Every finding on record at Guthrie Cortland Medical Center

Based on record review and interviews during the survey, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one (1) of five (5) residents (Resident #1) reviewed. Specifically, on 07/14/2024 at 3:36 PM, Resident #1, who had a history of exit seeking behaviors, was at risk for elopement, and had a wander alert device, exited the facility through the 3rd floor North Hall stairwell door. The resident was found outside by a visitor approximately 15-30 minutes later and brought back into the facility by nursing and security. This resulted in Immediate Jeopardy, past non-compliance, to Resident #1, and placed them at risk for serious harm serious injury, serious impairment, and death. Findings include:The facility policy Wandering Residents/Risk for Elopement and Recovery of Missing Resident, dated 06/01/2021, documented all residents will be assessed upon admission and on an on-going basis (quarterly, significant change, annually) to determine if wandering and elopement issues are present. The use of assigned staff to monitor a resident at times when wandering behavior may intensify (i.e. early morning, late evening, change of shift) may be necessary. Remote areas such as basements, loading docks, unsupervised stairways, non-resident areas including corridors and offices will be routinely monitored by staff or if appropriate, locked to prevent resident access. Resident #1 had diagnoses of Parkinson's Disease (progressive neurological disorder) and dementia with behavioral disturbances and anxiety. The 04/27/2024 Minimum Data Set (a resident assessment tool) documented the resident had moderately impaired cognition, used a manual wheelchair, had exit-seeking behaviors and used a wandering/elopement alarm daily. The Comprehensive Care Plan, initiated 08/16/2023 and revised 04/08/2024, documented the resident was an elopement risk/wanderer related to disorientation to place. Interventions included wandering device to left ankle. The 02/05/2024 physician order documented wandering device to right ankle and check for placement every shift.The 07/02/2024 facility maintenance work order documented maintenance disabled the 3rd floor alarm activation and placed a barricade at the door to prevent access. Nursing was made aware. Security Officer #6 documented they were called by security for assistance with resetting the wandering system alarm near the North stairwell door. The alarm would not turn off; they removed a screw from the bottom of the alarm box to lift up the alarm and it stopped alarming. A barricade was placed near the door to prevent access. Nursing and the nursing supervisor were notified. The 07/14/2024 facility video footage of the 3rd floor was reviewed and revealed:-at 1:40 PM, Resident #1 was exit-seeking at the North stairwell door. The resident opened the yellow plastic barrier (an accordion plastic barrier), wheeled themself around the barrier and closed the barrier behind them.-at 1:41 PM, two unidentified staff members looked at Resident #1, pushed the yellow plastic accordion-style barrier back open and walked away. Resident #1 was not redirected away from the door.-at 1:45 PM, Resident #1 attempted to remove their wander alert bracelet from their right ankle with a hairbrush and left the stairwell door area.-from 1:46 PM - 2:36 PM, the North Stairwell exit was empty.-at 2:36 PM, Resident #1 returned to the stairwell door and attempted to exit. The resident was redirected away from the door by an unidentified staff and returned to the door at 2:37 PM.-from 2:59 PM - 3:05 PM, Resident #1 was at the North stairwell door and attempted to exit. The resident pushed on the crash bar handle (delayed egress bar) with their right leg. The resident wheeled away from the exit at 3:05 PM-from 3:05 PM - 3:35 PM, the North Stairwell exit was empty.-at 3:35 PM, Resident #1 appeared at the North stairwell door and stood from their wheelchair and pushed on the door's crash bar with both hands. The door opened and the resident (still standing) attempted to pull their wheelchair through the door. -At 3:36 PM, Resident #1 fell backwards into the hall of the stairwell, landing on their buttocks while attempting to drag their wheelchair through the door. The resident remained sitting on the floor in the stairwell and pulled their wheelchair and pushed it through the door with their feet. The door was closed, and the resident was no longer visible.-At 3:46 PM an unidentified staff member approached the door, looked through the window of the door and approached the hallway and was pointing at the door. They exited using their badge and an empty wheelchair was seen at the top of the stairwell. The door closed. Another unidentified staff member came to the door, exited with their badge, and proceeded down the stairs. Several staff approached the door, and the wheelchair was brought back onto the unit. On 07/14/2024 at 1:00 AM, Registered Nurse #5 documented Resident #1 was missing from the unit at 3:30 PM. Staff initiated a search and discovered the resident's wheelchair in the 3rd floor North stairwell. Resident #1 exited through the 3rd floor North Stairwell door onto the loading dock and was found out in front of the building on the sidewalk by a visitor. The visitor alerted security and staff, and security retrieved the resident and brought them inside. An assessment was completed, and no injuries were noted.On 07/14/2024, the untimed Investigation summary completed by the Director of Nursing documented the root cause of Resident #1's elopement was the result of the 3rd floor North stairwell door alarm being disabled by maintenance. The door was broken and the resident exited through the stairwell door to the outside of the building.On 07/17/2024 at 9:00 AM, the vendor service receipt documented all door alarms were activated and tested on the 2nd and 3rd floor.During an interview on 02/05/2026 at 9:07 AM Registered Nurse #5 stated on 07/14/2024 during the 3:00 PM to 11:00 PM shift, they noticed the 3rd floor high side stairwell door had a yellow rectangular barricade across the door. They were told by staff on the unit that the door was broken. They did not know how long it was broken. Resident #1 was at the nursing station, and 15-20 minutes later, they noticed the resident was no longer at the nursing station. They alerted staff and looked for the resident. Resident #1 was found outside in front of the building and was brought back to the unit. They notified the Director of Nursing immediately and was told to place stretchers in front of the North end doors on both the 2nd and 3rd floors as the alarm systems were linked for both floors and the doors were broken. Registered Nurse #5 stated they questioned the action due to fire hazards but placed them per the Director of Nursing's orders. They did not recall when the door alarms were fixed.During an interview on 02/05/2026 at 2:14 PM Certified Nurse Aide #11 stated Resident #1 was exit-seeking all day on 07/14/2024. The resident normally wandered near the doors and tried to exit the facility, and staff re-directed the resident. On 07/14/2024, the resident went missing. The resident was found outside near the front of the building. After the incident, they placed a stretcher in front of the broken door to keep the resident from exiting again and they had to monitor the resident closely so they would not climb over the stretcher.During an interview on 02/05/2026 at 10:00 AM, Security Officer #6 stated they recalled an issue with the 3rd floor North stairwell door alarm not working, they went to the unit and assisted maintenance. The alarm was disabled, and they placed a yellow hard plastic, construction-like barrier against the door and notified nursing. They did not recall when the door was repaired. If maintenance could not repair an issue, then an outside vendor was notified.During an interview on 02/05/2026 at 11:17 AM, the Security Supervisor stated maintenance covered general hardware work orders and the security team covered door and wandering system concerns. On 07/14/2024, Resident #1 eloped due to the 3rd floor North stairwell door not being alarmed. The door was broken days prior to the event. Maintenance disabled the door alarm mistakenly due to a wandering system alarm issue and thought the door alarms were on the same alarm system. There was a yellow barrier in front of the door to prevent residents from exiting. Door checks were conducted by staff. On 07/08/2024, a wandering system vendor came in and checked the wandering system but due to the door alarms being separate, the 3rd floor stairwell door remained disconnected. The door was not repaired until 07/17/2024, three (3) days after Resident #1 eloped from the facility.During an interview on 02/05/2026 at 12:07 PM, the Director of Nursing stated on 07/14/2024 they were notified by the 3rd floor charge nurse that Resident #1 eloped from the building. They instructed Registered Nurse #5 to do an assessment to ensure the resident had no injuries. The Director of Nursing reviewed the facility video footage and stated the 3rd floor door alarm did not alarm and Resident #1 was seen kicking the door open and exiting. They did not recall when they reviewed it, but stated Security gave the footage to them. Resident #1 had exit seeking behaviors and was assessed as a high risk for elopement. The Director of Nursing stated after the incident, a stretcher was placed in front of the 3rd floor door in addition to the yellow accordion style barrier until the door was fixed. They did not know the outside vendor did not repair the door until 07/17/2024. They stated Resident #1 was placed under constant supervision after the incident and staff were educated on elopement and exit seeking behaviors.During an interview on 02/05/2026 at 2:14 PM, Certified Nurse Aide #11 stated on 07/14/2024 Resident #1 was exit-seeking all day, all of the time while they were working. Resident #1 constantly wandered in and out of resident rooms, near the doors, tried to enter the medication rooms, and was constantly trying to exit the facility. The resident was not on any special watches before the elopement; staff just knew to watch the resident all the time and redirect them. On 07/14/2024, the resident went missing. Staff were not aware the stairwell door was broken. Certified Nurse Aide #11 stated they assisted with searching for the resident, the resident was found outside near the front of the building and was returned to the unit. After the incident, they placed a stretcher in front of the broken door to keep the resident from exiting again and they had to monitor the resident closely so they would not climb over the stretcher. They did not have the staff to do a 1:1 (one to one) with the resident. They were not aware of any repairs to the door. Security accompanied the resident back to the unit with staff and stated the alarm on the door did not work. They did not recall when the door was fixed. New York Code Rules & Regulations: 415.12(h)(2).__________________________________________________________________Immediate Jeopardy past non-compliance was identified, and the Administrator on Record was notified on 02/06/2026 at 2:32 PM. The facility is currently in compliance. The facility provided verification the following corrective actions were completed:-Resident #1 was immediately placed on 15-minute safety checks and kept under line-of-sight supervision when outside of their room; continued with use of a wander alert device; and resided in a room adjacent to the nursing station for frequent observations.-All staff were educated on the Elopement policy and what measures to take if a resident went missing. Education included a power point presentation and post-tests. -On 07/17/2024, all exit and stairwell doors in the facility on the 2nd and 3rd floors were repaired by an outside vendor.

