. Resident #10 remained on Do Not Resuscitate and Do Not Intubate status. 2) Resident #28 was admitted to the facility with diagnoses including Diabetes Mellitus, Hypertension and Deep Venous Thrombosis. The Minimum Data Set, dated [DATE] documented Resident #28 has cognition is intact. The Physician Note dated 01/23/2026 documented that Medical Orders for Life-Sustaining Treatment form were reviewed, completed and witnessed documenting Do Not Resuscitate, Do Not Intubate, and Do Not Hospitalize status, and noted their family was also in agreement. The Medical Orders for Life-Sustaining Treatment form documented Do Not Resuscitate, Do Not Intubate, and Do Not Hospitalize was signed/completed on 01/23/2026. The Advance Directive Care Plan initiated 01/24/2026 documented Resident #28 is Do Not Resuscitate, Do Not Intubate, and Do Not Hospitalize. Interventions included placing yellow dot on chart/arm band when applicable to indicate the resident is a Do Not Resuscitate. Resident #28's current physician orders were reviewed on 01/29/2026 at 11:30AM and revealed resident has active orders for Full Code initiated 01/07/2026 in addition to active orders for Do Not Resuscitate, Do Not Intubate and Do Not Hospitalize initiated on 01/23/2026. On 01/29/2026 at 3:00 PM, the Director of Social Services was interviewed and stated they were responsible for establishing residents' advance directive wishes upon admission, readmission and when there are any changes. Director of Social Services stated Resident #10 was a prior resident who was hospitalized and readmitted to the facility with Do Not Resuscitate, Do Not Intubate code status. Resident #10's family requested resident's advance directives to full code status on 12/10/2025. Director of Social Services stated nursing was informed of the Do Not Resuscitate, Do Not Intubate to Full Code change, the care plan was updated to full code and they requested the Medical Orders for Life-Sustaining Treatment form to be reviewed/renewed by the physician. Director of Social Services also confirmed Resident #28 wished to execute Do Not Resuscitate, Do Not Intubate, and Do Not Hospitalize with family and physician all in agreement on 01/23/2026. Nurse Managers were informed of the change code so they could ensure the physician orders were updated in the electronic medical record. On 02/02/2026 at 3:13 PM, Registered Nurse #2 stated they had an admission care plan meeting with Resident #10's family sometime after they were readmitted from hospital and recalled that they requested a change to Full Code status. Registered Nurse #2 stated they were supposed to change the physician orders from Do Not Resuscitate, Do Not Intubate to Full Code, but it was not done. Registered Nurse #2 stated it was their fault for not changing the order. On 02/02/2026 at 3:34 PM, Registered Nurse #5 was interviewed and stated Resident #28 completed the Medical Orders for Life-Sustaining Treatment form and requested Do Not Resuscitate, Do Not Intubate, and Do Not Hospitalize status. Registered Nurse #5 acknowledged that full code was initiated upon admission as default and should have been discontinued when the Do Not Resuscitate, Do Not Intubate, and Do Not Hospitalize orders were initiated on 01/23/2026. Registered Nurse #5 stated it was a mistake on their part. On 01/30/2026 at 11:20 AM, Medical Doctor was interviewed and stated Resident #10 is well known resident to them who was Do Not Resuscitate, Do Not Intubate in the hospital. Therefore, Resident #10 was admitted to the facility with Do Not Resuscitate, Do Not Intubate status and code orders were initiated upon admission. However, if the resident/family requested a code change, they would have been informed, and code orders would be updated by the nurses. The Medical Doctor could not explain why Resident #10's physician orders did not reflect the same code status as the Medical Orders for Life-Sustaining Treatment form. 10NYCRR 400.21(c)

Based on observation, record review, and interviews, the facility failed to ensure that a resident with limited range of motion received appropriate treatment and services, including provision of equipment, to prevent further decline in range of motion. This was evident for one (1) (Resident #16) of two (2) residents reviewed for rehabilitation and restorative services out of a total sample of 38 residents. Specifically, Resident #16 was observed without a left-hand splint in place as per physician order. The findings include: The facility's policy titled, Splints and Orthotic Management Policy and Procedure, last review dated 09/2025 documented that splinting and orthotic management is a therapeutic procedure designed to prevent worsening contractures of a joint to increase range of motion and/or to prevent skin breakdown. Therapists will collaborate with nursing to get an order in place once trial has completed for ongoing orthotic wearing schedule. At which time the orthotic may be donned and doffed by nursing staff or certified nursing assistant or other designated trained personnel. Orthotic management will be continued until the goals are met, the patient reaches maximum rehabilitation potential, or the interventions are no longer appropriate. Resident #16 has active diagnosis of Hemiplegia following cerebral infarction affecting left non-dominant side and Diabetes Mellitus. The Quarterly Minimum Data Set, dated [DATE] documented that Resident #16 had relatively intact cognition and was dependent in upper and lower body dressing. The Minimum Data Set assessment also documented that Resident #16 had an impairment on both sides of the upper and lower extremities. A care plan focused on Activities of Daily Care: Self Care Performance Deficit related to Activity Intolerance, Impaired balance, decreased muscle strength and Cerebral Vascular Accident with left hemiparesis was last reviewed on 12/29/2025. Interventions included the use of a Left Resting Hand Splint and to remove/release it for activities of daily living care and skin checks. A physician's order dated 11/27/2025, and last revised on 11/30/2025, documented Left Resting Hand Splint and to remove/release for Activities of Daily Living care and skin checks. On 01/30/2026 at 10:50 AM and 1:16 PM, and on 02/02/2026 at 10:37AM and 2:20 PM, Resident #16 was observed in their room with no left hand splint in place. On 02/02/2026 at 2:23 PM, Certified Nursing Assistant #4 was interviewed and stated that as per the task, Resident #16 should have a left-hand splint. Certified Nursing Assistant #4 stated that they noticed that the left-hand splint was missing from the resident's room last Friday and they were not able to locate it. Certified Nursing Assistant #4 further stated that they reported to Nurse Manager #4 of the missing left hand splint on Friday and was informed that one would be obtained from the rehab department. On 02/02/2026 at 2:42 PM, Certified Nursing Assistant #4 and Registered Nurse #3 went through Resident #16 drawers and searched for the left-hand splint and failed to locate it. On 02/04/2026 at 2:15PM, in a subsequent interview, Certified Nursing Assistant #4 stated that they had documented code 5 (Refused) on the Certified Nursing Accountability for the left hand splint on 01/20/2026 because there were no other options to document it was missing. On 02/02/2026 at 2:34 PM, Nurse Manager #4 was interviewed and stated that Certified Nursing Assistant #4 notified them that morning that the left-hand splint was missing for Resident #16. The Nursing Manager #4 stated they requested another splint from the rehab department right away and was informed that rehab would deliver one. Nurse Manager #4 stated that they do not recall if Certified Nursing Assistant #4 had reported to them about a missing left-hand splint on Friday. Nurse Manager #4 further stated that Certified Nursing Assistants are always encouraged to make sure that residents wear assistive devices. Rounds are done by charge nurses and nursing managers frequently to ensure assistive devices are applied for residents. Nursing Manager #4 further stated that Resident #16 is status post stroke and wears a left hand splint to prevent contractures. On 02/04/2026 at 11:56 AM, the Occupational Therapist was interviewed and stated that Resident #16 was on an occupational therapy program from 08/20/2025 to 11/27/2025. At that time Resident #16 had a decline with their activities of daily living, self-feeding and grooming. When Resident #16 was reassessed, the Occupational Therapist noted the left hand had increased tightness. The Occupational Therapist stated that Resident #16 is status post Cerebral Vascular Accident on the left arm and the left upper extremity was declining as it was very tight. The Occupational Therapist further stated that if Resident #16 doesn't wear the left-hand splint consistently, they would continue to experience increased tightness, and providing daily care will become harder as the extremity would constrict permanently. It is the expectation that Resident #16 should have it on at all times. On 02/05/2025 at 10:15AM, the Director of Nursing Services was interviewed and stated that if there is a rehab recommendation for an assistive device, particularly a hand splint, it is to prevent further contractures. The Director of Nursing Services further stated that if there is a recommendation by rehab for an assistive device, it is important that it is in place for the proper physical functioning of that resident. 10 NYCRR 415.12 (e)(2)

Based on record review and interviews, the facility did not ensure residents, or their designated representatives were provided appropriate notification at the termination of Medicare Part A benefits. This was evident for three (3) of three (3) residents (Resident #95, #204, and #205) reviewed for Beneficiary Notification out of total 38 sampled residents. Specifically, the facility did not ensure the resident/representative received timely written Notice of Medicare Non-Coverage of potential liability and appeals rights.The findings are: The facility's policy and procedure titled, Medicare Beneficiary Notices, last review dated 01/21/2026 documented the purpose of Medicare Beneficiary Notices are to ensure that Medicare beneficiaries receive proper notice when items and services Medicare usually covers but may not pay because they are medically unnecessary or custodial in nature or the service are no longer medically necessary. Advance written notice of noncoverage should be issued to and understood by Medicare beneficiary or their representative and issued far enough in advance of potentially noncovered items or services so the beneficiary can consider available options. Resident #95 was discharged from Medicare skilled services on 09/14/2025 with no remaining days. Resident #95 remained in the facility. The Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage documented Resident #95's designated representative was notified on 09/13/2025 and written notice was mailed via regular mail postmarked 09/15/2025. Resident #204 was discharged from Medicare skilled services on 11/03/2025 with 62 remaining days. Resident #204 was discharged home. The Notice of Medicare Non-Coverage documented Resident #204's designated representative was notified on 10/30/2025 and written notice was mailed via regular mail postmarked 11/03/2025. Resident #205 was discharged from Medicare skilled services on 12/12/2025 with 41 remaining days. Resident #205 was discharged home. The Notice of Medicare Non-Coverage documented Resident #204's designated representative was notified on 12/10/2025 and written notice was mailed via regular mail postmarked 12/11/2025. The Notice of Medicare Non-Coverage and Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage forms were not mailed out on the same date that notification was made. In addition, there was no documented evidence that resident/designated representatives received the notices which were sent via regular mail. On 02/02/2026 at 2:29 PM, the Director of Social Services was interviewed and, they stated they were responsible for making sure residents or their designated representatives are notified of their Medicare Part A benefit ending date in advance and are provided with the written notice. The Director of Social Services stated Resident #204's and Resident #205's designated representatives were informed over the phone two days prior to the last coverage date. However, the Director of Social Services stated they could not confirm the exact date when the written notices were mailed out or if the designated representatives received the notices in the mail because they were mailed out by regular mail. On 02/05/2026 at 12:13 PM, the Minimum Data Set Coordinator was interviewed and stated it is the Director of Social Services who oversees Medicare benefits and notifies the appropriate residents and their representatives. 10 NYCRR 415.3(g)(2)(i)

Based on record review and interviews, the facility failed to ensure that Minimum Data Set 3.0 comprehensive and non-comprehensive assessments were submitted and transmitted into the Internet Quality Improvement Evaluation System (IQIES) Assessment Submission and Processing (ASAP) system in a timely manner. Specifically, resident's Quarterly, Discharge and comprehensive Minimum Data Set were not submitted and transmitted within 14 calendar days after the assessments were completed. This was evident for, but not limited to, 3 of the 12 residents reviewed for Resident Assessment. (Residents #19, #32 and #48), out of a total of 38 sampled residents. The findings include: The Center for Medicaid/Medicare Services Resident Assessment Instrument Manual Version 3.0 (Dated October 2017)Chapter 5 titled, Submission and Correction of the MDS Assessments, states The Minimum Data Set completion date must be no later than 14 days after the Assessment Reference Date for all non-admission, Omnibus Budget Reconciliation Act, and Prospective Payment System assessments and no later than 13 days after the entry date for admission assessments. Comprehensive assessments must be transmitted electronically within 14 days of the care plan completion date. All other Minimum Data Set assessments must be submitted within 14 days of the Minimum Data Set completion date. The facility policy for, Minimum Data Set 3.0 Submission, last review dated 09/2025 documented that all Minimum Data Set 3.0 assessments must be completed, encoded, and submitted to Center for Medicare/Medicaid Services within the established time frames to ensure regulatory compliance and the accuracy of resident assessment data. For Resident #19, admitted [DATE], the Quarterly Minimum Data Set Assessment Reference Date was 08/14/2025; it was completed on 08/28/2025 and submitted on 09/19/2025.For Resident #32, admitted [DATE], the Quarterly Minimum Data Set Assessment Reference Date was 08/07/2025; it was completed on 08/21/2025 and submitted on 09/19/2025. For Resident #48, admitted [DATE], the Annual Minimum Data Set Assessment Reference Date was 08/13/2025; it was completed on 08/27/2025 and submitted 09/19/2025. The Facility Minimum Data Set submission report printed 02/02/2026 documented that the submission date for all the residents reviewed is more than 14 days after the assessment. On 02/05/2026 at 10:45 AM, Registered Nurse #1 was interviewed and stated that they are not involved in documentation and completion of residents' Minimum Data Set. Registered Nurse #1 stated that they only update and document residents' assessment in the Point Click for the Minimum Data Set Coordinator to check and review when completing the resident assessments. On 02/05/2026 at11:06 AM, the Director of Social Services was interviewed and stated that they have not been involved in completion of residents' assessments in the Minimum Data Set, and that a separate staff is hired for the documentation, completion and submission of the residents' Minimum Data Set. The Director of Social Services further stated that they were just being informed that their sections of the Minimum Data Set will should be completed by them henceforth. On 02/05/2026 at 11:09 AM, the Minimum Data Set Coordinator was interviewed and stated that they are responsible for completing nursing and social services sections of the assessments, and that the Rehab, Dietary and Activity sections are completed by the respective trained staff of those departments. Minimum Data Set Coordinator stated that they check for the completion of all sections before submitting the assessments. Minimum Data Set Coordinator further stated that for quarterly, and discharge assessments, they have14 days from assessment reference date to complete, and another 14 days from the date of completion to transmit the assessment. They also stated that for admission assessment, there will be 7 days from assessment reference date to complete, but they are not sure of how many days from the date of completion to submit. The Minimum Data Set Coordinator stated that they submitted some of the assessments within 14 days of completion; and others were transmitted late because they were not completed timely: the information was not provided within the appropriate time frame. On 02/05/2026 at 1:37 PM, the Director of Nursing was interviewed and stated the Minimum Data Set Coordinator is responsible for the completion and submission of residents' assessments. The Director of Nursing stated that they are aware of the late submissions and the facility is hiring another Assessor to ensure that the assessment is completed and submitted in a timely manner. On 02/05/2026 at 1:49 PM, the Administrator was interviewed and stated that the Minimum Data Set Coordinator is responsible for prompt submission of the residents' assessments, and if they are not available, the consultant may be contacted to assist in the completion and submission of the assessment. The Administrator also stated that they are aware that some Minimum Data Set submissions are late, and they have been addressing the issue in QAPI meetings to correct the situation. Additionally, they are also planning to hire another staff to ensure timely completion and submission. 10 NYCRR 415.11(a)(1-5)

Based on record review and interviews during a survey, the facility did not ensure that all alleged violations are thoroughly investigated for 3 out of 3 residents (Resident #2, Resident # 3, Resident #4) reviewed for falls. Specifically, (1) on 11/09/2025 Resident #2 had an unwitnessed fall. The Accident/Incident report was missing the time of supervisor notification and did not document if the Physician and the family representative were notified. In addition, the certified nurse aide occurrence statement had no time the resident was last seen. The top portion of the post occurrence investigation conclusion statement -steps taken that led to conclusion dated 11/10/2025 was not completed. (2) On, 10/17/2025 Resident #3's representative called and reported the resident had fallen in their room. Review of the accident/incident report dated 10/17/2025 revealed no documentation of Physician notification and there were no staff statements attached to the accident/incident report. Review of the post occurrence investigation report dated 10/17/2025 documented Resident #3's site of injury was re-assessed. There was no documented evidence in the accident/incident report of Resident #3 sustaining any injury during their fall. The certified nurse aide occurrence statement dated 10/19/2025 did not document the name of the aide or time of occurrence. The post occurrence investigation conclusion dated 10/20/2025 was not signed and dated by the Administrator. (3) On 11/01/2025, Resident #4 was observed lying on the floor on their back to the left side of their bed. The resident was assessed and noted to have an abrasion to their right outer back. Review of the accident/incident report documented no injuries observed at the time of the incident despite the abrasion noted the residents back.The findings are:The facility Accident/Incident Reporting policy last reviewed 10/21/2025 documented the following data must be included on all accidents/incident report forms: date and time the accident/incident occurred, circumstances surrounding the accident/incident, where the accident/incident occurred and other pertinent facts as appropriate.1)Resident #2 admitted to the facility on [DATE] with diagnoses including but not limited to Dementia, Bipolar Disorder and History of falling.A Significant Change Minimum Data Set, dated [DATE] documented Resident #2 had severe cognitive impairment. The resident had impairment on one side of their lower extremities and required a wheelchair for locomotion. The resident required maximal assistance with eating, moderate assistance with bed mobility and dependent for toileting and transfers. The resident had a history of two or more falls without injury. The resident did not have restraints (bed rail). The resident did not have a bed alarm, chair alarm, floor mat alarm or a motion sensor alarm.The accident/incident report dated 11/09/2025 had attached statements from the licensed nurse and the certified nurse aide. Further review of the licensed nurse statement revealed it did not document the time the supervisor was notified, if the Physician was notified and which family member was notified. The certified nurse aide occurrence statement did not document the last time the resident was seen and documented that Resident #2 used alarms.Review of the facility post occurrence investigation conclusion dated 11/10/2025 revealed the top portion of the document labelled: Steps taken that led to conclusion of investigation was not completed by Nursing Administration.2) Resident #3 admitted to the facility on [DATE] with diagnoses including but not limited to Sequalae of Cerebral Infarction, Seizures and Hemiplegia left non-dominant side.A Comprehensive Minimum Data Set assessment dated [DATE] documented Resident #3 was cognitively intact. The resident required a walker or a wheelchair for locomotion and supervision for eating, toileting, bed mobility and transfers. The resident was occasionally incontinent of bladder and bowel. The resident did not have a history of falls.Review of an accident/incident report dated 10/17/2025 at 2:45 PM documented per the Registered Nurse on 2 [NAME] a telephone call was received from the resident's representative reporting Resident #3 called them and stated they were on the floor. The Accident/Incident report documented they immediately went to Resident #3's room and observed the resident lying in bed. Resident #3 verbally reported that they slid off the bed but was able to get themselves-up. The resident was advised to use their call bell for assistance. Resident #3 denied hitting their head and denied pain. Resident #3's bed was in the lowest position possible.There was no documentation of Physician notification and staff no statements attached to the accident/incident report. Review of the certified nurse aide occurrence statement dated 10/19/2025 did not document a time of the occurrence and did not document the certified nurse aide's name. The post occurrence investigation conclusion dated 10/20/2025 was not signed and dated by the Administrator.Review of the post occurrence investigation report dated 10/17/2025 documented Resident #3's site of injury was re-assessed. There was no documented evidence in the accident/incident report of Resident #3 sustaining any injury during their fall.3) Resident #4 admitted to the facility 05/08/2022 with diagnoses including but not limited to Dementia, Parkinson's disease and History of Falling.A Quarterly Minimum Data Set, dated [DATE] documented Resident #4 had severe cognitive impairment with no behaviors noted.The facility accident/incident report dated 11/01/2025 documented Resident #4 was observed lying on their back to the left side of their bed. The resident was immediately placed back to bed with the assistance of three staff members. The resident was assessed and noted to have an abrasion to their right outer back. The resident denied hitting their head and denied any pain. Range of motion in all extremities was within normal limits. Documented Resident #4 was unable to give a description of the occurrence. Further review of the accident/incident report revealed it documented no injuries observed at the time of the incident.During an interview on 12/05/2025 at 2:46 PM the Director of Nursing stated when there Is a reported fall, they collect statements from all the staff whether they witnessed the fall or not, to determine root cause- if there was a change in the resident prior to the fall. The Director of Nursing stated a statement must be obtained from the staff assigned to the resident, and any witnesses. And a time for all incidents. The Physician/the resident's representative will be notified and documented immediately. An assessment is also completed. is safe and the assessment is completed. Incident is reviewed to determine the cause of the fall. The Director of Nursing reviewed the post occurrence investigation and stated the documentation not being completed was an oversight and moving forward they will make sure the details are completed before they sign the report. The Director of Nursing reviewed the accident/incident report for Resident #3 dated 10/17/2025 and confirmed there were no statements attached, and they signed the report. The Director of Nursing stated they are responsible for reviewing and signing the accident/incident reports before they are sent to the Administrator for review and signature. The Director of Nursing stated this was an oversight by the Administrator as well.During an interview on 12/30/2025 at 11:34 AM Registered Nurse #3 reviewed the accident/incident report dated 11/01/2025 they completed for Resident #3 and stated documenting there was no injury was an error on their part. Registered Nurse #3 stated an abrasion is also an injury and they should have documented it that way. Registered Nurse #3 stated this was their fault. The Abrasion should have been entered on the injury section of the report.During an interview on 12/30/2025 at 11:20 AM the Administrator stated they were not aware of the missing components in the accident/incident reports provided for review. The Administrator stated they review the statements attached to the accident/incident reports and sign them. The Administrator stated they are the last step before the accident/incident report is filed. The Administrator stated it was an oversight that they did not sign the investigative conclusion for Resident #3's accident/incident that occurred on 10/17/2025. 10 NYCRR 415.4 (b)(1)(ii)

Based on record review and interviews during an abbreviated survey (2654597) the facility did not ensure the residents right to a dignified existence the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 out of 3 residents (Resident #5) reviewed for dignity. Specifically, on 12/05/2025 the Surveyor observed Certified Nurse Aide #2 providing personal care to Resident #5 with the door to their room open. Resident #5 was observed lying in bed, without a shirt on, and was noted to be exposed from the waist up and visible from the hallway. The findings are:The facility Resident Rights policy last reviewed 10/01/2025 documented it is the policy to provide care and services in such a manner to acknowledge and respect resident rights. Each resident has the right to be treated with dignity and respect. All interactions and activities with residents by any staff must focus on assisting the resident in maintaining and enhancing his or her self-esteem and self-worth and incorporating the resident's goals, preferences, and choices. When providing care and services, staff will respect each resident's individuality as well as honor and value their input.Resident #5 admitted to the facility on [DATE] with diagnoses including but not limited to Chronic Obstructive Pulmonary Disease, General Anxiety Disorder and Muscle Wasting and Atrophy.A Quarterly Minimum Data Set, dated [DATE] documented Resident #5 was cognitively intact with no behaviors noted. The resident had functional limitations to both lower extremities and used a wheelchair for locomotion. The resident required moderate assistance for eating, dependent for bathing, toileting, bed mobility and transfers. Review of a psychosocial wellbeing care plan last revised 12/30/2025 documented Resident #5 was at risk related to their anxiety and major depressive disorder diagnoses. Interventions listed included encourage participation from resident that depends on others to make their own decisions and provide opportunities for the resident to participate in care.During rounds on 12/05/2025, on the second floor, at 11:13 AM the door to Room-200 was noted to be open, and Certified Nurse Aide #2 was observed providing morning care, with the door open. Resident #5 was lying in bed undressed with a sheet covering them from the waist down, the resident chest was fully exposed. Certified Nurse Aide #2 was gloved up and started to provide care to Resident #5. The surveyor went to find the unit manager and went back to the room and Certified Nurse Aide #2 had pulled the curtain around Resident #5's bed, but the door was still open while they were providing care. The Surveyor informed the unit manager, Registered Nurse #2 and they addressed the Certified Nurse Aide #2. Certified Nurse Aide #2 popped their head out of the curtain and stated they cannot breathe in the room, that is why they had the door open while providing care.During an interview on 12/05/2025 at 11:15 AM Registered Nurse #2 stated they informed Certified Nurse Aide #2 that Residents #5's door should be closed when they are providing care. Registered Nurse #2 stated they always inform the certified nurse aides that they should always close the door for privacy and Certified Nurse Aide #2 informed them they cannot breathe in the room because of the heater. Registered Nurse #2 stated the process is the resident should be provided privacy regardless of anything when providing personal care.During an interview on 12/30/2025 at 1:49 PM Certified Nurse Aide #2 stated for the last couple of weeks the residents have been coughing a lot, and they do not cover their mouths, so they sometimes leave the door ajar when they are providing care. Certified Nurse Aide #2 stated they know the curtain around the resident's bed and the door should be closed when providing personal care to a resident.10 NYCRR 415.3(d)(1)(i)

Based on record review and interviews conducted during a survey the facility did not ensure that the comprehensive care plan was reviewed and revised for 2 out of 3 residents (Resident #2, Resident #3) reviewed for falls. Specifically, (1) Resident #2 had an unwitnessed fall on 11/09/2025 and the residents care plan was updated to reflect the use of a chair/bed alarm and to ensure the device is in place as needed. There was no documented evidence of Resident #2 using any alarms during their stay in the facility. The Director of Nursing stated this was documented erroneously as the facility does not use alarms. (2) Resident #3 had an unwitnessed fall on 10/19/2025 and was found by the certified nurse aide on the floor in a sitting position. Review of the post occurrence investigation documented the steps that led to conclusion of investigation were Resident #3's care plan was reviewed and revised. Review of Resident #3's risk for falls care plan last revised 10/19/2025 revealed there were no safety interventions implemented for Resident #3 after their fall on 10/19/2025.The findings are:The facility Care Planning Process policy last reviewed 10/01/2025 documented the facility shall have a care planning process in place which includes integrating assessment findings in care planning, developing and interdisciplinary care plan and regularly reviewing and revising the care plan. The purpose is to ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental and psycho-social wellbeing. 1)Resident #2 admitted to the facility on [DATE] with diagnoses including but not limited to Dementia, Bipolar Disorder and History of falling. A Significant Change Minimum Data Set, dated [DATE] documented Resident #2 had severe cognitive impairment. The resident had impairment on one side of their lower extremities and required a wheelchair for locomotion. The resident required maximal assistance with eating, moderate assistance with bed mobility and dependent for toileting and transfers. The resident had a history of two or more falls without injury. The resident did not have restraints (bed rail). The resident did not have a bed alarm, chair alarm, floor mat alarm or a motion sensor alarm.Review of a risk for falls care plan initiated 11/09/2025 documented Resident #2 was at risk for falls related to gait/balance problems. Interventions listed included the resident uses chair/bed alarm ensure the devices is in place as needed, anticipate and meet the resident's needs prompt response to all requests for assistance and educate the resident/family/caregivers about safety reminders and what to do if a fall occurs.There was no documented evidence of Resident #2 having an alarm in use during their stay in the facility.2) Resident #3 admitted to the facility on [DATE] with diagnoses including but not limited to Sequalae of Cerebral Infarction, Seizures and Hemiplegia left non-dominant side.A Comprehensive Minimum Data Set assessment dated [DATE] documented Resident #3 was cognitively intact. The resident required a walker or a wheelchair for locomotion and supervision for eating, toileting, bed mobility and transfers. The resident was occasionally incontinent of bladder and bowel. The resident did not have a history of falls.Review of an accident/incident report dated 10/19/2025 documented Resident #3 was found by the certified nurse aide on the floor in a sitting position and informed the charge nurse. Documented Resident #3 stated they slid off the bed and ended up on the floor in a sitting position. Review of the post occurrence investigation documented the steps that led to conclusion of investigation documented Resident #3's care plan was reviewed and revised. Review of a risk for falls care plan last revised 10/19/2025 documented Resident #3 was found sitting on the floor at the foot of their bed. Further review revealed there were no safety interventions implemented for Resident #3 after their fall on 10/19/2025.During an interview on 12/05/2025 at 11:15 AM Certified Nurse Aide #1 stated Resident #2 required total care, and they recall the resident did not have an alarm on their wheelchair during their stay in the facility. During an interview on 12/05/2025 at 2:46 PM the Director of Nursing stated after the notification is made regarding a fall, they review the incident to determine the cause of the fall, and they also review the care plans and implement an intervention related to the incident. The Director of Nursing stated the chair/bed alarm was erroneously entered on Resident #2's risk for falls care plan as an intervention, because they do not use alarms in the facility. The Director of Nursing stated they are going to review the template for the care plan because some of the options for selection no longer apply in the facility. The Director of Nursing reviewed Resident #3's care plan and stated they did not see an intervention, but they do not know why it was not entered on the resident's care plan.10 NYCRR 415.11 (c)(2)(ii)