Based on observations and interviews during the survey, the facility failed to ensure residents maintained acceptable parameters of nutritional status for three (3) of three (3) Residents (Residents #6, #43, and #74) reviewed. Specifically, Residents #6, #43, and #74 had severe weight loss, which was not addressed by the medical provider and their nutritional needs were not reassessed by the registered dietitian. Additionally, the registered dietitian recommended the addition of Liquacel (liquid protein supplement) for Resident #6 and there was no documented evidence the supplement was ordered. Failure to assess and address nutritional status resulted in immediate jeopardy to Residents #6, #43, and #74 and placed all residents with altered nutritional status at risk for serious harm, serious injury, serious impairment or death. Findings include:The facility policy Admission, Nutrition Assessment and Care Plan, revised 01/23/2026, documented nutritional problems, goals, and plan were documented in the interdisciplinary care plan. The Nutrition Assessment and interdisciplinary care plan was reviewed and adjusted at least quarterly according to the residents' needs. Additional progress notes were written at any time as the residents' conditions dictated, this included weight changes. The facility policy Weights, revised 01/06/2026, documented the facility monitored, recorded, and evaluated each resident's weights routinely as an indicator of overall health status and take corrective action as necessary. The nursing staff obtained weights unless there was a medical order for No Weights. If a resident had a weight change of five (5) pounds nursing staff obtained a re-weight within 24 hours. Nursing staff notified Dietary services of weight changes of five (5) pounds. Dietary Services addressed weight changes. Any refusals were documented in the resident's medical record. The undated facility policy Standards of Care, documented the registered dietitian used their clinical judgment and the following guidelines to determine estimated nutritional needs. The Standards of Care documented estimated calorie needs for females with unintended weights loss/weight maintenance for healthy older adults was 25-35 calories per kilogram of body weight and 30-20 calories per kilogram of body weight for males. 1) Resident #43 had diagnoses including heart failure, chronic kidney disease, and anxiety. The 11/20/2025 Minimum Data Set (a resident assessment tool) documented that the resident had moderate cognitive impairment, did not reject care, required set up or clean up assistance with eating, was 65 inches tall, weighed 111 pounds, and had unplanned weight loss of 5% or more at one (1) month or 10% or more in the past six (6) months. The 08/21/2025 Comprehensive Care Plan initiated, revised 12/02/2025, documented the resident required optimal nutrient and fluid intakes related to weight management. Interventions included interventions per nutrition standards of care, provide diet as ordered, assistance as needed, and snacks and supplements as accepting. The 08/21/2025 physician orders documented a regular diet. Resident #43's weight record documented the following weights: -07/02/2025, 144.5 pounds; 08/21/2025, 130.4 pounds; and 09/01/2025, 134.1 pounds. The weight record documented that the resident had a 10.4 pound weight loss from 07/02/2025 to 09/01/2025 (7.2%). The 09/02/2025 at 12:18 PM Registered Dietitian #10 progress note documented the resident had a 10.2% weight change (14.7 pounds) since 07/02/2025. The plan was to trial Ensure Plus High Protein (nutritional supplement) twice daily and continue to monitor. Resident #43's weight record documented the following weights on 10/01/2025, 120.8 pounds (9.9%/13.3-pound loss in one (1) month); and on 10/03/2025, 114.7 pounds; and 10/06/2025, 117.7 pounds. The resident had a 10% severe weight loss from 09/01/2025-10/01/2025. The 10/05/2025 at 6:38 PM Registered Nurse #3 progress note documented they spoke to the resident's family who voiced concerns about the resident possibly having issues with swallowing food and drink. The family reported the resident had lost quite a bit of weight. There was no documented evidence that the registered dietitian reassessed the resident's nutritional needs following the severe weight loss of 9.9%/13.3-pounds in 10/2025. The 10/29/2025, Physician #6 progress note documented the resident was seen for a 60 day follow up visit. They weighed 116.6 pounds, their weights were stable, and they had significant muscle wasting. There was no documented evidence that the physician was aware of the resident's severe weight loss. Resident #43's weight record documented the following weight on 11/05/2025, 117.4 pounds, re-weight 117.4 (severe 9.9%/13-pound loss in three (3) months). The 11/17/2025, Nurse Practitioner #5 progress note documented the resident was seen for a comprehensive assessment. The resident had bilateral lower extremity edema and was at risk for malnutrition. The resident had a condition or chronic disease that may result in a life expectancy of less than six (6) months. There was no documented evidence that the resident's severe weight loss was addressed. The 11/20/2025 Nutrition Assessment completed by Registered Dietitian #4 documented the resident weighed 111 pounds on 11/19/2025, their body mass index was 22, had a weight loss of 5% in one (1) month or a loss of 10% in six (6) months and was not on prescribed physician weight loss regimen. The resident was at risk for malnutrition related to limited mobility, history of depression, and psychological stress or acute disease in the past three (3) months. The resident did not accept supplements, and they would continue to monitor intakes and weights. The resident had no noted edema, their skin was intact, appeared well nourished. Their estimated daily nutritional needs were 1000-1250 calories (20-25 calories/ kilogram of body weight), 50 grams of protein (1 gram of protein per kilogram of body weight), and 1000-1250 milliliters of fluids (1 milliliter of fluids per kilogram of body weight). Resident's #43 weight record documented the following weights 12/01/2025, 105.8 pounds, (severe 9.8%/11.6-pound loss in two (2) months and 21.1% /28.3-pound loss at three (3) months); 12/03/2025, 110 pounds; 01/02/2026, 96.8 pounds, re-weight 96.7 pounds (severe 12%/13.3-pound loss at one (1) month, severe 17.5%/20.6-pound loss at three (3) months and 33%/47.7-pound loss at six (6) months); 01/07/2026, 91.2 pounds, re-weight 91.2 pounds (severe 5.7%/5.6-pound loss in five (5) days). There was no documented evidence that Registered Dietitian #4 reassessed the resident's nutritional needs after the November 2025 nutritional assessment and the resident continued to have severe weight loss. The 12/31/2025 Physician #6 progress note documented the resident was seen for a 60 day follow up visit. Their weight was 96.7 pounds, their weight was stable, and they had significant muscle wasting. There was no documented evidence that the resident's severe weight loss was addressed. The 01/25/2026, Nurse Practitioner #5 progress note documented the resident was seen for a comprehensive assessment, the resident had minimal bilateral lower extremity edema and was at risk for malnutrition. The resident had a condition or chronic disease that may result in a life expectancy of less than six months. There was no documented evidence that the resident's severe weight loss was addressed. During an interview on 02/10/2026 at 10:25 AM, Registered Nurse Unit Manager #9 stated significant weight changes were discussed during the monthly weight meetings attended by Registered Dietitians #4 and #10, Nurse Practitioner #5, the Director of Nursing, Minimum Data Set Registered Nurse, and the registered nurse unit managers. The team discussed significant weight changes and anything that could impact the resident's weight status. The registered nurse managers also notified Nurse Practitioner #5 about significant weight changes via electronic communication. Resident #43 had lost weight and their intakes wavered. Staff encouraged the resident to eat at meals, and their significant other would also come in to provide encouragement. Staff offered snacks or alternatives if their intakes were not good at meals. The resident was discussed frequently at the monthly weight meeting, and they thought the registered dietitian and medical providers were addressing the significant weight loss. During an interview on 02/10/2026 at 02:35 PM, Registered Dietitian #4 stated a resident triggered for a significant weight change if they lost or gained 5% in one (1) month, 7.5% in three (3) months, and 10% in six (6) months. The facility had a monthly weight meeting and all residents with significant weight changes were discussed. The nurse practitioner, Director of Nursing, and unit managers attended the meeting. They stated if a resident triggered for a significant weight change, they documented in a progress note and discussed any interventions. They did not always reassess the resident's nutritional needs right away if there was a significant weight change as they looked at the whole picture. They talked to the resident or family, updated menus, and asked if the resident was willing to try supplements. If a resident triggered a significant weight change, the facility completed a significant change assessment. They would complete a full comprehensive nutritional assessment at that time. They stated Resident #43 did have a significant weight loss in October 2025 and they did not document a note addressing the resident's significant weight loss and did not reassess their nutritional needs at that time. They stated they should have documented and were unsure why they did not. They also did not document a note about the residents' significant weight losses in December 2025 and January 2026. They were unsure why they did not address the weight loss and did not reassess the residents' needs. The resident was discussed in the monthly weight meeting and medical stated they had a poor prognosis. 