Based on record review and interviews during an abbreviated survey (2669836) the facility did not ensure that the resident environment remained as free of accident hazards as is possible; and each resident received adequate supervision and assistance devices to prevent accidents for 1 out of 3 residents (Resident #2) reviewed for falls. Specifically, Resident #2 had a known history of attempting to stand and trying to walk without supervision and multiple falls. There was no documented evidence of Resident #2 having safety measures in place to prevent falls from occurring when attempting to stand or walk. On 11/09/2025 the resident was found on the floor in the hallway by staff, after attempting to stand from their wheelchair. Resident #2 complained of back pain after their fall and had an x-ray done which showed a compression fracture of their T12 vertebrae age undetermined. Resident #2 was transferred to the hospital for further evaluation on 11/11/2025.The findings are:The facility Accidents/Incidents Reporting policy last reviewed 10/21/2025 documented the intent of the policy is to ensure this facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices are provided for each resident to prevent avoidable accidents. This includes implementing interventions to reduce hazards and risks and monitoring for effectiveness and modifying interventions when necessary. The policy defines position change alarms are alerting devices intended to monitor a resident's movement. The device emits a audible signal when the resident moves in a certain way. Types of position change alarms include chair and bed sensor pads, bedside alarmed mats, alarms clipped to a resident's clothing, seatbelt alarms and infrared beam motion detectors. Resident #2 admitted to the facility on [DATE] with diagnoses including but not limited to Dementia, Bipolar Disorder and History of falling. A Significant Change Minimum Data Set, dated [DATE] documented Resident #2 had severe cognitive impairment. The resident had impairment on one side of their lower extremities and required a wheelchair for locomotion. The resident required moderate assistance with bed mobility and was dependent for toileting and transfers. The resident had a history of two or more falls without injury and did not have any position change alarms (bed rail), a bed alarm, chair alarm, floor mat alarm or a motion sensor alarm. Review of Resident #2's fall risk assessment dated [DATE] documented the resident had a fall risk score of 16, indicting a high risk for falls. There was no documented evidence of Resident #2 having safety measures in place to prevent them from falling when attempting to stand or walk unsupervised. Review of a behavior care plan last revised 11/06/2025 documented Resident #2 has potential to demonstrate behaviors related to attempts unsafe maneuvers like standing, attempting to walk with no supervision, poor cognition, poor safety awareness and poor impulse control. Interventions listed included assess and anticipate resident's needs, give the resident as many choices as possible about care and activities, monitor and document observed behavior and attempted interventions in behavior log. Review of a risk for falls care plan last revised 11/09/2025 documented Resident #2 was a high risk for falls related to confusion and gait/balance problems. Interventions listed included anticipate and meet the resident's needs and educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Review of a risk for falls care plan initiated 11/09/2025 documented Resident #2 was at risk for falls related to gait/balance problems. Interventions listed included the resident uses chair/bed alarm ensure the devices is in place as needed, anticipate and meet the resident's needs prompt response to all requests for assistance and educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. The facility accident/incident report dated 11/09/2025 at 3:10 PM documented the writer was called by a certified nurse aide to inform them Resident #2 was found sitting on the floor in the hallway. When they arrived on the unit Resident #2 was still on the floor with their wheelchair on their left side. There were no visible injuries noted. Resident #2 was instructed not to get up on their own, their wheelchair was locked, and the certified nurse aide was informed to check on the resident to address their needs. Resident #2 was oriented to person and situation and had a known history of gait imbalance. Review of Registered Nurse #4's progress note dated 11/09/2025 at 3:39 PM documented Resident #2 was found on the on the floor following an unwitnessed fall. According to Resident #2, they were attempting to stand up and lost their balance, resulting in the fall. Resident #2 complained of back pain and their representative was notified. Review of Resident #2's fall risk assessment dated [DATE] documented the resident had a fall risk score of 16, indicating they were a high risk for falls. There was no documented evidence of Resident #2 having safety measures in place to prevent them from falling when attempting to stand or walk unsupervised. Review of Resident #2's Kardex revealed the resident had accidents with injury and was a fall risk. There was no documented evidence of Resident #2's having any assistive devices listed. Review of Medical Director #1's progress note dated 11/10/2025 at 4:40 PM documented Resident #2 was found on the floor in the hallway near their room. Resident #2 denied hitting their head, reported no pain and no injuries were noted by staff. Review of Resident #2's radiology report dated 11/10/2025 documented a two or three view of the lumbosacral region, due to low back pain. Osteopenia noted. Compression fracture T12 vertebral body age best determined by MRI. No additional fracture noted. The impression documented osteopenia noted. Compression fracture T12 vertebral body age best determined by MRI. Review of Attending Physician #1's progress note dated 11/11/2025 at 11:35 AM documented the assessment/plan as Resident #2 was status post fall yesterday when trying to stand and their legs gave out and they fell. Resident #2 complained of back pain. Resident #2 was noted to have T12 compression fracture and will be sent to the emergency room for evaluation by Orthopedics. During an interview on 12/05/2025 at 11:15 AM Certified Nurse Aide #1 stated Resident #2 required total care, and they recall the resident had bedside floor mats and they did not have an alarm on their wheelchair during their stay in the facility or any safety devices. Certified Nurse Aide #1 stated Resident #2 would always be seated outside of their room, which is front of the nurse's station and the resident would edge closer and closer to the edge of their wheelchair, and then they would end up falling on the floor. During an interview on 12/05/2025 at 2:46 PM the Director of Nursing stated when there Is a reported fall the Registered Nurse does the initial assessment of the resident to check for any injury. The Director of Nursing stated for the frequent fall residents sometimes they run out of interventions to implement. The Director of Nursing stated Resident #2 was on close supervision/monitoring because of their behaviors and the resident was aggressive, non-compliant and not easily redirected. The Director of Nursing stated Resident #2 was given a private room by the nurse's station so the resident could be monitored by staff. During an interview on 12/30/2025 at 11:20 AM the Administrator they know who the frequent fallers are and no matter what interventions they put into place the residents still fall. 10 NYCRR 415.12(h)(2)

Based on record review and interview during an abbreviated survey and partial extended survey (NY00349917), the facility did not ensure a resident received care, consistent with professional standards of practice, to prevent new ulcers from developing and promote healing of facility acquired pressure ulcers for 3 out of 5 residents (Resident #1, #7, #8) reviewed. Specifically, (1) Resident #1 was admitted to the facility with intact skin and was identified as a low risk for pressure ulcer development. Interventions/measures ordered by the physician to prevent pressure ulcer development were not consistently provided by direct care staff and Resident #1 developed a facility acquired pressure ulcer to their sacrum and bilateral heels. (2) Resident #7 developed a facility acquired Stage III pressure ulcer (a full thickness tissue loss where subcutaneous fat is visible within the wound, but bone, tendon, or muscle are not exposed) to the right buttocks after not receiving consistent incontinence care. (3) Resident #8 developed a facility acquired Stage III pressure ulcer to their sacrum. Resident #8 had upper/lower extremity impairment was dependent on staff for bed mobility and was not consistently provided skin observations or turning and positioning by direct care staff. Findings include: The facility's Pressure Injury/Pressure Ulcer Assessment, Prevention and Management policy dated 7/2018 documented it is the policy of the facility that residents will not develop pressure injury/ulcers unless clinically unavoidable. The facility shall provide care and service consistent with professional standards of practice to prevent pressure injury development. The purpose of the policy is to provide guidelines for the prevention as well as timely identification and treatment of pressure injury. When a pressure injury is present on an in-house resident, document the assessment of the wound on a weekly basis on the weekly evaluation form, update the pressure injury care plan to reflect the status of the pressure injury and plan of care. 1) Resident #1 was readmitted to the facility on [DATE] with diagnoses including, but not limited to, Chronic Obstructive Pulmonary Disease (lung disease causing restricted airflow and breathing problems), Muscle Wasting and Atrophy (the loss of muscle mass and strength, often occurring due to lack of use, injury, malnutrition, or certain diseases, resulting in a decrease in muscle size and function) and Muscle Weakness (lack of muscle strength). A 5-day Minimum Data Set (an assessment tool) dated 6/11/2024 documented the resident had moderate cognitive impairment. The resident required moderate assistance for eating, maximum assistance for bed mobility/transfers and was dependent for toileting. The resident was at low risk for pressure ulcers. There was no documented staged pressure ulcers or unstageable pressure ulcers. The resident had no dressings applied to their feet but received ointment or medication to areas other than their feet for dryness. Review of the Resident #1's admission/readmission nursing assessment dated [DATE] revealed the resident's skin was intact and they had dryness and skin discoloration to their bilateral heels. The Admission/Readmission assessment categorized Resident #1 as a low risk for pressure ulcer. Review of a risk for skin integrity impairment care plan initiated 6/5/2024 identified risks related to decreased mobility and documented Resident #1's skin would be free from pressure related injury through 6/25/2024. Interventions listed included assist with turning and positioning as needed, heel protectors and keep resident clean and dry. Review of an activities of daily living care plan dated 6/6/2024 revealed self-care performance deficit related to activity intolerance. Interventions listed included inspect skin every shift and observe for redness and open areas and report changes to the nurse. Toilet every 2 hours and as needed. The Admission Braden Scale (a risk assessment tool that predicts a patient's likelihood of developing pressure ulcers) dated 6/7/2024 documented Resident #1 had a score of 15 and was categorized as low risk for pressure ulcers. Review of an actual skin integrity impairment care plan initiated on 6/21/2024 documented on 6/19/2024 Resident #1 had a skin tear (a wound that occurs when the layers of skin separate due to mechanical forces, such as friction, shear or blunt trauma) to their right buttock measuring 4 cm x 5 cm. Interventions listed included apply treatment to site as ordered and prevent excessive moisture to other body parts. Review of Registered Nurse #2/wound care nurse's progress note dated 6/25/2024 documented Resident #1 was noted to have a skin tear on their right lower buttocks which measured 2 cm x 2 cm x 0.1 cm with scant serosanguinous (contains or relates to both blood and liquid part of blood) drainage. There was no further documented tracking of Resident #1's right buttock skin tear on the care plan after 6/21/2024 and no wound assessment documented in the nursing progress notes after 6/25/2024. Review of a pressure ulcer care plan initiated 6/24/2024 documented on 6/21/2024 Resident #1 had a right heel deep tissue injury (a type of pressure ulcer that occurs when the tissue beneath the skin is damaged by pressure or shearing force) 6.5 cm x 4 cm and redness to the left heel 6 cm x 4 cm. Interventions listed included assess/record/monitor wound healing weekly, turn/reposition at least every 2 hours or more as needed or requested, and wound care consults as ordered. Review of a nurse's progress note dated 6/24/2024 documented discoloration noted to right heel measuring 6 cm x 7 cm x 0 cm. Red and purple discoloration noted on left heel measuring 2 cm x 2 cm x 0 cm. Skin was noted to be intact. There was no documented evidence of a weekly skin assessment of the wound. There was no documented evidence of an updated pressure ulcer care plan related to Resident #1's heels after 6/24/2024. Review of Registered Nurse #2/wound care nurse's progress note dated 6/27/2024 documented they were informed Resident #1 had an opening to their right heel deep tissue injury measuring 6 cm. Treatment will be applied until Resident #1 is seen by wound specialist. Review of Registered Nurse #2/wound care nurse's skin/wound care progress note dated 7/9/2024 documented Resident #1 was noted with redness on their right bunion measuring 2 cm x 2 cm and red to purple discoloration on their right outer ankle measuring 1 cm x 1 cm. There is no documented evidence Resident #1 was evaluated by the wound specialist prior to their transfer to the hospital on 7/12/2024 for evaluation of left facial droop. Resident #1 was discharged to the hospital on 7/12/2024. Hospital records revealed the resident had a stage 3 pressure ulcer to the sacrum and 2 pressure ulcers to the right malleolus (ankle), and the right heel. The right heel pressure ulcer was debrided (a medical procedure that removes dead, damaged, or infected tissue from a wound to promote healing). The infectious diseases evaluation documented proposed diagnosis as sepsis with source being right heel necrosis. Review of Resident #1's certified nurse assistant accountability report for June 2024 revealed the following care was not provided: bilateral heel booties in place when in bed every shift - no documentation on six (6) occasions, skin observation of right buttock and bilateral heels every shift - no documentation on eight (8) occasions and turning and positioning every two (2) to four (4) hours - no documentation on 24 occasions. Review of Resident #1's certified nurse assistant accountability report for July 2024 revealed no documented evidence indicating care, as per the care plan, was implemented: bilateral heel booties in place when in bed on 5 occasions, skin observation of right buttock and bilateral heels on 2 occasions and turning and positioning on 12 occasions. During an interview on 10/17/2024 at 12:04 PM with Registered Nurse #2/wound care nurse, they stated when Resident #1 went to the hospital in July 2024, they had facility acquired wounds on their right buttocks and on bilateral heels. Registered Nurse #2/wound care nurse stated Resident #1 was not able to move around on their own and they were turned and repositioned by the certified nurse assistants. Registered Nurse #2/wound care nurse stated Resident #1 was not turned and positioned frequently enough, and their heel booties were not applied as ordered. Registered Nurse #2/wound care nurse stated interventions such as the turning and positioning and heel booties are entered on the care Kardex and the certified nurse assistants sign off on them when completed. During a telephone interview on 10/18/2024 at 11:32 AM, Registered Nurse #1 stated when Resident #1 was admitted to the facility, they had redness to their heels, and they developed a deep tissue injury. During an interview on 10/18/2024 at 1:18 PM, Registered Nurse #3 stated they did Resident #1's admission assessment on 6/5/2024 and the resident's skin was intact with some discoloration on their heels. Registered Nurse #3 stated the discolored areas were blanchable (pressing on the area will turn the redness white or pale) and very dry and there were no signs that their heels would turn into pressure ulcers. On admission Resident #1 had no skin breakdown on their sacrum. Registered Nurse #3 stated they were concerned about the dryness to Resident #1's heels, and they activated their admission order set which included: applying antiseptic to the sacrum, using bilateral heel booties, certified nurse assistants were to elevate the resident's bilateral legs with pillows and to report any skin changes or openings to the Registered Nurse or nursing supervisor. During an interview on 10/21/2024 at 2:20 PM, Certified Nurse Assistant #2 stated they remember Resident #1, and they recall repositioning the resident and applying their heel booties. Certified Nurse Assistant #2 stated an empty signature box on the certified nurse assistant accountability report looks like the care was not provided but they do not recall if they signed for Resident #1's care after completion. They usually do their documentation. During an interview on 10/21/2024 at 3:41 PM, Certified Nurse Assistant #3 stated they worked in the facility for about 3 years, and they remember Resident #1. The resident needed assistance with Activities of Daily Living care and turning and positioning in bed. Resident #1 also needed heel booties and pillows for positioning every 2 hours. Certified Nurse Assistant #3 stated if there is no signature in a box on the certified nurse accountability report then the care was not provided. Certified Nurse Assistant #3 stated they provided care to Resident #1 as ordered and cannot recall why they did not sign the accountability record. During an interview on 10/21/2024 at 3:50 PM, the Director of Nursing stated the residents are assessed to identify their risk factors for pressure ulcers and the Braden scale assessment is conducted weekly for 4 weeks for each resident after admission. Pressure relieving devices as well as heel booties and incontinence products are provided for all residents . The Director of Nursing stated all comorbidities are monitored and regulated from admission to lower risks of acquiring pressure ulcers. Upon identification of a pressure ulcer the physician is notified for a treatment order, the resident's plan of care is reviewed, preventative measures are implemented, and the residents are added to the list for wound rounds. 2) Resident #7 admitted on [DATE] with diagnoses including but not limited to Chronic Pulmonary Embolism (a medical condition that occurs when blood clots in the pulmonary arteries do not dissolve or are left untreated), Gastrointestinal Hemorrhage (a medical condition when a bleeding occurs within the gastrointestinal tract) , and Benign Prostatic Hyperplasia (a medical condition that causes the prostate to enlarge) without lower urinary symptoms. A last Quarterly Minimum Data Set (an assessment tool that measures health status) dated 8/2/2024 documented the resident had moderate cognitive impairment. The resident required moderate assistance with eating and bed mobility and was dependent for toileting and transfers. Foley catheter in place and frequently incontinent of bowels and has MASD (moisture associated skin damage). Review of a Registered Nurse #2 wound progress note dated 8/14/2024 documented Resident #7 was seen for a rash to their buttocks and was noted to have moisture associated skin damage measuring at 1.5 cm x 1 cm x 0.1 cm. Review of a wound progress note dated 8/21/2024 documented Resident #7 was seen for a bilateral buttock rash which is now a Stage III pressure ulcer to the right buttocks measuring 1.8 cm x 0.6 cm x 0.1 cm. Review of Resident #7's wound assessment reports revealed the following: - On 8/14/2024 the wound assessment report documented Resident #7 had moisture associated skin damage to their bilateral buttocks measuring 1.5 cm x 1 cm x 0.10 cm. The treatment ordered to cleanse daily with soap and water and apply medical grade honey and cover with a bordered gauze. - On 8/21/2024 the wound assessment report documented a Stage III pressure ulcer to the right buttocks measuring 1.8 cm x 0.6 cm x 0.10 cm. - On 8/28/2024 Stage III pressure ulcer to the right buttocks measuring 1.2 cm x 0.6 cm x 0.10 cm. - On 9/11/2024 Stage III pressure ulcer to the right buttocks measuring 3.0 cm x 4.0 cm x 0.10 cm. - On 9/18/2024 and 9/24/2024 documented a stage III pressure ulcer to the right buttocks measuring 2.2 cm x 2.0 cm x 0.10 cm. Review of Resident #7's treatment administration records for August 2024 and September 2024 revealed the physician ordered treatments were not documented as completed on 8/26/2024, 8/31/2024, 9/1/2024 and 9/3/2024. Review of a potential for pressure ulcer development care plan last updated 10/21/2024 documented Resident #7 would have intact skin by/through 11/21/2024. Interventions listed included to assist with turning and positioning every two (2) hours and as needed. Review of a bladder incontinence care plan initiated on 8/16/2022 documented Resident #7 will remain free of complications related to urinary incontinence such as skin breakdown. Interventions listed included assist with toileting as requested and check the resident every two (2) to four (4) hours and as needed as required for incontinence. There were no documented updates to the interventions on the bladder incontinence care plan. A target date of 11/21/2024 was documented. Review of the foley catheter care plan, last updated 8/19/2024, listed interventions to change catheter every four (4) weeks, monitor intake and output, position catheter bag and tubing below the level of the bladder. Review of Resident #7's certified nurse assistant accountability report for August 2024 revealed the following care was not provided: skin observation of sacrum and bilateral buttocks every shift - not documented on 31 occasions, bladder incontinence care every shift - not documented on 31 occasions. Review of Resident #7's certified nurse assistant accountability report for September 2024 revealed the following care was not provided: skin observation of sacrum and bilateral buttocks every shift - not documented on 36 occasions, bladder incontinence care every shift - not documented on 30 occasions. 3)Resident #8 was admitted with diagnoses including but not limited to Nontraumatic Intracerebral Hemorrhage (a type of stroke that occurs when blood pools in the brain without trauma or surgery), other Encephalopathy (any brain disease that alters brain function or structure) and Muscle Wasting and Atrophy (the loss of muscle mass and strength, often occurring due to lack of use, injury, malnutrition, or certain diseases, resulting in a decrease in muscle size and function). An Admission Minimum Data Set (an assessment tool that measures health status) dated 8/7/2024 documented the resident had moderate cognitive impairment. The resident had upper and lower extremities impairment and was dependent for eating, toileting, bed mobility and transfers. The resident was a high risk for pressure ulcers but had no skin conditions noted. Review of Resident #8's Admission/Reassessment nursing assessment dated [DATE] documented the resident's skin was intact and categorized them as a low risk for pressure ulcers. Review of Registered Nurse #1's progress note dated 8/11/2024 documented they were informed by the certified nurse assistant that Resident #8 had a wound to their sacral area. Resident noted to have a superficial skin opening to the sacral area measuring 0.5 cm x 0.5 cm x 0.1 cm. Review of the wound care Nurse Practitioner's progress note dated 8/14/2024 documented Resident #8 had a Stage III pressure ulcer to the sacrum measuring 0.6 cm x 0.2 cm x 0.1 cm. Review of a risk for skin integrity impairment care plan initiated 8/14/2024 documented Resident #8 would be free from pressure related injuries by 12/21/2024. Interventions listed included assist with turning and positioning as needed and turn and position every two (2) hours. Review of Resident #8's certified nurse assistant accountability report for August 2024 revealed the following care was not provided: skin observation every shift - not documented on 41 occasions and turning and positioning every two (2) hours - not documented on 53 occasions. Review of Resident #8's certified nurse assistant accountability report for September 2024 revealed the following care was not provided: skin observation every shift -not documented on 39 occasions and turning and positioning every two (2) hours -not documented on 160 occasions. Review of Treatment Administration Record for August/September 2024 revealed wound treatments for the Stage III pressure ulcer were not documented as completed on the following dates: 8/18/2024, 8/22/2024, 8/31/2024, and 9/1/2024. During an interview on 10/21/2024 at 2:13 PM, Certified Nurse Assistant #1 stated if their signature was not in the box, then it would look as if they did not provide the care, but they make rounds on their residents regularly and sometimes, they forget to sign off on their tasks in the computer, because they get caught up in their work. During an interview on 10/21/2024 at 3:50 PM, the Director of Nursing stated the expectation is the certified nurse assistants complete their documentation for all residents assigned before the end of their shift. It is the responsibility of the unit managers to check the documentation and notify the certified nurse assistants of incomplete documentations. The Director of Nursing stated the certified nurse assistants can go back and document any missed information. The last In-service on documentation was completed 10/20/2024. The Director of Nursing stated they have not received any recent complaints from the residents about not receiving care, and there have been no complaints regarding care from the families in the past. During an interview on 11/25/2024 at 10:13 AM, Registered Nurse #2/wound care nurse stated they were not wound care certified but are in the process of taking online seminars. Registered Nurse #2/wound care nurse stated when they assess a wound and it is superficial, they categorize it as a skin tear, meaning it is affecting only the epidermal layer (the outermost layer) of the skin. These wounds are pressure ulcers, but the Nurse Practitioner must categorize them as such. Registered Nurse #2/wound care nurse stated they are not allowed to stage the wounds if they are not sure of the staging. Registered Nurse #2/wound care nurse stated they initiate the initial treatment plan per the facility protocol until the wound Nurse Practitioner comes in and stages the wound. The wound Nurse Practitioner is the one who does the staging of the wounds. During an interview on 11/25/2024 at 11:21 AM, the Director of Nursing stated Registered Nurse #2/wound care nurse can stage a wound, but they are scared to stage. The Director of Nursing stated they even provided Registered Nurse #2/wound care nurse with different terms to describe the wounds. The nurses are very good at identifying and treating the wounds, but they need to build their confidence to stage the wounds. The Director of Nursing stated Registered Nurse #2/wound care nurse was re-educated to determine the cause of the wound, because that is how they can identify pressure from non-pressure injuries. The Director of Nursing stated Registered Nurse #2/wound care nurse and all staff in the facility were provided education last month by a wound care company. The Director of Nursing also stated Registered Nurse #2/wound care nurse has attended training on wounds for the last 2 consecutive months. During a telephone interview on 11/21/2024 at 11:55 AM, the Medical Director stated they are aware of the facility acquired pressure ulcers in the facility and that there is a wound care specialist team that provides service in the building. The Medical Director stated the wound care specialist team works very closely with nursing and the Director of Nursing. The nurses communicate any concerns and issues about wounds to them. The Medical Director stated they see an incredible service being provided by the wound care specialist team and that there is always room for improvement with the facility acquired pressure ulcers. The Medical Director stated residents need to be checked constantly/around the clock for their incontinence needs, skin condition and wound status. If a resident has fragile skin, the resident needs to be turned and positioned and have their incontinence brief changed frequently to avoid skin breakdown. On admission, residents are assessed by the admitting nurse. If there is the need for wound care, a verbal order is given by them to the nurse. Verbal orders are also given for turning and repositioning. The Director of Nursing is in constant communication with the wound care consultants to follow through with recommendations provided. The Medical Director stated that turning and repositioning is part of their preventative measures/protocol to minimize facility acquired pressure ulcers, which is done with or without orders from them. The Medical Director stated with any wound or skin issue that occurs, the nurses are expected to institute turning and positioning as per protocol. All measures must be written on the physician orders for final signature including orders as per the facility protocol such as turning/repositioning/skin observations/heel booties. 10 NYCRR 415.12