2) Resident #74 had diagnoses including Parkinson's disease (a progressive neurological disease), dysphagia (difficulty swallowing), and dementia. The 12/05/2025 Minimum Data Set documented the resident had severely impaired cognition; did not reject care; required supervision or touching assistance with meals; was 60 inches tall; weighed 105 pounds; and did not have any significant weight changes in the last one (1) or six (6) months. The 10/25/2025 physician order documented a mechanical soft (ground diet). The Comprehensive Care Plan, revised 12/18/2025, documented the resident was at risk for malnutrition related to decreased intakes, history of weight loss, and dementia. Interventions included to monitor for swallowing difficulties, notify medical of refusals of meals, report significant weight changes to medical, provide diet as ordered, and offer snacks and supplements as accepted. The resident required supervision or touching assistance intermittently throughout meal. Resident #74's weight record documented a weight of 115.2 pounds on 10/01/2025. The 10/01/2025 Nutrition Assessment completed by Registered Dietitian #10 documented the resident weighed 112.9 pounds, their body mass index was 22, and they had a significant weight loss of 5% at one (1) month or 10% at six (6) months. The resident refused oral nutritional supplements and chocolate ice cream was added to their lunch and dinner meals. Their estimated daily nutritional needs were 1530-1785 calories (30–35 calories per kilogram of body weight), 51-61 grams of protein (1-1.2 grams of protein per kilogram of body weight), and 1785-2040 milliliters of fluid (35-40 milliliters of fluid per kilogram of body weight). The resident's average meal intakes were 31% and 636 milliliters of fluid. The plan was to continue with diet as ordered, monitor weights and labs as available, and update preferences as needed. Resident #74's weight record documented the following weights; on 11/03/2025, 106.0 pounds (severe 7.9%/9.2 pound loss at one (1) month and severe 8.6%/10 pound loss at three (3) months); 11/17/2025, 107.7 pounds; 11/19/2025, 106.6 pounds; There was no documented evidence that the registered dietitian reassessed the residents' nutritional needs following the severe weight loss of 7.9%/9.2-pounds in November of 2025. The 11/29/2025, Nurse Practitioner #5 progress note documented the resident was seen for a comprehensive assessment. The resident was frail and had Parkinson's disease and dementia, received a mechanical soft diet, and had severe protein/calorie malnutrition. The resident had a life expectancy of less than six (6) months related to a condition or chronic disease. There was no documented evidence the resident's severe weight loss was addressed. Resident #74's weight record documented on 12/01/2025, 104.9 pounds. The 12/10/2025 Nutrition Assessment completed by Registered Dietitian #10 documented the resident weighed 104.9 pounds, their body mass index was 21, and they had an 8.9%/10.3 pound weight loss since 10/01/2025. Their estimated daily nutritional needs were 1440-1680 calories (30–35 calories per kilogram of body weight), 48-58 grams of protein (1-1.2 grams of protein per kilogram of body weight), and 1680-1920 milliliters of fluid (35-40 milliliters of fluid per kilogram of body weight). The resident's average meal intakes were 25% and 603 milliliters of fluid. The plan was to continue with diet as ordered, monitor weights and labs as available, and update preferences as needed. Resident #74's weight record documented 01/07/2026, 102 pounds (severe 11.4%/13.2 pound loss at three (3) months). There was no documented evidence that Registered Dietitian #10 reassessed the resident's nutritional needs following the severe weight loss of 11.4%/13.2-pounds in January of 2026. The 01/19/2026, Nurse Practitioner #5 progress note documented the resident was seen for a comprehensive assessment, continued on a mechanical soft diet and had severe protein/calorie malnutrition. The resident had a life expectancy of less than six (6) months related to a condition or chronic disease. There was no documented evidence the resident's severe weight loss was addressed. During an interview on 02/10/2026 at 12:16 PM, Registered Nurse Unit Manager #12 stated the dietitians, Director of Nursing, nurse managers, and nurse practitioner met monthly to review significant weight changes. The team reviewed significant weight changes and discussed them. Medical and the registered dietitians documented significant weight changes. Resident #74 refused supplements and liked chocolate. The resident lost weight, and they were unsure of the etiology of the weight loss. The team had discussed the resident's weight loss in the monthly weight meetings. During an interview on 02/10/2026 at 1:34 PM, Registered Dietitian #10 stated nursing staff obtained resident weights and if there was five (5) pound weight change since the previous documented weight, a reweight was obtained. Significant weight changes were 5% or more in one (1) month, 7.5% or more in three (3) months, and 10% or more in six (6) months. If a resident triggered for a significant weight change, the team discussed the weight change in the monthly weight meeting with the interdisciplinary team, including medical. Resident #74 had a significant weight change in November of 2025. They did not document the resident's significant weight change but did complete a nutritional assessment in December of 2025. There were no new nutritional interventions to the resident's plan of care. They did not document the resident's significant weight loss in January 2026 and there were no nutritional interventions to the resident's plan of care. They did not always document significant weight changes because they were discussed in the monthly meeting. During an interview on 02/10/2026 at 4:43 PM, Nurse Practitioner #5 stated they were made aware of significant weight changes in the monthly weight meeting. They assessed the residents as needed. During the meeting, the team reviewed intakes and looked at possible causes of weight changes. They did not routinely document significant weight changes in their notes due to time constraints. They had not told anyone at the facility they were not documenting significant weight changes and were aware they should be documenting significant weight changes. Resident #43 was fading away, had heart failure and was on comfort care, but weights were still being obtained. The resident had a life expectancy of less than six (6) months. The resident was discussed at the monthly weight meeting, and they were aware of their significant weight loss and did not document on their significant weight loss. They thought their weight loss could be attributed to their disease process. If weights were not being followed, it could impact a resident's skin and nutritional status. They were not aware the registered dietitians were not documenting significant weight changes. 3) Resident #6 had diagnoses including kidney disease, dialysis (filtration of blood when kidneys do not function properly), diabetes, colostomy (artificial opening in abdomen to collect stool), and urostomy (artificial opening in the abdomen that collects urine). The 01/16/2026 Minimum Data Set documented the resident was cognitively intact, required set up or clean up assistance with eating, was 72 inches in height, weighed 175 pounds, and had weight loss of 5% or more at one (1) month or 10% or more in the past six (6) months. The Comprehensive Care Plan initiated 11/26/2025 and revised 01/16/2026 documented the resident qualified for malnutrition related to weight loss, limited mobility, psychological stress or acute disease in the past three (3) months, history of depression, and multiple pressure injuries. Interventions included monitor intake, weights, labs, bowels, skin, and other nutrition related parameters were monitored. Resident #6's weight record documented the following weights: on 11/11/2025 193.6 pounds; 11/25/2025 186 pounds (a 3.9%/7.6 pound weight loss in 2 weeks); and 11/26/2025 188.5 pounds. The 11/26/2025 Nutrition Assessment completed by Registered Dietitian #10 documented the resident weighed 186 pounds, had a body mass index of 25 (normal), had weight loss of 5% in one (1) month or a loss of 10% in (6) six months and was not on prescribed physician weight loss regimen. The resident qualified for malnutrition related to weight loss, limited mobility, psychological stress or acute disease the past three months, and history of depression. They would continue the resident on Liquacel (nutritional supplement) three (3) times a day from previous admission and would continue to communicate with the dialysis registered dietitian for any further recommendations or requests. Intakes were monitored and improved consistency of weights. The resident had no noted edema, had an unstageable pressure injury on coccyx (improving), right third and fourth toe (improving), and appeared well nourished. Their estimated daily nutritional needs were 1700-2125 calories (20-25 calories/kilogram of body weight), 127-170 grams of protein (1.5-2 gram of protein per kilogram of body weight), and 1800 milliliters of fluid restriction per medical doctor. There was no documented evidence of a physician order for Liquacel. There was no documented evidence of Liquacel included on the 12/2025, 01/2026, and 02/2026, Medication Administration Record and Treatment Administration Records. Resident #6's weight record documented the following weights: 11/28/2025 186.3 pounds; 12/01/2025 183 pounds; 12/03/2025 176.4 pounds and reweigh 176.5 pounds (a weight loss of 3.6%/ 6.6 pounds in two (2) days and 8.9%/ 16.6 pounds in three (3) weeks); and 12/23/2025 175 pounds (a severe 9.6%/18.6-pound weight loss in six (6) weeks). The 12/28/2025 Nutrition Assessment completed by Registered Dietitian #10 documented the resident weighed 175 pounds, their body mass index was 24, they had weight loss of 5% in one (1) month or a loss of 10% in six (6) months and was not on prescribed physician weight loss regimen. The resident qualified for malnutrition related to weight loss, limited mobility, psychological stress or acute disease in the past three (3) months, and history of depression. They would continue the resident on Liquacel three (3) times a day from previous admission and would continue to communicate with the dialysis registered dietitian for any further recommendations or requests. Intakes were monitored and improved consistency of weights. The resident had no noted edema, had pressure injuries to left knee, coccyx, right third and fourth toes and appeared well nourished. Their estimated daily nutritional needs were 1580-1975 calories (20-25 calories/kilogram of body weight), 119-158 grams of protein (1.5-2 grams per kilogram of body weight), and 1800 milliliters of fluid restriction per medical doctor. Physician orders documented: -On 01/13/2026 the resident was on a renal and a fluid restricted diet with a total volume of 3000 milliliters a day. -On 01/16/2026 the resident was malnourished. Resident #6's weight record documented the following weights: 01/14/2026 183 pounds; and 01/16/2026 178.3 pounds (a 2.6%/4.7 pound weight loss in two (2) days). The 01/19/2026 Nutrition Assessment completed by Registered Dietitian #10 documented the resident weighed 178.3 pounds, their body mass index was 24, they had weight loss of 5% in one (1) month or a loss of 10% in six (6) months and was not on prescribed physician weight loss regimen. The resident qualified for malnutrition related to weight loss, limited mobility, psychological stress or acute disease in the past three (3) months, and history of depression, and multiple pressure injuries. They would continue the resident on Liquacel three (3) times a day from previous admission and would continue to communicate with the dialysis registered dietitian for any further recommendations or requests. Intakes were monitored and improved consistency of weights. The resident had no noted edema, had pressure injuries to left knee, coccyx, right third and fourth toes and appeared well nourished. Their estimated daily nutritional needs were 1620-2025 calories (20-25 calories/ kilogram of body weight), 122-162 grams of protein (1.5-2 gram of protein per kilogram of body weight), and 1800 milliliters of fluid restriction per medical doctor. Resident #6's weight record documented the following weights: 02/04/2026 163.5 pounds (a 10.6%/19.5 pound weight loss in three (3) weeks); 02/06/2026 164.4 pounds (a severe 15.1%/29.2 pound weight loss in three (3) months). The 02/04/2026 Physician #6 progress note documented the resident's chart was reviewed and they had a discussion of care goals and treatment plan with the resident's spouse. A review of systems was not performed as they did not see the resident. The spouse requested the physician speak with the resident about the possibility of trying mirtazapine (medication) for appetite stimulation. The plan was to discuss with the resident when they saw them next week. There was no documented evidence Physician #6 