Based on record review and interview during an abbreviated survey (NY00349917, NY00347905) and a partial extended survey the facility did not ensure the residents representative was informed of a significant change in the resident's physical status or a need to alter treatment significantly for 3 out of 4 residents (Resident #1, Resident #6, Resident #7) reviewed for notification of changes. Specifically, (1) Resident #1 developed multiple facility acquired pressure ulcers to their right buttocks on 6/20/2024 and bilateral heels on 6/25/2024. There was no documented evidence that Resident #1's representative was notified of these changes in the resident's condition until they inquired about them on 6/26/2024 and 7/1/2024. (2). Resident #6 developed a facility acquired sacral pressure ulcer on 7/27/2024. There was no documented evidence of Resident #6's representative was notified that the resident developed a sacral pressure ulcer or informed of the ordered treatment. (3) Resident #7 developed a facility acquired pressure ulcer to their sacrum on 8/21/2024. The facility documented a telephone conference with Resident #7's representative on 8/22/2024, but there was no documented evidence that Resident #7's representative was made aware that the resident developed a Stage III right buttock pressure ulcer or informed of ordered treatment. The findings are: The facilities Notification Policy dated 9/2017 and last revised on 6/2019 documented it was to ensure that residents and/or resident's representative receive notification of specific changes during the resident's stay in the facility. The facility must immediately inform the resident, consult with the resident's physician, and notify, consistent with his/her authority, the resident representative when there is: a significant change in the resident's physical status or a need to alter treatment significantly. 1) Resident #1 admitted to the facility initially on 12/7/2018 and last readmitted on [DATE] with diagnoses including but not limited to Chronic Obstructive Pulmonary Disease, Muscle Wasting Atrophy and Muscle Weakness. A 5-day Minimum Data Set (an assessment tool that measures health status) dated 6/11/2024 documented the resident had a Brief Interview for Mental Status (a screening tool that assess a person's cognitive health) score of 12 indicating moderate cognitive impairment. Documented the resident required moderated assistance for eating, dependent for toileting, maximal assistance for bed mobility and transfers. The resident was at risk for pressure ulcers with no documented staged pressure ulcers or unstageable pressure ulcers. Documented the resident did not have any dressings applied to their feet but received ointment or medication to areas other than their feet. Review of a risk for skin integrity impairment care plan initiated 6/5/2024 documented related to decrease in mobility, Resident #1's skin would be free from pressure related injury through the next review date. Interventions listed included assist with turning and positioning as needed, heel protectors and keep resident clean and dry. During a telephone interview on 10/15/2024 at 12:12 PM Resident #1's representative stated, they visited the resident, and they noticed the resident's foot was wrapped in a bandage, no one at the facility mentioned why the foot was wrapped. The representative stated a family member visited the resident in the facility and during the visit the nurse came in the room and applied cream to the resident's buttocks. The representative stated they asked what was going on and Registered Nurse #1 stated Resident #1 had bed sores. Stated the facility had never informed them that Resident #1 had bed sores prior, and they visited the resident daily, except for 2 days during the duration of their stay in the facility. The representative stated Resident #1's roommates family brought their attention to the resident's bandaged foot and asked them what was going on with the resident's foot. The representative stated they went to Registered Nurse #1 and asked what was going on, and the nurse stated Resident #1 had a bedsore. The representative stated they saw that Resident #1 was more and more wrapped up as they visited, and that bandages were getting larger in size. Review of the Resident #1's admission assessment dated [DATE] documented the resident's skin was intact and they had dryness and skin discoloration to bilateral heels. The resident was scored as a low-pressure ulcer risk. Review of a nurse progress note dated 6/20/2024 documented Resident #1 was noted with an open wound to the left upper buttock measuring at 4 cm x 5 cm. Documented a dressing was applied and the nursing supervisor was made aware. Review of a nurse's progress note dated 6/24/2024 documented red and purple discoloration noted on left heel measuring 2 cm x 2 cm x 0 cm. Red to purple discoloration noted to right heel with measurement 6 cm x 7 cm x 0 cm, skin intact. Both heels were cleansed with normal saline, patted dry, then skin prep wipes were applied as skin protectant. Applied bilateral heel booties for offloading and unit Manager made aware. Review of nurse's progress note dated 6/25/2024 documented Resident #1 was noted to have a skin tear on their right lower buttocks which measured 2 cm x 2 cm x 0.1 cm, with scant serosanguinous drainage. The right lower buttocks were cleansed with normal saline, patted dry, and xeroform dressing applied then site covered with a dry protective dressing, unit manager made aware. Review of a nurse's progress note dated 6/26/2024 documented Resident #1's daughter approached them about the residents dressing that is wrapped on their foot, and they informed them that the resident's bilateral heels are being treated with skin prep and wrapped for additional protection. The complainant also asked about the skin openings on Resident #1s buttocks, and they informed them it is being treated by the wound care nurse. Documented the complainant also expressed concern about the time it takes before the resident is attended to by staff when the certified nurse assistant is with another resident. Review of a nurse note dated 6/27/2024 documented they were informed by Registered Nurse #2 wound care nurse that Resident #1 was observed with a skin opening on their right heel, a deep tissue injury measuring 6 cm. The right heel was cleansed with normal saline, patted dry, and xeroform dressing applied, then covered with a dry protective dressing, until seen by wound specialist. Review of Registered Nurse #1's progress note dated 7/1/2024 documented the resident's representative approached them regarding the wound on their buttocks. They asked how frequent Resident #1 was being seen by the wound specialist. The note documented that they informed the representative that the resident was being assessed by Registered Nurse #2 wound care nurse every day and would be evaluated by the wound specialist weekly. There was no documented evidence that the facility notified Resident #1's representative of the changes in their condition, prior to the representative inquiring. During a telephone interview on 10/18/2024 at 11:32 AM Registered Nurse #1, they stated they were the unit manager on 1 West. Registered Nurse #1 stated as the unit manager they are responsible to notify the family if there are any changes in condition or wounds or any changes in the resident health status. Registered Nurse #1 stated, they were not sure if they were working the day Resident #1's wound was discovered. They further stated that, if they were not working then the nursing supervisor on duty would be responsible to notify the family. Registered Nurse #1 stated whomever is the nurse assigned to a resident at the time of discovery would inform them or the nursing supervisor of any changes and they would contact the family on the same day. Registered Nurse #1 stated that Resident #1's family was in the facility daily and was notified about the development of the wounds. Registered Nurse #1 stated when they are at the nurse's station, they provide updates to family representatives when they ask about the residents. Review of the staffing schedule for June 20th and 21st revealed Registered Nurse #1 was on schedule. During an interview on 10/21/2024 at 3:50 PM the Director of Nursing stated the Registered Nurse #1 was very familiar with Resident #1's family who were in the facility daily and they are not sure why Registered Nurse #1 did not notify the family about the resident's pressure ulcers. 2) Resident #6 initially admitted to the facility on [DATE] and last readmitted on [DATE] with diagnoses including but not limited to Muscle Wasting and Atrophy, Type 2 Diabetes Mellitus and Bipolar Disorder. A 5-day Minimum Data Set (an assessment tool that measures health status) dated 8/28/2024 documented the resident had severe cognitive impairment. The resident had a facility acquired Stage III pressure ulcer to their sacrum. Pressure relieving devices in use in bed and wheelchair. Review of a pressure ulcer care plan initiated 7/31/2024 documented Resident # 6 had a sacral pressure ulcer on their sacrum that was a Stage II. The goal was the pressure ulcer would show signs of healing and remain free from infection through the review date. Review of a nurse's progress note dated 7/27/2024 documented made aware by nurse on duty that Resident #6 had a skin tear on their right buttock. Physician made aware and ordered to apply xeroform daily and a wound consult. Review of a wound care note dated 7/31/2024 documented Resident #6 was seen for a new wound development a Stage II pressure ulcer noted to the sacrum measuring at 0.8 cm x 0.5 cm x 0.1 cm. The treatment plan was to cleanse with normal saline, apply collagen to wound and cover with a bordered gauze and change daily. All preventive measures discussed with staff at visit. Review of Resident #6's wound assessment reports documented that on 08/07/2024 Resident #6 had a facility acquired sacrum pressure ulcer Stage II that developed on 7/27/2024. It documented on 08/14/2024 facility acquired ulcer to the sacrum worsened to a Stage III measuring at 1.5 cm x 2.5 cm x 0.10 cm. It further documented worsening on 08/28/2024 where the facility acquired ulcer to the sacrum was now a Stage III measuring at 1.5 cm x 3 cm x 0.20 cm. On 09/11/2024 the report documented the facility acquired ulcer to the sacrum was now a Stage III measuring at 1 cm x 2.5 cm x 0.10 cm. Review of Resident #6's progress notes revealed there was no documented evidence of the representative being made aware of the facility acquired wound developing on 7/27/2024 or the treatment ordered on 7/31/2024. There was also no documented evidence of the representative being made aware of the changes in size to the wound or the stage category. 3) Resident #7 initially admitted to the facility on [DATE] and last readmitted on [DATE] with diagnoses including but not limited to Chronic Pulmonary Embolism, Gastrointestinal Hemorrhage, and other Lack of Coordination. A Quarterly Minimum Data Set (an assessment tool that measures health status) dated 8/2/2024 documented the resident moderate cognitive impairment. The resident required moderate assistance with eating and bed mobility and was dependent for toileting and transfers. Foley catheter in pace and frequently incontinent of bowels. Documented the resident has moisture associated skin damage. A Discharge Minimum Data Set (an assessment tool that measures health status) dated 9/3/2024 documented Resident #7 had a Stage III facility acquired pressure ulcer. Review of a potential for pressure ulcer development care plan initiated 8/16/2022 documented Resident #7 would have intact skin by/through the review date. Interventions listed included inform the resident family of any new areas of skin breakdown and interventions initiated 10/21/2024 listed assist with turning and positioning every 2 hours and as needed, administer treatments as ordered. Review of a wound progress note dated 8/14/2024 Resident #7 was seen for a rash to their buttocks and was noted to have moisture associated skin damage measuring at 1.5 cm x 1 cm x 0.1 cm. The treatment plan was to cleanse with soap and water, apply medical grade honey and cover with a bordered gauze. Review of a wound progress note dated 8/21/2024 documented Resident #7 was seen for a bilateral buttock rash which is now a stage III to the right buttocks. Review of a nurse's progress note dated 8/21/2024 documented Resident #7 was seen by the wound care Nurse Practitioner, moisture associated skin damage was now categorized as a stage iii pressure ulcer to the right buttocks. Unit manager on duty made aware. Review of Resident #7's wound assessment reports documented the following: on 8/14/2024 Resident #7 had moisture associated skin damage to their bilateral buttocks measuring 1.5 cm x 1 cm x 0.10 cm. The treatment ordered to cleanse daily with soap and water and apply medical grade honey and cover with a bordered gauze. The report documented on 8/21/2024 a stage III pressure ulcer to the right buttocks measuring 1.8 cm x 0.6 cm x 0.10 cm. On 8/28/2024 it documented a stage III pressure ulcer to the right buttocks measuring 1.2 cm x 0.6 cm x 0.10 cm. On 9/11/2024 the report documented a stage III pressure ulcer to the right buttocks measuring 3.0 cm x 4.0 cm x 0.10 cm. On 9/18/2024 it documented a stage III pressure ulcer to the right buttocks measuring 2.2 cm x 2.0 cm x 0.10 cm. On 9/24/2024 the report documented a stage III pressure ulcer to the right buttocks measuring 2.2 cm x 2.0 cm x 0.10 cm. Review of a care plan meeting progress note dated 8/22/2024 documented a phone conference was held with Resident #7's representative, and they were made aware of a recent urology consult and foley catheter change. Resident #7's representative was provided with updates from the team regarding diet, weight, and rehabilitation and informed Resident #7 was functioning at baseline, and the resident was on a maintenance program. There was no documented evidence of Resident #7's daughter being made aware of the resident's stage III right buttock pressure ulcer or treatment ordered. During an interview on 10/21/2024 at 3:50 PM the Director of Nursing stated family notification must be done at least within 24 hours of identification of pressure ulcer and this should be documented in the nurse's progress note and discussed during the care plan meeting. During an interview on 10/21/2024 at 4:30 PM the Administrator they stated it is their expectation that resident's families are notified of changes in their condition immediately following any incidents, issues and discoveries. 10 NYCRR 415.3(f)(2)(ii)(c)

Based on record review and interview during an abbreviated survey (NY00347905) the facility did not ensure that a resident with urinary incontinence received appropriate treatment and services for 4 out of 4 residents (Resident #6, #9, #3, #4) reviewed for incontinence care. Specifically, (1) Resident #6 was incontinent and was dependent on direct care staff for toileting. Review of Resident #6's certified nurse assistant accountability report for July and August 2024 revealed numerous signature omissions for bladder incontinence care indicating care was not provided by direct care staff. (2) Resident #9 was known to be frequently incontinent of urine and always incontinent of bowel. Review of Resident #9's certified nurse assistant accountability report for June and July 2024 revealed there were numerous signature omissions indicating bladder incontinence care was not provided by direct care staff. (3) Resident #3 was incontinent and dependent on direct care staff for toileting. Review of Resident #3's certified nurse assistant accountability for August and September 2024 revealed numerous signature omissions for bladder incontinence care indicating care was not provided by direct care staff. (4) Resident #4 was frequently incontinent of bladder and required supervision with toileting. Review of Resident #4's certified nurse assistant accountability for August and September 2024 revealed there were numerous signature omissions indicating bladder incontinence care was not provided by direct care staff. The findings are: The facilities Incontinence Care policy last reviewed 5/2024 documented the purpose is to at preserves resident dignity, promote cleanliness, and prevent infection, remove irritating and odorous secretions, and prevent extended skin exposure to incontinence of urine and feces. Incontinence care will be provided after each incontinence episode. Resident's will be checked every 2 hours depending upon each resident's needs/patterns. More frequent checking, example hourly, may be required if the resident is having acute frequent episodes of urine or bowel incontinence related to acute change in condition. 1)Resident #6 initially admitted to the facility on [DATE] and last readmitted on [DATE] with diagnoses including but not limited to Muscle Wasting and Atrophy, Type 2 Diabetes Mellitus and Bipolar Disorder. A 5-day Minimum Data Set (an assessment tool that measures health status) documented the resident had severe cognitive impairment. The resident had impairment to both upper and lower extremities on both sides and was dependent for eating, toileting, bed mobility and transfers. The resident was always incontinent of bladder and bowel and had a facility acquired Stage III pressure ulcer to their sacrum. Review of a bladder incontinence care plan dated 10/11/2018 documented Resident #6 had frequent incontinence related to impaired mobility and medication side effects. The goal was the resident would remain free of complications related to incontinence such as skin breakdown and urinary tract infections through 12/5/2024. Interventions listed included assist resident with toileting as requested and check resident every 2-4 hours, as needed and as required for incontinence. Wash, rinse and dry perineum and change clothing as needed after incontinence episodes. Review of Resident #6's certified nurse assistant accountability report for July 2024 revealed there was no signature indicating the following cares were provided: bladder incontinence-occasional incontinence care on 6 occasions, apply bilateral heel booties and elevate heel when in bed on 11 occasions. Review of Resident #6's certified nurse assistant accountability report for August 2024 revealed there was no signature indicating the following cares were provided: bladder incontinence-occasional incontinence care on 6 occasions, apply bilateral heel booties and elevate heel when in bed on 6 occasions. 2) Resident #9 admitted to the facility on [DATE] with diagnoses including but not limited to Metabolic Encephalopathy, Bipolar Disorder and Type 2 Diabetes. A Modification of Admission 5-day Minimum Data Set (an assessment tool that measures health status) dated 7/1/2024 documented the resident was cognitively intact and exhibited rejection of care behavior. The resident had impairment to the upper extremity on one side and used a walker and a wheelchair for locomotion. The resident required supervision for eating, dependent for toileting, maximal assistance for bed mobility and transfers. Resident was frequently incontinent of urine and always incontinent of bowel. Review of Resident #9's certified nurse assistant accountability report for June 2024 revealed there was no signature indicating the following care was provided: bladder incontinence-occasional incontinence care on 5 occasions. Review of Resident #9's certified nurse assistant accountability report for July 2024 revealed there was no signature indicating the following care was provided: bladder incontinence-occasional incontinence care on 16 occasions. 3) Resident #3 admitted to the facility on [DATE] with diagnoses including but not limited to Acquired Absence of Left Great Toe, Chronic Myeloid Leukemia and other Abnormalities of Gait and Mobility. A Quarterly Minimum Data Set (an assessment tool that measures health status) dated 8/8/2024 documented the resident was cognitively intact. The resident had limited range of motion to the lower extremities and required a wheelchair for locomotion. The resident required supervision for eating, was dependent for toileting, moderate assistance for bed mobility and maximal assistance with transfers. The resident was occasionally incontinent of bladder and frequently incontinent of bowel. Review of Resident #3's certified nurse assistant accountability for August 2024 revealed bladder incontinence care was not signed as being provided by direct care staff on 49 occasions. Review of Resident #3's certified nurse assistant accountability for September 2024 revealed bladder incontinence care was not signed as being provided by direct care staff on 31 occasions. During an interview on 10/21/2024 at 9:15 AM Resident #3 stated they are independent mostly but use incontinence briefs at night and when they urinate in their incontinence brief, they will ring their call bell, and the certified nurse assistants may or may not come. Resident #3 stated they go to bed at 9 PM and no one comes and attends to them until 9 AM. Stated this happens often and they have not reported this to the unit manager. Resident #3 stated the incontinence brief they had on currently was soaked with urine, and that they had urinated in it 2 or 3 times overnight, and now after 9 AM they still had the same incontinence brief on. 4)Resident #4 admitted to the facility on [DATE] with diagnoses including but not limited to Unspecified Dementia, Type II Diabetes Mellitus and Acquired of Right Leg Below the Knee. A Quarterly Minimum Data Set (an assessment tool that measures health status) documented the resident was cognitively intact. The resident had limited range of motion in one lower extremity and required a wheelchair for locomotion. The resident required set-up assistance for eating, supervision for toileting and transfers and was independent for bed mobility. The resident was frequently incontinent of bladder and bowel. Review of Resident #4's certified nurse assistant accountability for August 2024 revealed bladder incontinence care was not signed as being provided by direct care staff on 54 occasions. Review of Resident #4's certified nurse assistant accountability for September 2024 revealed bladder incontinence care was not signed as being provided by direct care staff on 39 occasions. During an interview on 10/21/2024 at 9:25 AM Resident #4 stated they are left in their incontinence brief for 9 hours or more at a time. During an interview on 10/21/2024 at 2:06 PM Certified Nurse Assistant #6 they always provide cares to their assigned residents. Stated a blank signature box on the certified nurse assistant accountability signifies the task was not completed and they thought they had signed for all of their assigned resident's tasks. During an interview on 10/21/2024 at 2:13 PM Certified Nurse Assistant #1 stated if their signature is not in the box, then it would look as if they did not provide the care. Certified Nurse Assistant #1 stated they make rounds on their residents regularly, but sometimes they forget to sign off for their tasks in the computer, because they get caught up in their work. During an interview on 10/21/2024 at 3:50 PM the Director of Nursing stated the expectation is that the certified nurse assistants will complete their documentation before the end of their shift and check to ensure they have documented on all the residents they were assigned to. Stated they have not had any complaints recently from the residents about complaints regarding not receiving care from the staff. Stated it was not really an issue in the past and that they had not gotten any complaints from the families. 10 NYCRR 415.12(d)(2)