was aware of the resident's severe weight loss. During an observation and interview on 02/02/2026 at 12:44 PM, the resident was lying in bed dressed and had just returned from dialysis. Their lunch was untouched on the over-the-bed table. They stated they did not want the sandwich, and they were going to ask staff for a salad. During an interview on 02/10/2026 at 10:09 AM, Resident #6 stated they lost weight. The dietitian at dialysis spoke with them often about their phosphorus and potassium intake. They did not recall any specific conversations with the facility's dietitian. During an interview on 02/10/2026 at 10:59 AM, Registered Nurse Manager #12 stated there were monthly weight meetings. Resident #6 had weight loss. They stated they used the weights from dialysis and those were entered into the electronic medical record by the registered dietitian. During an interview on 02/10/2026 at 1:34 PM, Registered Dietitian #10 stated there was a monthly weight meeting. If there was a 5% loss in a month, 7.5% in three (3) months, or 10% in six (6) months it was considered a significant change. If this significant change was identified the resident was put on weekly weights. For Resident #6, it was a team effort between dialysis and the facility. They were working on better communication with the registered dietitian at the dialysis center. The dietitian at dialysis emailed the resident's weights to them every two (2)- three (3) weeks. Weights were obtained at dialysis because weights were inconsistent with the facility staff and there were large changes that they could not verify if they were accurate. The resident had a decline in the past few weeks. The resident did not like the food and often refused meals, but they were on a supplement. They followed the direct recommendations from dialysis. Upon review of their standards of care document, they were not meeting the resident's nutritional needs. They had not reassessed the resident since their readmission in January 2026. During an interview on 02/10/2026 at 4:05 PM, Nurse Practitioner #5 stated they attended the monthly weight meetings and anyone with significant weight loss was discussed. They did not recall being notified of any significant weight loss for Resident #6. If they had, they would have contacted dialysis and talked to their nephrologist (kidney doctor) as they should oversee the resident's care. They had not seen the resident. If they had, they would have documented a note. They were one person and relied a lot on the nurses. 10 New York Codes, Rules and Regulations 415.12(i)(1) Immediate Jeopardy was identified, and the Administrator was notified on 02/24/2026 at 10:59 AM. Immediate Jeopardy was removed on 02/25/2026 at 12:38 PM based on the following corrective actions: -Policies and Procedures were revised to include reweight parameters, registered dietitian assessments for significant weight changes, provider notifications, and nutritional supplement orders. -100% of in-house staff were educated on the updated policies and procedures with a plan to educate all staff prior to their next scheduled shift. -All residents' weights were reviewed and residents with weight loss were assessed by the registered dietitian and the medical provider was notified. All nutritional supplements were included in physician orders. -Staff were interviewed and were able to accurately report the educational content.

Based on observation and interviews during the recertification survey, the facility failed to ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for one (1) of one (1) meal reviewed (the 02/09/2026 lunch meal) and 10 of 10 anonymous residents during a resident council meeting. Specifically, food was not served at palatable and appetizing temperatures during the lunch meal on 02/09/2026 and 10 anonymous residents during a resident council meeting stated the food was cold. Findings include:The facility policy Food Safety and Infection Control, last revised 07/02/2025, documented food and sauces were held at a temperature of 135 degrees Fahrenheit.The 11/24/2025 Test Tray Audit form documented entrees, soups and hot beverages should be 135 degrees Fahrenheit or above.During a meal observation on 02/09/2026 at 12:26 PM, Resident #46 was served their lunch tray. A replacement tray was ordered, and Resident #46's original meal tray was tested. At 12:26 PM, Registered Nurse #14 verified the measured food temperatures. The chicken tenders measured 114 degrees Fahrenheit and were chewy.During an interview on 02/02/2026 at 12:44 PM Resident #46 stated food was cold, there was no variety and the quality was poor. During an interview on 02/10/2026 at 03:30 PM, the Food Service Director stated they had a monthly food council where residents talked about flavors and textures of food. They had never heard of cold food complaints. They completed food temperature checks at the start of the meal services. Hot food should be served at 135 degrees Fahrenheit and should be palatable. If the temperature was not in the danger zone it was ok. The chicken tenders should be hotter than 114 degrees Fahrenheit and not chewy. The food might be getting soft in transit to the floors. They stated when they placed the lid on it the steam could make the product chewy.10 New York Codes, Rules and Regulations 415.14(d)(1)(2)

Based on observations, record review, and interviews during the recertification survey, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (1) of one (1) resident (Resident #6) reviewed. Specifically, -Resident #6 required a colostomy (a surgical opening in the abdomen that allows stool to pass out of the body) and did not have orders for changing the appliance and was not provided with appropriate colostomy supplies.-Resident #6 required use of a urostomy (surgical opening in the abdomen that allows urine to pass out of the body) and there were no orders to change the appliance. -the person-centered comprehensive care plan did not include the diagnoses of diabetes mellitus and insulin use, use of an anticoagulant (blood thinner), or the use of opiates (narcotic pain medication). -the physician was not notified when the resident had low blood pressure. Findings include: The facility policy Colostomy and Ileostomy Appliance Care, Long-Term Care, revised 12/15/2025, documented a resident with a colostomy wore an external pouch to collect emerging fecal matter. The pouching system that a resident used depended on which type provided the best adhesive seal and skin protection. Documentation associated with colostomy appliance care included the date and time the pouching system was applied or changed, the drainage characteristics, the appearance of the stoma and surrounding skin, and type of appliance applied. The facility policy Urostomy Care, Home Care, revised 12/15/2025 documented the resident was required to wear a urine collection appliance or pouching system. Nursing care included the stoma and surrounding skin was assessed, and the pouching system was emptied and replaced. Documentation included the date and time of urostomy care, the amount and characteristics of urine in the pouch, as well as stoma and surrounding skin assessment.The facility policy [Minimum Data Set] Assessment and Care Plans, revised 06/02/2025, documented care plans reflected the residents' medical and nursing assessment. The facility policy Notification of Changes to Provider, effective 01/23/2026, documented any unusual change in vital signs was reported to a physician/ nurse practitioner in a timely manner with documented evidence noted in the clinical electronic medical record by the licensed nurse. Resident #6 had diagnoses including diabetes, colostomy and urostomy status, and long term use of insulin, anticoagulants, and opiates. The 01/16/2026 Minimum Data Set assessment (a health status assessment tool) documented the resident was cognitively intact, had diagnoses of high blood pressure, low blood pressure with position changes, and diabetes, had a colostomy and a urostomy, and received insulin, anticoagulants, and opiates. The Comprehensive Care Plan initiated 11/25/2025 documented the resident had a colostomy bowel appliance. Interventions included the appliance was changed weekly with shower and emptied every shift and as needed and the drainage bag was emptied as needed. The care plan did not include the specific type of appliance. The resident had a urostomy appliance. Interventions included intake and output were monitored per facility policy, and signs and symptoms of discomfort on urination and frequency were monitored. The care plan did not include the specific type of appliance or frequency the drainage bag was emptied or changed. The person-centered care plan did not address the diagnosis of diabetes, or the use of insulin, anticoagulants, and opiates. Physician orders documented:-On 01/13/2026 colostomy and urostomy care every shift.-On 01/13/2026 hydromorphone hydrochloride (opiate) oral tablet 4 milligrams every 12 hours as needed for moderate/ severe pain-On 01/14/2026 apixaban (anticoagulant) oral tablet 5 milligrams, give a half tablet by mouth twice daily for a history of deep vein thrombosis (blood clot).-On 01/14/2026 Humalog mix 50/50 subcutaneous suspension (short acting insulin) as per sliding scale (amount of insulin is based on blood sugar results) subcutaneously with meals for diabetes mellitus. There was no documented evidence of physician orders to change the colostomy or urostomy appliances.On 01/28/2026 at 12:00 AM the Vitals Summary by Registered Nurse #27 documented a blood pressure of 82/58 (low).There was no documented evidence that the physician was notified of the low blood pressure. During an observation and interview on 02/02/2026 at 12:44 PM, Resident #6 was lying in bed. They stated they had a urostomy and colostomy and they could care for them themself but had to ask for supplies. The facility was out of colostomy supplies, so their spouse ordered some off the internet, but they had not come in yet. They had to change the colostomy bags more often than the urostomy bags. Staff had to help clean them up today after dialysis because their bag burst. They were using urostomy bags for their colostomy because the facility was out of colostomy bags. They lifted their shirt and the urostomy and colostomy appliances were identical; they were [NAME] bags with a twist drainage port. They stated they had used a urostomy bag for the colostomy site last night as well. During a follow up interview on 02/05/2026 at 9:43 AM, the resident stated the supplies their spouse ordered on the internet came in yesterday. When they had to use the urostomy appliance instead of the colostomy appliance they had to change it more often because the drain port was not equipped to drain any chunks and the seal was not equipped for the acidity. The facility did provide them with more urostomy supplies and the facility still did not have any colostomy supplies for them.During an observation on 02/05/2026 at 2:52 PM of the clean utility room, there were no ostomy supplies. During an observation on 02/05/2026 at 3:02 PM of the medication room, there were no ostomy supplies. During an interview on 02/06/2026 at 2:20 PM, Certified Nurse Aide #15 stated the resident's spouse ordered colostomy supplies on the internet last weekend. They thought the hospital supplied them but last weekend they ran out of supplies because they were going through three bags a shift. The resident had to use urostomy bags last weekend because they did not have colostomy bags. The bags were different, the colostomy bags rolled up with Velcro or a clip, the urostomy bag had a twist cap. The urostomy bag was smaller and did not hold as much. The resident taped the urostomy bag because it was not staying on the colostomy site. They thought the medication room was where extra supplies were kept but the resident kept their supplies in their closet. During a follow up interview on 02/09/2026 at 1:59 PM, Certified Nurse Aide #15 stated the care plan told them what the resident needed. They referenced it every day because it changed. If a resident was diabetic, they could not cut their toenails. They were not sure if Resident #6 was diabetic or what medications they were on.During a telephone interview on 02/10/2026 at 8:41 AM, Registered Nurse #27 stated when a resident's blood pressure was really off, they contacted the on-call provider. If they called the on-call provider, they would chart a nursing note. Resident #6's blood pressure was normally in the 130's. They did not recall the blood pressure of 82/58 on 01/28/2026 and it was a concerning blood pressure. Resident #6 was very sick and that blood pressure could indicate sepsis. They often took residents' blood pressures on the night shift, but they usually had a workload of 35 patients and that was a lot.During an interview on 02/10/2026 at 10:09 AM, Resident #6 stated the facility still had not provided them with colostomy supplies and they were on their last urostomy bag. During an interview on 02/10/2026 at 10:25 AM, Licensed Practical Nurse #19 stated they told Registered Nurse Manager #12 if they needed more colostomy or urostomy supplies during the week. Over the previous weekend, they asked the resident's spouse to order more colostomy supplies because they did not know how to order them on the weekends. Because the residents had liquid stools, they could use urostomy bags. They asked Registered Nurse Manager #12 to order more urostomy supplies today. There was no documentation when the bag was changed. Blood pressures lower than 100/60 were considered low and they should tell Registered Nurse Manager #12 if the resident had low blood pressure. Care plans were completed by Registered Nurse Manager #12. They referred to the care plans for a resident's transfer status. They were not sure if there should be diabetic or high-risk medication care plans. They relied on the registered nurses for that. During an interview on 02/10/2026 at 10:59 AM, Registered Nurse Manager #12 stated ostomy supplies were ordered from central supply. There was a new process and not everyone knew how to do it. Nurse managers, unit secretaries and charge nurses have been trained so far. There was no trouble getting ostomy supplies. They ordered supplies from home before if staff reached out to them on the weekend. Resident #6 was going through a lot of colostomy supplies. They did not know the resident was using urostomy supplies for their colostomy. They ordered colostomy supplies on 02/03/2026 and ordered 5 bags and 5 wafers of all 3 sizes because they did not know which size was needed. This last shipment they asked nursing staff to keep in the medication room so they could keep a better eye on it and order more supplies when they were down to 1-2. Ostomy appliances should be changed weekly on shower days. They referenced the resident's orders and did not see an order to change their urostomy and colostomy appliances on shower days. If there was no documentation, there was no proof it was done. The provider was notified for a blood pressure that was lower than 90. Diabetic residents had a care plan for that diagnosis. There were also care plans for high-risk medications, like insulin, anticoagulants, and opiates. Care plan would alert the staff what side effects to monitor for. In reviewing Resident #6's care plan, they did not have a diabetic care plan, or a care plan for their high-risk medications of insulin, anticoagulant, and opiates. The resident had been back and forth so much from the hospital, and they must have missed it. 10 New York Codes, Rules, and Regulations 415.12

Based on observation, record review, and interviews during the recertification survey, the facility failed to ensure that residents who required dialysis services (filtration of blood when the kidneys do not work efficiently) received such services consistent with professional standards of practice for one (1) of one (1) resident (Resident #6) reviewed. Specifically, Resident #6 received hemodialysis treatments at a community-based dialysis center and did not have on-going assessments and oversight before and after dialysis treatments, there was no documented evidence the resident's dialysis access site (Permacath, a central catheter) was routinely assessed, and there were no physician orders for dialysis, pre or post dialysis assessments, or dialysis vascular site monitoring.Findings include:The facility policy, Offsite Hemodialysis Care and Coordination, revised 12/31/2025, documented a continuous 24-hour communication process was maintained between the facility and the dialysis center. Before each treatment a licensed nurse monitored the resident's vital signs, weight, and general condition as ordered by the physician. The facility checked and monitored the resident's vascular access site. Upon the resident's return, the nursing staff performed an immediate assessment, including vital signs and an examination of the vascular access site for bleeding or other complications. Staff monitored post-dialysis symptoms such as dizziness, nausea, vomiting, or fatigue. Resident #6 had diagnoses including end stage kidney disease, dependence on renal dialysis, and diabetes. The 01/16/2026 Minimum Data Set assessment documented the resident was cognitively intact, was medically complex, had end stage kidney disease, and required dialysis treatments.The Comprehensive Care Plan initiated 11/25/2025 documented the resident received dialysis on Monday, Wednesday, and Friday. Interventions included the vascular access site was checked daily and as needed. The care plan did not specify the location, type of access site, or what specifically the site was checked for.There was no documented evidence of a physician order for dialysis, pre or post dialysis assessments, or dialysis vascular site monitoring. The dialysis and nursing home handoff communication tool documented the resident attended dialysis on 01/16/2026, 01/19/2026, 01/21/2026, 01/23/2026, 01/26/2026, 01/28/2026, 01/30/2026, 02/02/2026, 02/04/2026, and 02/06/2026. There was no documented evidence of a pre-dialysis evaluation on 01/23/2026.There was no documented evidence of a post-dialysis evaluation on 01/16/2026, 01/28/2026, and 02/02/2026.During an interview on 02/09/2026 at 1:59 PM, Certified Nurse Aide #15 stated Resident #6 left for dialysis at the time they started their shift. There was a binder that went with them. When the resident returned from dialysis, they got back in bed and had lunch. They stated they were careful with helping to take the resident's shirt off and pulling it down because they had a port. During an observation and interview on 02/10/2026 at 10:09 AM, Resident #5 was seated in their wheelchair in their room. The resident lifted their shirt for the surveyor, and they had a dual lumen right chest Permacath for dialysis, covered with a white dressing that was clean, dry, and intact. The lumens were also wrapped with a white dressing that was clean, dry and intact. The resident stated staff at the facility did not look at their access site and the dressing was changed at dialysis. During an interview on 02/10/2026 at 10:25 AM, Licensed Practical Nurse #19 stated when Resident #6 came back from dialysis they took their vital signs and documented them on the paper sheet. The resident had a right chest port, but they were not sure what it was called. They stated it was checked by the nurse every shift. They were not sure if this was documented anywhere. During an interview on 02/10/2026 at 10:59 AM, Registered Nurse Manager #12 stated there was a communication sheet for Resident #6 that was completed by the nurse before and after dialysis. If the communication sheet was not completed, there should be a nurse's note. The dialysis site was only checked on dialysis days. 10 New York Codes, Rules, and Regulations 415.12(k)

Based on observations, record review, and interviews during the recertification survey, the facility failed to consult with the physician when there was a significant change in the resident's physical status for one (1) of one (1) resident (Resident #6) reviewed. Specifically, Resident #6 returned from the emergency department on 01/30/2026 with a diagnosis of clostridioides difficile (a highly contagious bacteria causing diarrhea) and instructions to start vancomycin (an antibiotic) 125 milligram capsule every six (6) hours for ten (10) days and the physician was not notified. Subsequently, the antibiotic was not ordered until five days later on 02/04/2026. Findings include:The facility policy, Admission/ readmission Process of a New Resident, revised 01/23/2026, documented if a resident was admitted to the facility without discharge orders, nursing staff would contact the discharging facility. The nurse manager/ designee would discuss the resident's condition, status, and orders with the medical provider. The facility policy, Notification of Changes to Provider, effective 01/23/2026 documented that physician/ provider was notified of any changes in physical or mental status or any unusual occurrences of the residents by the charge nurse. Notification was documented in the progress notes of the residents' chart. Consult/ emergency department recommendations were reported to the physician/ nurse practitioner in a timely manner with documented evidence noted in the clinical electronic medical record by the licensed nurse. Resident #6 had diagnoses including kidney disease with dialysis (filtration of blood when kidneys do not function properly), diabetes, and colostomy (surgical opening from intestine that redirects stool into a collection bag). The 01/16/2026 Minimum Data Set assessment documented the resident had intact cognition, required set up/clean up assistance with toileting, and had an ostomy appliance. The Comprehensive Care Plan initiated 11/25/2025 documented the resident had a colostomy appliance. Interventions included emptying the drainage bag as needed, changing the appliance weekly with shower, emptying every shift and as needed, and gastroenterology consult as ordered. The 01/30/2026 hospital after visit summary documented diagnoses including clostridioides difficile diarrhea. Instructions included to start vancomycin 125 mg capsule every 6 hours for 10 days. The 01/30/2026 at 10:47 PM Licensed Practical Nurse #20 progress note documented the resident returned from the emergency department around 6:00 PM. No new orders were found with the resident. There was a new diagnosis of clostridioides difficile, and all precautions were in place.The 02/04/2026 physician orders documented vancomycin 125 mg capsule every 6 hours for 14 days for clostridioides difficile and contact/gastrointestinal precautions maintained. During an observation and interview on 02/02/2026 at 12:44 PM, there was a gastrointestinal precaution sign on the resident's door. The resident was lying in bed and stated they were on precautions and antibiotics for a diagnosis of clostridioides difficile. During an interview on 02/06/2026 at 2:20 PM, Certified Nurse Aide #15 stated Resident #6 was on precautions because they had clostridioides difficile.During an interview on 02/10/2026 at 10:09 AM, Resident #6 stated the emergency department told them they were going to start an antibiotic. The hospital did not provide discharge paperwork and said they would send the paperwork over to the facility. During a telephone interview on 02/10/2026 at 11:43 AM, Licensed Practical Nurse #20 stated they were assigned Resident #6 when they returned to the facility with a clostridioides difficile diagnosis. The resident did not return with paperwork, and they stated they should have called the emergency department, but they did not. They should have also called the provider on call and let them know, but they did not. The resident's spouse told them the resident had clostridioides difficile. Residents were usually on vancomycin for clostridioides difficile, but they were not sure if Resident #6 had an order for that antibiotic. Antibiotics should be given as soon as possible after an infection was identified.During an interview on 02/10/2026 at 10:59 AM, Registered Nurse Manager #12 stated if a resident returned without discharge paperwork, the nurse assigned was responsible to call the emergency department and request the paperwork. The nurse assigned to the resident was also responsible for notifying the provider. They stated in report the following Monday morning (02/02/2026) they were informed Resident #6 had clostridioides difficile. They did not look at the paperwork or see if the resident was ordered an antibiotic. During an interview on 02/10/2026 at 4:05 PM, Nurse Practitioner #5 stated when residents went to the hospital or returned to the hospital, it was discussed in morning report. They were not made aware of Resident #6's 1/30/2026 emergency department visit until 02/04/2026 and that is when they ordered the antibiotic for their diagnoses of clostridioides difficile. They were not on call when the resident returned to the facility. They were upset that this was missed. They were one person and relied a lot on the nurses. 10 New York Codes, Rules, and Regulations 415.3(2)(ii)(a)

44838 Based on observation, record review, and interview during the recertification survey conducted 3/11/2024 - 3/15/2024, the facility did not ensure food was stored in accordance with professional standards for food service safety in the main kitchen. Specifically, walk-in freezer #3 within the main kitchen had ice dripping from the compressor onto food that was stored below. Findings include: The facility policy Food Safety Operations and Infection Control revised 8/20/2023 documented all walk-in refrigerators and freezers have temperature dials and thermometers inside. The temperature of the thermometers and condition of the food is monitored daily. The following observations were made: - on 3/11/2024 at 9:58 AM, walk-in freezer #3 had ice dripping from the compressor onto cases of food product stored below. - on 3/12/2024 at 12:14 PM, walk-in freezer #3 had ice dripping from the compressor onto a case of bread, a gallon jug of chocolate milk, and a sheet pan of cake partially covered with plastic wrap. The ice was in contact with the cake. During an interview on 3/12/2024 at 3:22 PM, the Food Service Director stated the coolers were cleaned weekly. They stated the source of the ice was a leak from the compressor condensation. The Executive Chef periodically used a golf club to knock down the ice which had been an issue for at least a year. They believed maintenance had been informed of the problem via a work order. The Food Service Director stated it was important for food to be stored unadulterated to protect the residents from the possibility of unsafe food. The ice that dripped from the compressor onto the food below was unacceptable. During an interview on 3/15/2024 at 10:00 AM, the Executive Chef stated the freezer was cleaned and deiced monthly by the kitchen cleaner. They checked it themself at least every other week and had not removed ice from the compressor. [NAME] freezer #3 has been looked at by maintenance and an outside contractor. The seals were worn and could not be fixed. They were aware of the condensation on the walls forming ice and falling on food boxes below. It was not appropriate for ice to be on the food. They tried to keep all stored items away from the back of the cooler where they saw the ice. During an interview on 3/15/2024 at 11:06 AM, Facilities Supervisor stated that work orders were to be entered into the electronic system. The work was then assigned to maintenance for completion. If there was an emergency, maintenance should be called. Walk-in freezer #3 had preventive maintenance performed every 3 months and staff should notify the maintenance department if there was ice buildup in the freezer. They had not been notified that ice buildup was present in walk-in freezer #3. If ice was falling onto food products or the freezer floor, that would not be safe. They had an app on their phone that notified them of any freezer temperatures out of range and they had not received any such notifications. The Preventative Maintenance Work Orders documented walk-in freezer #3 had the evaporator cleaned, condenser cleaned, and the door gasket checked on 12/14/2023, 2/4/2023, 11/21/2022, and 3/21/2022. On 12/14/2023 and 11/21/2022 the Facilities Supervisor documented under comments, Preventative maintenance completed to manufacturer's specification. Additional documentation had an entry on 3/9/2022, Old Walk in Freezer #3, and on 8/17/2023, Freezer 3 door not closing tight. There was no documented evidence the dripping ice was addressed. 10NYCRR 415.14(h)

Based on observation, interview, and record review during the recertification survey conducted 3/11/2024-3/15/2024, the facility did not ensure drugs and biologicals were labelled and stored in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions when applicable for 1 of 3 medication carts (3rd floor Team1 cart) reviewed. Specifically, the 3rd floor Team 1 medication cart contained 1 insulin pen and 1 insulin vial without an opened date, and 1 insulin pen that was expired. Findings include: The facility policy Medication Storage in the Facility dated May 2018 documented medications and biologicals were stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. When the original seal of a manufacturer's container or vial was initially broken, the container or vial was dated. The nurse placed a date opened sticker on the medication and entered the new date of expiration. The expiration date of the vial or container was 30 days unless the manufacturer recommended another date or regulations/guidelines required different dating. The facility policy, Residential Care Facility FlexPen revised 3/1/2019 documented FlexPens (prefilled insulin pens) were stored in the refrigerator until needed. Once a FlexPen was opened, it was labeled with the resident's name and date. The FlexPen no longer required refrigeration and was stored in the medication cart. The manufacturer's recommendations for expiration date were used. Manufacturer's instructions for lispro insulin (rapid acting insulin) documented once opened insulin lispro vials, prefilled pens, and cartridges were to be thrown away after 28 days. During an observation of the 3rd floor Team 1 medication cart with licensed practical nurse #1 on 3/13/2024 at 12:00 PM there was an insulin lispro pen with no opened date, an insulin lispro pen with an opened date of 2/10/2024, and an opened vial of insulin lispro with no documented opened date on the vial or box. Licensed practical nurse #1 stated all 3 insulins were currently being used for residents on the unit. The nurse stated when insulin was opened, it should be dated as a safety precaution. They could not tell when 2 of the insulins were opened because there was no date on the pen or vial. They stated they could tell the undated pen was not expired by the amount of insulin in the pen because the pens were usually used up quite quickly. Expired medications should not be used, they may not be as effective and blood sugar could stay too high. When giving insulin, they should always check expiration dates. They stated the insulin lispro pen with pen date opened of 2/10/2024, may be expired. They were not sure how long it was good for after opening. The nurse that opened the insulin was responsible for dating it so the expiration date could be determined. During an interview on 3/13/2024 at 12:45 PM, registered nurse Unit Manager #2 stated expired medication's potency may decrease or increase and could change the desired effect of the medication. The nurses should be checking expiration dates daily when administering medications. Pharmacy technicians came periodically to check the medication carts. The Unit Manager stated they did spot checks periodically and was not sure when they last checked the Team 1 medication cart. Insulin expired 28 days from opening and the nurse that opened the insulin should have dated it when opened. The nurse administering the insulin should check to make sure it was dated and not expired. They stated insulin may not be as effective if expired. During an interview on 3/15/2024 at 9:35 AM, the Director of Nursing stated nurses were responsible for making sure medications in the cart were not expired. During administration they should check for proper labeling and expiration dates. Expired meds may not have the expected potency and may not have the desired effect. Insulin was stored in the refrigerator until opened and should be dated when opened because insulin was only good for a specific number of days after opening. Insulin should always be checked when administered for an opened date to ensure it was not expired. 10 NYCRR 415.18(d)

Based on observation, record review, and interview during the recertification and abbreviated (NY00294915) surveys conducted 3/11/2024-3/15/2024, the facility did not ensure residents were free of any significant medication errors for 1 of 5 residents (Resident #34) reviewed. Specifically, Resident #34's prepared medications were left in a cup unattended on their bedside table for over 2 hours and licensed practical nurse #1 documented the medications were administered at 8:00 AM when they were not. Additionally, licensed practical nurse #1 crushed extended release medications (potassium chloride extended release and pantoprazole delayed release). Findings include: The facility policy Medication Administration revised 12/1/2020 documented the nurse should stay with the resident until the medication was swallowed and should not leave medications at the bedside. All medications were signed for at the time of administration after the resident had taken the medications. Medications could be administered an hour before or an hour after the scheduled administration time. A facility Pharmacist's Letter titled Meds that Should Not be Crushed updated February 2023 documented crushing extended-release medications could result in administration of a large dose all at once. Crushing delayed release medications could alter the mechanism designed to protect the drug from gastric (stomach) acids or prevent gastric mucosal (lining of the stomach) irritation. Pantoprazole delayed release and potassium chloride extended-release medications were included in the list of common medications that should not be crushed. The facility policy Medication Administration Standardization Schedule and Terminology revised 2/5/2024 documented all residents received their medications in a manner that optimized therapeutic effect. The standardized time schedule met the resident's needs in accordance with accepted medical and pharmaceutical practice. Medications ordered daily