Based on record review and interview during a partial extended survey (NY00349917, NY00347905), the facility did not provide sufficient nursing staff to consistently meet the needs of all residents. The Facility Assessment resident to staff ratios (certified nurse assistant) levels were frequently below the levels determined by the facility to be necessary to meet the needs of the residents. Specifically, review of the unit staff assignment sheets for June 2024, July 2024, August 2024 and September 2024 revealed staffing was not adequate across various shifts based on the unit needs and the staffing needed as documented in the facility assessment. The findings are: The facility Staffing Assignments policy dated 7/9/2007 and last reviewed 7/21/2024 documented the policy of the facility to determine the appropriate staffing on a unit based on the census, acuity, shift and needs of the residents. The purpose of the policy is to ensure that each floor is staffed with sufficient competent staff each shift. Review of the Facility assessment dated [DATE] and revised 10/18/2024 and reviewed by the Quality Assurance Performance Committee in the 3rd Quarter revealed the following staffing levels for certified nurse assistants per shift per unit: For the 7 AM to 3 PM shift per each unit in the facility is as follows: 1 West-4 certified nurse assistants, 1 East-5 certified nurse assistants, 2 West-5 certified nurse assistants. The 3 PM to 11 PM certified nurse assistant per shift for unit 1 [NAME] was 3 certified nurse assistants, for 1 East-4 certified nurse assistants for 2 [NAME] was 2 certified nurse assistants. The 11 PM to 7 AM shift certified nurse assistant per unit for 1 West-2 certified nurse assistants, 1 East-3 certified nurse assistants, 2 West-2 certified nurse assistants Review of the Certified Nurse Assistant Assignment staffing assignment sheets for June 2024 revealed the following: On the 1 [NAME] unit-2 certified nurse assistants for the 11 PM to 7 AM shift on the following days: 6/1/2024 to 6/4/2024, 6/6/2024 to 6/24/2024 and 6/26/2024 to 6/30/2024. On the 1 East unit-4 certified nurse assistants for the 7 AM to 3 PM shift on the following days: 6/2/2024, 6/15/2024, 6/17/2024, 6/22/2024 to 6/24/2024, 6/26/2024 and 6/30/2024. On the 1 East unit 3 certified nurse assistants for the 3 PM to 11 PM shift on the following days: 6/3/2024, 6/7/2024, 6/9/2024, 6/10/2024, 6/11/2024, 6/13/2024, 6/14/2024, 6/16/2024 to 6/24/2024, 6/27/2024, 6/29/2024 and 6/30/2024. 1 certified nurse assistant on 6/23/2024. 2 certified nurse assistants on 6/1/2024 to 6/4/2024, 6/6/2024 to 6/11/2024, 6/14/2024 to 6/18/2024, 6/20/2024 to 6/22/2024, 6/24/2024 to 6/27/2024, 6/29/2024 and 6/30/2024. On 2 [NAME] unit 4 certified nurse assistants for the 7 AM to 3 PM shift on the following days: 6/2/2024, 6/3/2024, 6/9/2024, 6/15/2024 to 6/17/2024 and 6/21/2024 to 6/30/2024. 2 certified nurse assistants for the 11 PM to 7 AM on the following days: 6/1/2024 to 6/11/2024, 6/13/2024 to 6/15/2024, 6/17/2024, 6/23/2024 to 6/28/2024 and 6/30/2024. Review of the staffing assignment sheets for July 2024 revealed the following: On 1 [NAME] 3 certified nurse assistants for the 7 AM to 3 PM shift on 7/7/2024, 1 certified nurse assistant on the 11 PM to 7 AM shift on 7/24/2024 On 1 East 4 certified nurse assistants for the 7 AM to 3 PM shift on the following days: 7/5/2024 to 7/9/2024, 7/13/2024, 7/14/2024 and 7/28/2024. 3 certified nurse assistants for the 3 PM to 11 PM shift on the following days:7/4/2024 to 4/8/2024, 7/11/2024, 7/12/2024, 7/14/2024, 7/21/2024, 7/23/2024, 7/24/2024 to 7/28/2024 and 7/31/2024.2 certified nurse assistants for the 11 PM to 7 AM shift on the following days: 7/2/2024 to 7/18/2024, 7/20/2024, 7/22/2024 to 7/24/2024, 7/26/2024 and 7/28/2024 to 7/31/2024. 1 certified nurse assistant for the 11 PM to 7 AM shift on 7/21/2024 and 7/27/2024 On 2 [NAME] 4 certified nurse assistants for the 7 AM to 3 PM shift on the following days: 7/3/2024, 7/5/2024 to 7/11/2024, 7/13/2024, 7/14/2024, 7/20/2024, 7/21/2024, 7/25/2024, 7/27/2024 to 7/29/2024 and 7/31/2024. 1 certified nurse assistant on the 11 PM to 7 AM shift on the following days: 7/4/2024 and 7/10/2024 Review of the staffing assignment sheets for August 2024 revealed the following: On 1 [NAME] 3 certified nurse assistants for the 7 AM to 3 PM shift on 8/21/2024. On 1 East 4 certified nurse assistants for the 7 AM to 3 PM shift on the following days: 8/4/2024, 8/11/2024 and 8/31/2024. 3 certified nurse assistants for the 3 PM to 11 PM shift on the following days: 8/2/2024, 8/4/2024, 8/6/2024, 8/8/2024, 8/12/2024, 8/13/2024, 8/16/2024, 8/17/2024, 8/18/2024, 8/20/2024, 8/22/2024, 8/23/2024, 8/25/2024, 8/26/2024 and 8/29/2024. 2 certified nurse assistants for the 11 PM to 7 AM shift on the following days: 8/2/2024 to 8/16/2024, 8/18/2024, 8/19/2024, 8/21/2024, 8/24/2024, 8/25/2024, 8/27/2024 to 8/31/2024 On 2 [NAME] 4 certified nurse assistants for the 7 AM to 3 PM shift on the following days: 8/4/2024, 8/9/2024, 8/11/2024, 8/12/2024, 8/18/2024, 8/20/2024, 8/23/2024 to 8/25/2024 and 8/30/2024. 1 certified nurse assistant for the 11 PM to 7 AM shift on 8/6/2024. Review of the staffing assignment sheets for September 2024 revealed the following: On 1 [NAME] 2 certified nurse assistants for the 3 PM to 11 PM shift on 9/9/2024 On 1 East 3 certified nurse assistants for the 3 PM to 11 PM shift on the following days: 9/3/2024, 9/8/2024, 9/16/2024, 9/20/2024, 9/22/2024 and 9/29/2024. 2 certified nurse assistants for the 11 PM to 7 AM shift on the following days: 9/1/2024 to 9/4/2024, 9/6/2024 to 9/13/2024, 9/15/2024, 9/16/2024, 9/19/2024 to 9/22/2024 and 9/24/2024 to 9/30/2024 On 2 [NAME] 4 certified nurse assistants for the 7 AM to 3PM shift on the following days: 9/8/2024, 9/16/2024, 9/21/2024, 9/23/2024, 9/28/2024 and 9/29/2024 During an interview on 10/18/2024 at 2:01 PM, the Administrator stated they have been with the company for 6 years. The Administrator stated in the facility assessment they have included that the facility had recently began a certified nursing assistant training program in the facility. The Administrator stated the students receive hands on training in the facility and are trained by the facility, these students are then hired in the facility as support staff. The Administrator stated the support staff assist with the following tasks: bed making, runners for residents and basic nominal things like helping with putting on clothing protectors. The Administrator stated the certified nurse assistant school has helped them with retaining staff in the facility as these students when they finish the program, work in the facility as certified nurse assistants. During an interview on 11/25/2024 at 12:02 PM, the Payroll/Accounts payable staff stated their previous title was Staffing Coordinator for [AGE] years. The Payroll/Accounts payable staff stated the staffing now is good, the number of staff has increased. The Payroll/Accounts payable staff stated during and after COVID staff did not want to return to work, facility started a certified nurse assistant school, and this helped with increasing the staffing levels. The Payroll/Accounts payable staff stated they will ask the staff in-house if they can stay for the shift or call another staff to come in. The Payroll/Accounts payable staff stated they would call someone first and if they are running out of time then they will go to the units and ask staff if they can stay. Review of the schedule for 11/25/2024 during on site visit revealed the schedule is short a certified nurse assistant on the night shift, stated the staffing coordinator will try to find someone to fill the shift before the shift. 10NYCRR 415.13 (A)(1)(i-iii)

Based on record review and interviews during an abbreviated survey (NY00349917, NY00347905), the facility did not ensure the comprehensive care plans were reviewed and revised in a timely manner for 2 of 4 residents (Resident #7, Resident #8) reviewed for care planning. Specifically, Resident #7 developed a facility acquired stage II pressure ulcer to their right buttocks on 8/21/2024. There was no documented evidence of the potential for pressure ulcer development care plan being revised to reflect the actual pressure ulcer. (2) Resident #8 developed a facility acquired stage III pressure ulcer to their sacrum on 8/14/2024. There was no documented evidence of the potential for pressure ulcer development care plan being revised to reflect the actual pressure ulcer. Findings include: Review of the facility Care Planning Process dated 1/1/2018 and last revised 1/1/2023 documented the facility shall have a care planning process in place which includes integrating assessment findings in care planning, developing and interdisciplinary care plan, regularly reviewing and revising the care plan, providing the care, and documenting the care. 1) Resident #7 had diagnoses including but not limited to Chronic Pulmonary Embolism, Gastrointestinal Hemorrhage, and other Lack of Coordination. A Quarterly Minimum Data Set, dated dated dated [DATE] documented the resident had a Brief Interview for Mental Status score of 10 /15 associated with moderate cognition impairment. The resident required moderate assistance with eating and bed mobility and was dependent for toileting and transfers. Foley catheter in place and frequently incontinent of bowels. The resident has moisture associated skin damage. A Discharge Minimum Data Set, dated dated dated [DATE] documented Resident #7 had a Stage III facility acquired pressure ulcer. Review of a potential for pressure ulcer development care plan initiated 8/16/2022 documented Resident #6 would have intact skin by/through the review date. Interventions listed included inform the resident family of any new areas of skin breakdown and interventions initiated 10/21/2024 listed assist with turning and positioning every 2 hours and as needed, administer treatments as ordered. There was no documented evidence of Resident #7's potential for pressure ulcer development care plan being revised to reflect an actual pressure ulcer on 08/21/2024. 2) Resident #8 had diagnoses including but not limited to Nontraumatic Intracerebral Hemorrhage, other Encephalopathy and Muscle Wasting and Atrophy. An Admission Minimum Data Set, dated dated dated [DATE] documented the resident had a Brief Interview for Mental Status score of 03/15 associated with severe cognition impairment. The resident had impairment of upper and lower extremities on both sides and was dependent for eating, toileting, bed mobility and transfers. The resident was a high risk for pressure ulcers but had no skin conditions noted. Review of a risk for skin integrity impairment care plan initiated 8/14/2024 documented Resident #8 would be free from pressure related injuries by the next review date. Interventions listed included assist with turning and positioning as needed and turn and position every 2 hours. The care plan did not include an actual facility acquired stage III pressure ulcer to their sacrum. During an interview on 10/17/2024 at 12:04, Registered Nurse #2 stated prior to the new wound care company starting, the unit manager would put in a wound care consult order and provide them with the document. The Nurse Practitioner or Physician Assistant would then see the resident on wound rounds. Registered Nurse #2 stated they were responsible for documenting the findings during wound rounds in the resident's charts and updating the care plans. During an interview on 10/17/2024 at 2:10 PM, the Director of Nursing stated there was a transition from June 24th to July 5th with the wound care providers and the wound rounds were done by Registered Nurse #2, and the attending physician was notified of the findings. The Director of Nursing stated Registered Nurse #1's treatments and measurements would be reflected in their nurse's progress notes and on the resident's care plans. During a telephone interview on 10/18/2024 at 11:32 AM, Registered Nurse #1 stated Registered Nurse #2 would be the one to update the residents care plans for the resident's seen on wound rounds. Registered Nurse #1 stated Registered Nurse #2 would document in their progress notes and update the care plans if there was a significant change in the Resident's wounds. 10 NYCRR 415.11 (c)(2)(i-iii)

Based on record review and interviews during an abbreviated survey (NY00349917, NY00347905), the facility did not ensure a performance review was completed for every nurse aide at least once every 12 months, and that regular in-service education was provided based on the outcome of these reviews for 2 of 7 records reviewed. Specifically, (1) Certified Nurse Assistant #7 with a date of hire of 4/28/2015 had no documented annual performance evaluations prior to 11/22/2023 and none for 11/22/2024. (2) Certified Nurse Assistant #8 with a date of 8/1/2014 did not have any documented annual performance evaluations in their personnel file prior to 11/22/2023 and none foe 11/22/2024. The Findings are: The Facility Performance Review policy last reviewed 9/2/2024 documented all written performance reviews will be performed annually based on the staff member's overall performance in relation to the job responsibilities and will also consider the staff member's conduct, demeanor, and record of attendance and tardiness. The most recent evaluation supersedes prior evaluations. Review of the Facility Performance Evaluation revealed they were not based on the in-service education required per year. The annual in-service education was also not completed for the employees according to their employment date in the facility. Review of Certified Nurse Assistant #7's in-service log attendance sheet revealed their last in-service date was 3/14/2024. Certified Nurse Assistant #7 received 5 hours mandatory training on 3/14/2024. Certified Nurse Assistant #7's last performance review provided by the facility was dated 11/22/2023. Their date of hire was 4/28/2015. There were no other documented performance reviews in the employees file and the facility did not provide additional performance reviews for this employee. Review of Certified Nurse Assistant #8's in-service log attendance sheet revealed their last in-service was on 3/14/2024 and had received 9 hours of training by 8/27/2024. Certified Nurse Assistant #8's last performance review provided by the facility was dated 11/22/2023. Their date of hire was 8/1/2014. There were no other documented performance reviews in the employees file and the facility did not provide additional performance reviews for this employee. During an interview on 11/25/2024 at 2:42 PM, the Human Resources Director stated each employee has one personnel file and that some of the employee documents are not filed due to renovations, but once the renovations are completed the files will be updated. The Human Resources Director stated competencies and performance evaluations are maintained in the employee personnel files and they have a binder with all staff performance evaluations. The Director of Human Resources stated the performance evaluations are completed annually for current employees, and there is also a 90-day evaluation for new employees. The Director of Human Resources stated they manage the general resources portion such as: fire safety, corporate compliance, resident's rights, and abuse prevention. During an interview on 11/25/2024 at 3:57 PM, the Director of Nursing stated they completed an audit in 2022 and found the annual performance evaluations were not being completed timely, so at that point the facility decided to start fresh and reevaluate all staff for their annual performance. The Director of Nursing stated the audit was done in November 2023, and now all staff will have their annual performance evaluations completed timely. The Director of Nursing stated the performance evaluations are currently in progress and will be submitted to them after completion. The Director of Nursing stated there was no established tracking of the staff performance evaluations prior to November 2023 but now they use excel spreadsheet to all staff evaluations that are due and assigns them to the nurses for completion. 10 NYCRR 415.26

Based on record review and interviews during an abbreviated and partial extended survey (NY00349917, NY0034705), the facility did not ensure the Quality Assessment and Performance Improvement committee developed and implemented appropriate plans of action to correct identified quality deficiencies. Specifically, (1) there were no documented evidence of the facilities actionable plans being implemented for their identified facility acquired pressure ulcer issue; (2) there was also no documentation of the continued performance improvement plan for 2 areas discussed in the 2nd quarter meeting. The findings are: The facility Quality Assurance and Performance Improvement Program policy documented the purpose was to ensure the development of a plan that describes the process for conducting QAPI/QAA activities, such as identifying and correcting quality deficiencies as well as opportunities for improvement, which will lead to improvement in the lives of nursing home residents, through continuous attention to quality care, quality of life and resident safety. The facility must document the development, implementation and evaluation of corrective actions or performance improvement activities. Review of the 2nd quarter Quality Assurance and Performance Improvement documentation dated 7/24/2024 listed the following areas of concern: Call light audit and delayed Minimum Data Set assessments. There was no documented evidence of a performance improvement plan being reviewed or included in the 3rd quarter Quality Assurance and Improvement meeting agenda or minutes. Review of the 3rd Quarter Quality Assurance and Improvement meeting documentation dated 10/30/2024 submitted by the facility included the sign-in sheet, a copy of the weekly skin tracker/quality assurance report dated 11/5/2024 and 11/7/2024, and a list of residents identified on admission with pressure ulcers. The departmental reports provided by the facility as part of the Quality Assurance and Improvement Meeting were dated 11/13/2024. The Quality Assurance and Performance Improvement agenda for the 10/30/2024 meeting referenced facility acquired pressure ulcers, the facility did not provide the Quality Assurance and Performance Improvement plan for facility acquired pressure ulcers. There were no documented details or plans and processes on how the facility would prevent facility acquired pressure ulcers. During an interview on 11/25/2024 at 3:18 PM, the Administrator stated that the facility acquired pressure ulcers were discussed in the last Quality and Assurance Performance Improvement meeting on 10/30/2024. When asked when the meeting took place, the Administrator stated the last Quality Assurance and Performance Improvement meeting was set for 10/30/2024, but something happened, and the meeting did not occur. The Administrator stated the sign-in sheet for the meeting was already dated for 10/30/2024 and was not re-done to reflect the actual date of the meeting which was 11/13/2024. All the documentation from the meeting was dated 11/13/2024 because that is the day the meeting actually took place. The Administrator stated the performance improvement plan for facility acquired pressure ulcers would be presented in the next Quality Assurance and Performance Improvement meeting with the internal audit identifying [NAME] and a plan of correction for the issue. The Administrator stated the plan to address the issues was already in process but there is no documented action plan for the identified issues, from the 11/130/2024 meeting. The Action plan from the 11/13/2024 meeting will be discussed at the next Quality Assurance and Performance Improvement meeting. The Administrator stated they would inform the Social Worker to include the performance improvement plans with percentages of compliance until the issues are resolved. 10NYCRR 415.27(a-c)

Based on observations, record reviews and interviews conducted during the recertification survey from 6/10/24-6/14/24, the facility did not ensure that for 1(Resident #57) of 5 residents reviewed for environment, they were provided with reasonable accommodations of needs and preferences. Specifically, the call bell system designated for Resident #57 whom has left sided weakness, was observed not within the resident's reach, on multiple occasions. The findings are: The undated facility policy titled Resident Call System documented the purpose was to ensure that residents had a means of direct communication between the resident and his/her caregivers. Resident #57 was admitted to the facility with diagnoses including but not limited to cerebral vascular accident, dementia, difficulty in walking, and hemiplegia and hemiparesis following cerebral infarction affecting left nondominant side. The Quarterly Minimum Data Set, dated dated dated [DATE], documented the resident had moderately impaired cognition, was dependent on staff with toileting and transfers, and required moderate assistance with bed mobility. The comprehensive care plan dated 10/9/23, documented the resident was high risk for falls related to gait/balance problems, incontinence, and left sided weakness; and interventions included that Resident #57 would have a working and reachable call light. The comprehensive care plan dated 9/16/22, documented the resident had an Activity of a Daily Living self-care performance deficit related to activity intolerance, dementia, limited mobility, and limited range of motion; interventions included to encourage Resident #57 to use the bell to call for assistance. On 06/10/24 at 08:24 AM, Resident #57 was observed in bed and the call bell was observed on left side of bed hanging from siderail. Resident #57 was unable to reach for the call bell and stated that they could not use their left hand due to a having had a stroke. On 06/11/24 at 12:48 PM, Resident #57 was observed sitting on the right side of their bed in their wheelchair with left arm secured in wheelchair armrest strap. The call bell was observed across the bed, towards the left side, and was not within the resident's reach. Resident #57 was unable to stretch over and reach the call bell. On 06/13/24 at 10:55 AM, Resident #57 was observed in bed. The call bell was observed sitting on the nightstand, and not within of reach of resident. Resident #57 stated that when they needed help, they pushed the button and demonstrated that they were unable to reach for the call bell. Resident #57 stated that staff always put the call bell on the left side of the bed and stated that it was difficult to reach due to left sided weakness and that the call bell would be much better if placed within reach on their stronger side. During an interview on 06/13/24 at 10:56 AM, Registered Nurse #2 observed the call bell on Resident #57's night stand out of the resident's reach and stated that the call bell must be always in reach of resident while in their room. They also stated that the call bell should have been placed on the right side of resident because the resident had left sided weakness. During an interview on 06/13/24 at 11:11 AM, Certified Nurse Aide#13 stated that residents were always to have their call bell within reach and that they did not notice Resident #57's call bell was not in reach. During an interview on 06/13/24 at 05:10 PM, the Director of Nursing stated that Resident #57's call bell should always be in reach of the resident and that the resident did utilize their call bell. The Director of Nursing also stated that the call bell should be placed on the right side of the bed, within reach, due their left sided weakness. 10NYCRR 415.5(e)(1)

Based on observations, record reviews and interviews conducted during the recertification survey from 6/10/2024 to 6/14/2024, the facility did not ensure the development of comprehensive person-centered care plans that included measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs as identified in the comprehensive assessment for 3 (Residents #47, #51, and #66) of 35 residents reviewed for comprehensive care plans. Specifically, (1) for Resident #47, the facility did not ensure a comprehensive care plan was developed to address the use of indwelling urinary catheter; and the use of a left resting hand splint, (2) for Resident #51, the facility did not ensure a comprehensive care plan was developed to address the use of bilateral palm guards and soft hip abductor cushion at all times, and (3) for Resident #66, the facility did not ensure a comprehensive care plan was developed to address the toileting schedule put into place to achieve or maintain as much normal bladder/bowel function as possible. This is evidenced by: An undated Policy and Procedure titled 'Care Planning' documented that a comprehensive care plan shall be developed for each resident that includes measurable, objective and timetables to meet the residents medical, nursing, mental and psych-social needs. 1) Resident #47 had diagnoses which included heart failure, obstructive uropathy, and peripheral vascular disease. An admission Minimum Data Set (an assessment tool) dated 5/4/2024 documented the resident was cognitively intact. The resident required substantial assistance with eating and was dependent on staff for all other areas of activities of daily living. The resident had a urinary catheter. The physician order dated 4/28/2024 documented a Foley (urinary catheter) for urinary retention, 16 French (size) with 10 cubic centimeter (cc) balloon, may use leg bag when out of bed, to change the Foley every 28 days and as needed, and to assess urine in bag. The physician order dated 5/24/2024 documented a left resting hand splint use at all times, remove and release for care and skin checks. During an observation on 06/11/24 at 09:25 AM, the resident was observed without their resting splint on their left hand. The resident's urinary catheter bag was observed hanging from their bed, with a privacy cover in place. During an observation on 06/12/24 at 02:48 PM, the resident was in bed asleep. The resident's hand splint was observed on dresser and not on the resident. During an observation on 06/13/24 at 11:23 AM, the resident was observed in bed not wearing their resting hand splint. A review of the medical record including the current comprehensive care plan and the Kardex (instructions for direct care staff) revealed no documentation to address the left resting hand splint or the use of a urinary catheter. During an interview on 06/13/24 at 12:11 PM, Certified Nurse Aide #7 stated the resident wore a hand splint but refused to wear it when in bed. Certified Nurse Aide #7 stated they knew the resident had a catheter and they emptied it. During an interview on 06/13/24 12:09 PM, the Director of Nursing stated the care plan for a urinary catheter was not developed and should have been. They stated there should have been a care plan for the left-hand splint, and they were not sure why it was not there. They stated they usually put any splints or positioning devices on the ADL care plan. They stated the Nurse Manager was responsible for developing care plans. 2) Resident #51 had diagnoses which included adult failure to thrive, muscle wasting and atrophy, and cerebral infarction. The 5 day Minimum Data Set (resident assessment tool) dated 5/30/24 documented the resident had severely impaired cognition and was dependent on staff for other activities of daily living. The physician's order dated 6/3/24 documented bilateral palm guard at all times, remove/release for ADL. Soft hip abductor cushion at all times, remove/release for ADL care and skin checks. When observed on 06/11/24 at 07:45 AM, 06/11/24 at 10:46 AM, 06/11/24 at 11:54 AM, and 06/12/24 at 09:49 AM, Resident #51 was in their bed without palm guards and the soft hip abductor. The soft hip abductor was observed laying on the top of the resident's nightstand. A review of the care plan on 6/11/24, revealed the bilateral palm guard and soft hip abductor cushion at all times were not documented. On 06/12/24 at 10:28 AM during an interview and observation, Registered Nurse #15 stated they knew the Resident #51 well and was not aware the resident had orders for the soft hip abductor and palm guards. Registered Nurse #15 pulled the linen that covered the resident to check the palm guards, which the nurse and surveyor did not observe. There was no hip abductor observed in place either. Registered Nurse #15 and the surveyor observed the hip abductor lying on the resident's nightstand. Registered Nurse #15 stated they did not know why the device has not been applied to the resident. They said that they saw the soft hip abductor on the night stand earlier when they started the shift, but they did not question why this hip abductor was not applied for the resident. Registered Nurse #15 searched the nightstand drawers and was unable to find palm guards. Registered Nurse #15 checked the Kardex (care instructions for direct care staff) and did not find the palm guards and soft hip abductor. On 06/12/24 at 10:33 AM during an interview, Registered Nurse Manager #16 stated once the rehab department created the order, the night Supervisor or a day Nurse Manager documented on the care plan, which would be reflected on the Kardex. Registered Nurse Manager #16 observed Resident #51's care plan and stated the palm guards and hip abductor were not on the care plan and should have been. 3) Resident #66 was admitted with diagnoses including but not limited to anxiety disorder, history of falling, lack of coordination, and osteoarthritis. The Quarterly Minimum Data Set, dated dated dated [DATE], documented that Resident #66 had intact cognition, required supervision with bed mobility, toileting, and transfers, and was frequently incontinent of bowel and bladder. The comprehensive care plan titled Activity of a Daily Living self-care performance deficit related to impaired balance, limited mobility dated 4/20/22, documented interventions including a toileting schedule for every two hours and as needed. The comprehensive care plan titled bladder incontinence related to impaired mobility and medications side effect, dated 4/20/22, documented goals to include that resident would remain free of complications related to urinary incontinence such as skin breakdown and urinary tract infection through the next review date, with interventions including to check the resident every 2 - 4 hours and as needed, and as required for incontinence. Review of the certified nurse aide Kardex (care instructions) documented Resident #66 was on a toileting schedule and was to be toileted every 2 hours and as needed. Review of the certified nurse aide documentation revealed that there was no evidence that toileting was being done. On 06/11/24 at 12:42 PM, Resident #66 was observed in her room and there were 3 unused green briefs observed in a pink basin on their bed. Resident #66 stated that the briefs were always in their room and the staff left the briefs for the resident to use. On 06/10/24 at 08:28 AM, Resident #66 was observed in her room sitting in her wheelchair. There were unused green briefs observed on her nightstand. Resident #66 stated that the certified nurse aides taught them how to put their brief on by themselves so that they don't have to call for help to be assisted with changing soiled briefs. Resident #66 stated that the that staff has told her that they are independent and that they are unaware that they are on a toileting schedule. Resident #66 stated that they are unsteady on their feet and that they need assistance with incontinence cares. During an interview on 06/14/24 at 11:01 AM, Registered Nurse Unit Manager #18 stated that Resident #66 was on an every 2 hour and as needed toileting schedule. Registered Nurse Unit Manager #18 stated that they were the one that implemented and updated the care plans and that the toileting schedule was not showing up for the certified nurse aides to document because in the edit intervention section in the care plan the box Intervention will appear on the documentation record, was not checked off. During an interview on 06/13/24 at 05:10 PM, the Director of Nursing stated that all care plans must be reviewed and updated quarterly and as needed. The Director of Nursing stated that all if a resident was on a toileting schedule it must be in the care plan and carried over to the certified nurse aide documentation so that they could document. The Director of Nursing stated that if the toileting scheduled was showing in the Kardex, the certified nurse aides should have been able to document and that it was an error on their part. 10 NYCRR 415.11(c)(1) 48847 49255

Based on observations, record review and interviews conducted during the recertification survey from 6/10/24 to 6/14/24, the facility did not ensure that the Comprehensive Care Plans were reviewed and revised in a timely manner for 1(Resident #57) of 5 residents reviewed for Unnecessary Medications. Specifically, Resident #57 was no longer receiving Lorazepam effective 8/4/23 and Apixaban effective 4/8/22 which was replaced with Xarelto on 4/8/22, and the Care Plans were not updated and revised to reflect the discontinuations and the changes with the medications. The findings are: The undated facility policy titled Care Planning Process documented that the facility shall have a care planning process in place which includes: integrating assessment findings in care Planning, developing and interdisciplinary care plan, regularly reviewing and revising the care plan, providing, and documenting the care. When a change in a resident's status is noted during the course of a resident's treatment, the specific focus, goal, and/or interventions related to the change must be updated by the responsible discipline to reflect the change in the resident's status. Resident #57 was admitted to the facility with diagnoses including but not limited to cerebral vascular accident, dementia, and hemiplegia and hemiparesis following cerebral infarction affecting left nondominant side. The Quarterly Minimum Data Set, dated dated dated [DATE], documented the resident had moderately impaired cognition. The resident required supervision with eating, was dependent with toileting and transfers, and required moderate assistance with bed mobility and Resident #57 received an anxiety medication. The Care Plan titled The resident is on Anticoagulant therapy (Apixaban) related to diagnoses of bilateral pulmonary emboli, and history of deep vein thrombosis dated 9/9/21, was not reviewed and revised to reflect the discontinuation of Apixaban effective 4/8/22, and the implementation of Xarelto which began on 4/8/22. The Care Plan titled The resident uses anti-anxiety medications (Lorazepam) related to anxiety disorder dated 2/23/23 which documented interventions to give anti-anxiety medications ordered by physician, was not reviewed, and revised to reflect that Resident #57 was no longer receiving anti-anxiety medications specifically Lorazepam, as of 8/4/23. During an interview on 6/12/24 at 12:00 PM, Registered Nurse Unit Manager #18 stated that Resident #57 was no longer receiving anti-anxiety medications and that Lorazepam had been discontinued. Registered Nurse Unit Manager#18 stated that they reviewed and updated the Care Plans every 3 months and as needed, and that the anti-anxiety medication Lorazepam and the anti-coagulant Apixaban should have been removed from the Care Plan. During an Interview on 6/12/24 at 03:00 PM, the Director of Nursing stated that Care Plans must be updated by nurses and that if a resident was no longer receiving a medication, the Care Plan should be revised. The Director of Nursing stated that Care Plans were supposed to be reviewed quarterly and as needed. 10 NYCRR 415.11(c)(1)