were given at either 8:00 AM or 9:00 AM and medications ordered twice daily were given at either 8:00 AM and 4:00 PM or 9:00 AM and 5:00 PM. Resident #34 was admitted to the facility with diagnoses including hypertension (high blood pressure), hypokalemia (low blood potassium), and gastro-esophageal reflux disease (stomach acid flows up). The Minimum Data Set assessment dated [DATE] documented the resident had moderate cognitive impairment, was independent with eating, and did not reject care. The comprehensive care plan initiated 4/27/2023 and revised 3/8/2024 documented the resident had coronary artery disease (blockage of heart arteries), hypertension, congestive heart failure (the heart does not pump efficiently), and gastro-esophageal reflux disease. Interventions included administer medications as ordered. The 4/28/2023 physician orders documented the resident was to receive the following oral medications: - amlodipine besylate (treats high blood pressure) 10 milligram oral tablet, one tablet by mouth one time a day for hypertension; - aspirin 81 milligram chewable tablet, one tablet by mouth one time a day for coronary artery disease; - clopidogrel bisulfate (blood thinner) 75 milligram tablet, one tablet by mouth one time a day for coronary artery disease; - furosemide (diuretic) 20 milligram tablet, one tablet by mouth one time a day for edema (swelling). - lisinopril (treats high blood pressure) 20 milligram tablet, one tablet by mouth one time a day for hypertension; - potassium chloride (mineral) extended release 10 milliequivalent tablet, one tablet by mouth one time a day for hypokalemia (included on do not crush list); - pantoprazole sodium (acid reducer) delayed release 40 milligram tablet, one tablet by mouth before meals two times a day for gastro-esophageal reflux disease (included on do not crush list). There was no documented evidence of a physician order to self-administer medications or an evaluation for self-administration of medication. During an observation and interview on 3/11/2024 at 10:25 AM, Resident #34 was lying in their bed. There was a plastic medication cup on their bedside table that contained a spoon and applesauce with colorful flecks. There was no staff present in the room. The resident stated the plastic medication cup contained their morning medications for that day. The Medication Administration Record documented the following medications were administered by licensed practical nurse #1 on 3/11/2024 during the scheduled 8:00 AM medication pass. - amlodipine besylate 10 milligram oral tablet, one tablet by mouth one time a day - aspirin 81 milligram chewable tablet, one tablet by mouth one time a day - clopidogrel bisulfate 75 milligram tablet, one tablet by mouth one time a day - furosemide 20 milligram tablet, one tablet by mouth one time a day - lisinopril 20 milligram tablet, one tablet by mouth one time a day - potassium chloride extended release 10 milliequivalent tablet, one tablet by mouth one time a day - pantoprazole sodium delayed release 40 milligram tablet, one tablet by mouth before meals. During an interview on 3/11/2024 at 11:59 AM Resident #63 stated the nurses frequently left medications on their bedside table and did not watch them take their medications. They stated the nurses knew they would take their medications. The resident stated they were concerned because someone else could take a medication from their cup. They stated licensed practical nurse #1 left a syringe on their bedside table that morning because they were not ready for their injection at that time, and they did not think that was safe. During an interview on 3/14/2024 at 2:07 PM, licensed practical nurse #1 stated they administered medications scheduled for 8:00 AM to Resident #34 on 3/11/2024. They had an hour before and an hour after the scheduled time to administer the medication. They stated they crushed the resident's medications on 3/11/2024 and put them in applesauce and it was sometimes time consuming to watch the resident take their medications. If they did not watch the resident take their medications, then they had no way of knowing they took them. There were certain medications that should not be crushed such as extended-release medications. If they were uncertain there was a document in the medication room that referenced medications that could not be crushed. If a medication was documented as administered on the medication administration record it meant they witnessed the medication taken. It was not appropriate to leave medications at the bedside because there were residents that wandered who could take medications that were not intended for them. It was not appropriate for medications to be documented as given if the medication cup was left untouched at the bedside. Syringes should not be left on bedside tables because there could be an accidental needle stick and it was also an infection control issue. During an interview on 3/14/2024 at 2:33 PM registered nurse Unit Manager #2 stated Resident #34 sometimes took medications whole one at a time and sometimes crushed. They stated some medications could not be crushed such as extended-release medications. They expected nurses to watch residents take their medications to ensure they were taken without difficulty. If it was documented as given in the medication administration record, it meant the nurse watched the resident swallow the medication. Nurses had an hour before and after scheduled administration time to give the medications. If a resident did not take the medications, they expected it to be documented as refused. It was not appropriate to leave medications at the bedside for safety reasons because anyone could take the medications. It was important residents took medications because they were ordered to address medical conditions and there could be a negative effect if they did not take them. It was also not appropriate to leave syringes on bedside tables because residents or staff could get injured. They stated they sometimes did the medication pass and many residents had told them that other nurses left medications in their room and did not watch them take them. During an interview on 3/14/2024 at 2:54 PM the Director of Nursing stated there were medications that could not be crushed, and that information was posted in the medication room. Residents needed to be watched when given their medications to ensure they were taken. It was acceptable to give medications up to an hour before and after the scheduled administration time. If a medication was documented as given, they expected the nurse had witnessed ingestion of the medications. If a nurse did not watch the resident take the medications, they could not be certain they were taken. If a resident refused a medication, it should be documented as a refusal. It was not appropriate for medications to be left unattended at the bedside because there were residents that wandered who could take the medications. It would only be appropriate for medications to be left at bedside if there was an order and an assessment that determined a resident could safely self-administer medications. Resident #34 was not cognitively appropriate to self-administer medications and medications should not be left at their bedside. If the registered nurse Unit Manager #2 was aware that nurses were leaving medications at the bedside, they expected them to educate the nurses and write it up as a medication error. 10NYCRR 415.11(c)(3)(i)

Based on observation, record review, and interview during the recertification survey conducted 3/11/2024-3/15/2024, the facility did not ensure nursing staff had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 1 resident (Resident #45) reviewed. Specifically, Resident #45 used an external catheter device (a soft flexible wick that draws urine away from the body into a sealed canister using suction) to manage urinary incontinence and there was no documented evidence nursing possessed the competencies and skill sets to manage the device. Additionally, there was no medical order for use of the device. Findings include: The facility policy Compliance Training and Education revised 1/25/2023 documented employees were to be provided with ongoing training and education to mitigate noncompliance. Training/education were completed upon hire, annually, and as needed. The facility policy External urine collection device use, assigned female at birth revised 12/11/2023 documented external urine collection devices serve as an alternative to indwelling urinary catheters. The device reduces the risk of urinary tract infection, prevents incontinence associated dermatitis (irritated skin due to urine or feces), and promotes comfort. After securing the device properly, turn on the continuous suction to at least 40 millimeter of mercury, assess the patient's skin, empty the urine collection canister as needed, and replace the device every 8 to 12 hours or whenever it becomes soiled. Documentation associated with the device included: date and time of application/replacement, assessment findings, tolerance to the procedure, provider notification (if applicable), and teaching provided to the patient/family as needed. Resident #45 had diagnoses including acute kidney failure and difficulty walking. The 1/25/2023 Minimum Data Set assessment documented the resident was cognitively intact, was frequently incontinent of urine, had an external catheter, moisture associated skin damage, and was dependent on staff for toileting, personal hygiene, and bed mobility. The comprehensive care plan initiated 3/7/2024 documented the resident had alteration in skin integrity related to incontinence associated dermatitis (skin inflammation). Interventions included assessment and documentation of skin integrity upon admission and per policy, thorough skin care after episodes of incontinence with barrier cream application, and treatment for any areas of breakdown upon admission. The care plan did not include use of an external urinary catheter device. The resident Kardex (care instructions) with a print date of 3/15/2024 documented the resident was frequently incontinent and had an external catheter. The 3/14/2024 order summary report did not include a medical order for an external catheter. Nursing progress notes dated 2/22/2024-3/9/2024 did not include the use of an external catheter. There was no documented evidence the March 2024 treatment administration record included external catheter care and maintenance from 3/1/2024-3/14/2024. During an observation and interview on 3/13/2024 at 10:40 AM, Resident #45 was lying in bed. There was a urine collection canister on the wall, half full of clear yellow urine. Resident #45 stated they had been using an external urinary catheter device for a few months due to increased skin breakdown from incontinence. They stated it was usually changed daily by a nurse or a certified nurse aide, and some of the nurses had never worked with one before so they would need to find assistance and have someone else change it. They stated they could feel when the catheter fell off and they would have to remind staff it needed to be changed. During an interview on 3/14/2023 at 1:54 PM, certified nurse aide #7 stated they looked at the resident's care plan (Kardex) to know how to care for them. It included if they had a catheter, and what kind of assistance they needed. Resident #45 used an external urinary catheter device, but they were not sure if it was on the care plan. They thought the nurse was responsible for changing the external urinary catheter device and thought it should be changed