Based on interview and record review conducted during the recertification and abbreviated surveys (NY00330768) from 6/10/24 to 6/14/24, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice for 1 of 6 residents (Resident #340) reviewed for skin impairments. Specifically, the Treatment Administration Record for Resident #340 revealed the treatments ordered by the physician were not administered as per order. The findings are: The undated facility policy, 'Skin Integrity' documented that the resident with pressure ulcers/injuries receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers/injuries from developing. Resident #340 was admitted with diagnoses which included Diabetes Mellitus, COVID-19, and Pneumonia. On 10/20/23, a new diagnosis of orthopedic aftercare following surgical amputation was documented. The admission Minimum Data Set (resident assessment tool) dated 8/29/23 documented intact cognition. Resident required 1-person extensive assistance with bed mobility and toilet use and personal hygiene and bathing, 2-person extensive assist with transfers and dressing, dependent with locomotion, limited assistance with eating. The 5-day Minimum Data Set (resident assessment tool) dated 10/23/23 documented intact cognition. Resident required supervision with eating, partial/moderate assistance with oral hygiene and upper body dressing and bed mobility, substantial/maximal assistance with toileting hygiene and lower body dressing and transfers. Surgical wound present on admission, and surgical wound care was documented. The 'Actual Impairment to Skin Integrity care' care plan dated 9/5/23 documented Diabetic right toes. The interventions included to apply treatments to site as ordered. The physician's orders documented: 10/21/23 'Cleanse right foot Trans Metatarsal Amputation with normal saline solution, pat dry, wrap with Kerlix/gauze, then tape every day shift, for wound care', discontinued 12/7/23. 11/19/23 'Monitor surgical site right foot Trans Metatarsal Amputation for bleeding, drainage, signs and symptoms of infection. Notify RN/MD' discontinued 12/7/23. 12/09/23 'Cleanse with normal saline solution, pat dry then wrap with Kerlix, every day shift, for wound care' start date, discontinued 12/27/23. 12/07/23 'Monitor surgical site right foot Trans Metatarsal Amputation for bleeding, drainage, sign and symptoms of infection. Notify RN/MD' discontinued 2/1/24. 12/28/23 'Cleanse right foot Trans Metatarsal Amputation with normal saline solution, pat dry then wrap with Kerlix, every day shift, for wound care' discontinued 2/1/24. The Nursing Skin/Wound Care Notes dated 10/21/23 documented follow-up from readmission, skin assessment done. Noted surgical site on right foot status post Trans Metatarsal Amputation, measurement 13.5 cm with 15 sutures, clean, dry and intact. Cleanse surgical site with normal saline solution, pat dry, then apply dry protection dressing. The Nursing Skin/Wound Care Notes dated 10/24/23 documented resident was not seen by wound specialist during wound rounds, transfer of care to Vascular as per wound specialist. The November 2023 Treatment Administration Record documented 'Cleanse right foot Trans Metatarsal Amputation with normal saline solution, pat dry, wrap with Kerlix/gauze, then tape, every day shift, for wound care' start date 10/21/23, discontinued 12/7/23. The treatment was not signed as administered on 11/22/23. The December 2023 Treatment Administration Record documented 'Cleanse right foot Trans Metatarsal Amputation with normal saline solution, pat dry then wrap with Kerlix, every day shift, for wound care' start date 10/21/23, discontinued 12/7/23. The treatment was not signed as administered on 12/2, 12/3, 12/4, or 12/6/23. The December 2023 Treatment Administration Record documented 'Cleanse with normal saline solution, pat dry then wrap with Kerlix, every day shift, for wound care' start date 12/09/23, discontinued 12/27/23. The treatment was not signed as administered on 12/14, 12/16, 12/17, or 12/18/23. The December 2023 Treatment Administration Record documented 'Monitor surgical site right foot Trans Metatarsal Amputation for bleeding, drainage, signs and symptoms of infection. Notify RN/MD' start date 11/19/23, discontinued 12/7/23. The treatment was not signed as administered on 12/2, 12/3, or 12/6/23. The January 2024 Treatment Administration Record documented 'Cleanse right foot Trans Metatarsal Amputation with normal saline solution pat dry then wrap with Kerlix, every day shift, for wound care' start date 12/28/23. The treatment was not signed as administered on 1/1/24, 1/3/24, 1/7/24, 1/13/24, 1/14/24, 1/22/24, 1/24/24, 1/25/24, or 1/28/24. The January 2024 Treatment Administration Record documented 'Monitor surgical site right foot Trans Metatarsal Amputation for bleeding, drainage, signs and symptoms of infection. Notify RN/MD' start date 12/07/23. The treatment was not signed as administered on 1/1/24, 1/3/24, 1/7/24, 1/13/24, 1/14/24, 1/22/24, 1/24/24, 1/25/24, or 1/28/24. On 6/11/24 at 1:25 PM during an interview, the Director of Nursing stated the nurse on duty who performed the treatment was responsible for documenting in the Treatment Administration Record, and if the treatment was not administered, the nurse was responsible to document the reason why the treatment was not administered. The Director of Nursing stated the Registered Nurse Unit Manager was responsible to assure that the treatments were administered as ordered for the nurses on their shift. The Director of Nursing stated that during the week, the treatment nurse was responsible for administering the treatments, and in the event that a treatment nurse was not available, it was the responsibility of the Unit Manager during the week and the Supervisor on the weekends to administer the treatments. The Director of Nursing checked the resident's electronic health record and stated there were no documented Nurse's Note dated in November, December, or January documenting the reasons for not administering treatments on the dates not documented as administered in the November, December, and January Treatment Administration Records. On 6/11/24 at 2:26 PM during an interview, Registered Nurse #2 stated they were assigned to administer medications on 12/2 and 12/3/23. They stated Resident #340 was alert and usually asked staff to apply the treatments if the treatments had not been administered yet. Registered Nurse #2 stated they administered the treatments but they forgot to sign the Treatment Administration Record. They stated they knew that treatments should have been documented in the Treatment Administration Record. On 6/11/24 at 2:38 PM during an interview, Registered Nurse #3 stated they were assigned to administer medications on 12/4/23. They stated they were not responsible to administer treatments on 12/4/23 because the Registered Nurse Unit Manager was responsible to administer treatments during the week. Registered Nurse #3 stated Resident #340 was alert and usually asked staff to have their treatment applied if the treatments had not been administered yet. Registered Nurse #3 stated that on 1/13 and 1/14/24 they were assigned to administer medications and there was no treatment nurse that weekend. They stated it was their responsibility to apply the treatments and document in the Treatment Administration Record. They stated they did not remember whether or not they administered Resident #340 treatments on 1/13 and 1/14/24. On 6/11/24 at 2:58 PM during an interview, Registered Nurse Supervisor #4 stated they were the Registered Nurse Supervisor on 1/3 and 1/28/24. They stated they were responsible to administer treatments on those days because the medication nurse asked for their assistance because the medication nurse did not have time to administer treatments. Registered Nurse Supervisor #4 stated Resident #340 was alert and usually asked staff to have their treatment applied if the treatments had not been administered yet. Registered Nurse Supervisor #4 stated that on 1/3 and 1/28/24 they administered the treatments to Resident #340 and they were responsible to document in the Treatment Administration Record but they forgot. On 6/11/24 at 3:06 PM during an interview, Registered Nurse Unit 1 [NAME] Manger #5 stated that on 1/7/24 they were supervising and they were responsible for administering treatments to major wounds if the unit medication nurse asked them for assistance with administering treatments. Registered Nurse Unit 1 [NAME] Manger #5 stated that on 1/24 and 1/25/24 they were performing their routine responsibilities as a unit manager and they had limited time and they were only responsible to administer treatments to major wounds if there was no treatment nurse that day and if the medication nurse asked them for assistance. Registered Nurse Unit 1 [NAME] Manger #5 stated that Resident #340's wound was considered a major wound and they thought they administered the treatments on the days mentioned above, but they could not be sure. They stated that they were responsible to document the treatments in the Treatment Administration Record if they had administered them. On 6/11/24 at 3:24 PM during an interview, Registered Nurse/Treatment Nurse #6 stated that on 12/14/23 they were not working as the treatment nurse because they were assigned to administer medications and they were not responsible to administer treatments on that day because it was a weekday, and the Registered Nurse Unit Manager was responsible for administering the treatments on weekdays. Registered Nurse #6 stated that on 12/16 and 12/17/23 they were not working as the treatment nurse because they were assigned to administer medications, and they were therefore not responsible for administering treatments on that day. Registered Nurse #6 stated that the Registered Nurse Supervisor was responsible for administering the treatments on 12/16/23 and 12/17/23. Registered Nurse #6 stated they notified the Registered Nurse Supervisor that they did not have time to administer Resident #340 treatments. 10NYCRR 415.12

Based on observation, record review and staff interviews during the recertification survey from 6/10/24 to 6/14/24, the facility did not ensure that needed services, care and equipment were provided to assure that residents with limited range of motion and mobility maintained or improved function based on the residents' clinical condition for 2 of 4 residents (Resident #51 and Resident #46) reviewed for position and mobility. Specifically, 1. Resident #51 was observed on 3 occasions without bilateral palm guard and soft hip abductor in place, and 2. Resident #46 was observed without bilateral resting hand splints or palm guard in place. Findings include: The undated Policy and Procedure titled, Adaptive Equipment Device, documented splinting and orthopedic management is a therapeutic procedure designed to prevent worsening contractures of a joint, to increase range of motion, and /or to prevent skin breakdown. 1. Resident #51 had diagnoses which included adult failure to thrive, muscle wasting and atrophy, and cerebral infarction. The 5 day Minimum Data Set (resident assessment tool) dated 5/30/24 documented the resident had severely impaired cognition and was dependent on staff for activities of daily living (ADL). The physician's order dated 6/3/24 documented bilateral palm guard at all times, remove/release for activities of daily living, and soft hip abductor cushion at all times, remove/release for ADL care and skin checks. A review of the care plan on 6/11/24, titled ADL Self Care Performance Deficit revealed that the bilateral palm guard and soft hip abductor cushion interventions were missing. On 06/11/24 at 07:45 AM, 06/11/24 at 10:46 AM, 06/11/24 at 11:54 AM, and 06/12/24 at 09:49 AM, Resident #51 was observed in their bed without the palm guards and soft hip abductor in place. The soft hip abductor was observed laying on the top of the resident's nightstand. On 06/12/24 at 10:14 AM during an interview, Certified Nurse Aide #14 stated they were not aware of Resident #51's palm guards and soft hip abductor. On 06/12/24 at 10:28 AM during an interview and observation, Registered Nurse #15 stated that they worked on the floor two- three- days a week and knew the Resident #51 well. The nurse stated that they were not aware the resident had orders for the soft hip abductor and palm guards. They stated that palm guards and other positioning devices would come from rehab department orders. Registered Nurse #15 pulled the linen that covered the resident to check the palm guards, which the nurse and surveyor did not observe. There was no hip abductor observed in place either. Registered Nurse #15 and the surveyor observed the hip abductor lying on the resident's nightstand. Registered Nurse #15 stated they did not know why the device has not been applied to the resident. They said that they saw the soft hip abductor on the night stand earlier when they started the shift, but they did not question why this hip abductor was not applied for the resident. Registered Nurse #15 searched the nightstand drawers and was unable to find palm guards. Registered Nurse #15 checked the Kardex (care instructions for direct care staff) and did not find the palm guards and soft hip abductor. On 06/12/24 at 10:33 AM during an interview, Registered Nurse Manager #16 stated once the rehab department created the order, the night Supervisor or a day Nurse Manager documented on the care plan, which would be reflected in the Kardex. Registered Nurse Manager #16 observed Resident #51's care plan and stated the palm guards and hip abductor were not on the care plan and should have been. On 06/12/24 at 01:54 PM during an interview, Assistant Rehab Coordinator #17 stated once the Rehab Department recommended devices or treatment, they endorsed devices for the staff on the floor to use. They stated they provided in-service on how to correctly apply palm guards and had a sign-in sheet. 2. Resident #46 had diagnoses which included Quadriplegia, diabetes insipidus, and traumatic brain injury. The Annual Minimum Data Set (an assessment tool) dated 3/30/2024 documented the resident had severely impaired cognition, received 100% of nutrition via a gastric tube and was dependent on staff with all activities of daily living care. A review of the Care Plan; ADL dated 2/23/23 documented assistive device bilateral palm guards at night. Bilateral resting hand splints during the day, remove / release ADL and skin checks A review of the Kardex documented bilateral resting hand splints during the day, remove / release for ADL care and skin checks. Bilateral palm guards at night remove release for ADL care and skin checks. A review of the Physician's Orders dated 3/26/24 documented bilateral resting hand splints during the day, bilateral palm guards use during night. During observations on 6/10/2024 at 7:00 AM, 06/12/24 at 2:46 PM, and 6/13/2024 at 12:00 PM, Resident #46 was in bed without hand splints or palm guards in place. During an interview with Certified Nurse Aide # 8 on 06/13/24 at 12:50 PM, they stated the therapy department was responsible for putting on the resident's splints. During an interview with the Director of Nursing on 06/13/24 at 01:00 PM, they stated the therapy staff put on the residents' splints. They stated the nursing staff did not put splints on and they were unaware Resident #46 did not have their splints on. During an interview with Occupational Therapist #9 on 06/13/24 at 04:47 PM, they stated therapy staff was responsible to put on the residents splints. They stated that Resident #46 could be resistant. They stated Resident #46 had them on but they were not able to put them on earlier this week. 10 NYCRR 415.12 (e)(2) 49255