daily. It was usually changed every shift when it became soiled. They stated they were notified by one of the nurses when resident #45 started to use the external urinary catheter device. The nurse showed them how to change it, and they did not recall if they received formal education on the device. Resident #45 notified them if it fell off and they notified the nurse. They stated it was important to know how to change the external urinary catheter device because if it was not changed properly the resident could get an infection or their skin could get worse and breakdown. During an interview on 3/14/2024 at 2:20 PM, licensed practical nurse #9 stated Resident #45 had an external urinary catheter device. They were not sure who was responsible for changing the external urinary catheter device and they had not taken care of Resident #45 since they started to use it. They stated they received education from the Nurse Manager, but they were not sure how often it had to be changed. They stated it was important to know how often it needed changed so it did not put Resident #45 at risk for infection or more skin breakdown. During an interview on 3/14/2024 at 2:31 PM, registered nurse Unit Manager #8 stated each resident had their care instructions in their room and the care instructions were generated from the care plan. The resident used an external urinary catheter device that needed to be changed every 12 hours and as needed. The nurses were responsible for changing the device. Resident #45 let the nurses know when it needed to be changed and staff knew to change it when providing care if it was soiled. They were not sure if staff needed to document in the electronic medical record when it was changed, and they did not think instructions for changing the external urinary catheter device were on the treatment administration record. They stated all the nurses on the unit watched an educational video on how to manage the external urinary catheter device, and they signed their names after receiving the education. They stated if it was not changed, or staff did not know the resident had an external urinary catheter device Resident #45 would be at increased risk for infection or skin breakdown. There was no documented evidence staff received education on the use and care of an external wick catheter device. During an interview on 3/14/2024 at 3:17 PM, Director of Nursing/interim Administrator #3 stated nursing staff looked at the resident's care instructions to know how to care for them and the care instructions were generated from the care plan. The external urinary catheter device should be listed on Resident #45's care plan, so staff knew they had one and how to care for it. They stated the certified nurse aide, or the nurse could change the external urinary catheter device, but they were not sure how often it had to be changed. Registered nurse Unit Manager #8 had instructions for use and provided education to the staff on the unit. They thought nursing staff should have been documenting when the external urinary catheter device was changed, and it was important to change it as needed to prevent infections and skin breakdown. During an interview on 3/15/2024 at 8:37 AM, interim Director of Nursing #12 stated registered nurse Unit Manager #8 had nursing staff watch a video on managing the external urinary catheter device but did not have an attendance record of who received the education. 10 NYCRR 415.26(c)(1)(iv)

Based on observation and interview during the recertification survey conducted 3/11/2024-3/15/2024, the facility did not ensure the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction were posted in a place readily accessible to residents, family members, and legal representatives. Specifically, the survey results and plan of correction were in a pink binder on a shelf behind the nursing station on Cedar Run (second floor) and in a black binder on a shelf in the dining room on Misty Glen (third floor). Additionally, there were no notices of the availability of such reports posted in areas that were prominent and accessible to the public. Findings include: The facility policy Resident Rights revised 2/2024 documented the facility allowed residents to examine the results of the most recent survey of the facility conducted by Federal or State surveyors including any statements of deficiencies, any plan of correction in effect with respect to the facility and any enforcement actions taken by the Department of Health. The results would be made available for examination. They would be in a place readily accessible to residents and designated representatives without staff assistance. A copy of the most recent survey reports (statement of deficiencies) is available for inspection in the Cedar Run (second floor) dining room. Inquiries concerning the examination of survey results would be referred to the Administrator and/or the Director of Nursing. During an anonymous resident group meeting on 3/12/2024 at 10:03 AM, two residents stated they did not know where the previous survey results were posted. During an observation on 3/12/2024 at 10:37 AM, the Department of Health survey results were not located on Cedar Run (second floor), Misty Glen (third floor), or the main lobby. During an observation on 3/13/2024 at 11:51 AM, the Department of Health survey results were not located on Cedar Run (second floor), Misty Glen (third floor), or the main lobby. During an observation on 3/14/2024 at 11:51 AM, the Department of Health survey results were not located on Cedar Run (second floor), Misty Glen (third floor), or the main lobby. During an observation and interview on 3/14/2024 at 11:37 AM Staffing Coordinator #11 was seated at their desk located at the main entrance. They stated part of their duties included allowing visitors into the facility. They had never observed the Department of Health survey results in the main lobby area. During an interview on 3/14/2024 at 11:42 AM unit clerk #10 stated the Department of Health survey results were in a pink binder on a shelf bind the Cedar Run nursing station. They stated the Department of Health survey results had been there for a while and they were unsure who placed them there. Only staff was able to go behind the desk, and non-employees would have to ask for staff assistance to view the survey results. During an interview on 3/14/2024 at 2:51 PM registered nurse Unit Manager #2 stated the Department of Health survey results were kept in a binder on a shelf in the dining room next to the audio equipment. They stated there was no signage to alert residents or visitors of the location of the survey results and they were unsure how they would know where the survey results were located without asking for staff assistance. During an interview on 3/14/2024 at 3:05 PM the Director of Nursing/ Acting Administrator stated a copy of the Department of Health survey results were in a binder behind the nursing station on Cedar Run (second floor) and in the dining room on Misty Glen (third floor). There was no signage to alert residents and visitors of the location of the survey results and the survey results were not readily accessible to view without staff assistance. They were aware that Department of Health survey results needed to be in a place readily accessible to view without staff assistance, but they thought the previous Administrator had ensured the survey results were in visible locations. 10NYCRR 415.3(1)(c)(1)(v)

Based on record review and interview during the abbreviated surveys (NY00316770 and NY00322185), the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 of 2 residents reviewed (Residents #2 and #7). Specifically, Resident #2 had a left leg surgical wound from a below knee amputation (BKA) with 21 sutures in place and wound treatments were not completed as ordered. There was no documented evidence of ongoing monitoring of the wound and when the wound worsened, there was no documented evidence the medical provider was notified or that an assessment was completed. The resident's wound dehisced (re-opening of the incision) requiring hospitalization , debridement (surgical removal of dead tissue), and antibiotic treatment for the infection of the amputation. Resident #7 did not receive wound treatments as ordered and instead, staff applied a wound treatment, unapproved for use on humans, without a physician's order. Subsequently, Residents #2's surgical site dehisced and became infected and required debridement. This resulted in actual harm to Resident #2 and no actual harm with potential for more than minimal harm that was not Immediate Jeopardy to Resident #7. Findings include: The facility policy Wound and Skin Care, revised 5/28/2021 documented resident's skin was assessed on admission and at a minimum of every 7 days after. The facility policy Administration of Required Treatments, revised 5/19/2023, documented nursing staff would administer treatments as ordered by the physician/medical provider and document the treatments in the electronic medical record. Nursing staff were to communicate with the oncoming shift if there were circumstances that prevented the treatment from being done. Failure to complete treatments would be investigated as neglect with failure to provide care. 1) Resident #2 was admitted to the facility with diagnoses including peripheral vascular disease (PVD, impaired blood flow), diabetes, and a BKA of the left leg. The 5/7/2023 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance with most activities of daily living (ADL), had a surgical site that required wound care, and received application of a non-surgical dressings, ointments, and medications. The 5/1/2023 wound assessment by registered nurse (RN) Manager #5 documented the resident was admitted to the facility with a left lower leg surgical wound from a BKA with 21 sutures There was a brown scab along the suture line with light drainage from the lateral (side) portion of the incision. There was no odor. The wound edges were well approximated (closed together), and the current treatment was to cleanse the wound with normal saline (NS), dry, apply a petroleum dressing to the edges of the wound, cover with a sterile dressing, gauze wrap, and an elastic bandage daily. The medical provider was notified. The 5/1/2023 physician's orders documented to cleanse the wound with NS, dry, apply a petroleum dressing to the edges of the wound, cover with a sterile dressing, gauze wrap, and an elastic wrap daily. The 5/1/2023 comprehensive care plan (CCP) documented the resident had diagnoses including PVD and a left BKA. Interventions included to monitor the resident's extremities for signs and symptoms of injury, infection, ulcers, or edema. Staff were to monitor and document redness, blistering, itching, burning, bruises, cuts, or skin lesions. The 5/2023 Treatment Administration Record (TAR) documented the 5/1/2023 treatment ordered by the attending physician #8 (Medical Director) for the resident's left BKA surgical site. The TAR documented the treatment was completed as ordered on 5/1/2023 and 5/2/2023. On 5/3/2023 the treatment was not done and documented see the nursing note. There was no corresponding nursing note for the 5/3/2023 TAR entry. The 5/4/2023 at 9:47 AM, licensed practical nurse (LPN) #19's progress note documented the resident's wound was visualized yesterday and the left side of the incision had dehisced, and the incision site was wider on the right side. The dressing was intact on this day (5/4/2023) and LPN #19 did not remove the dressing to visualize the wound. There was no documentation the medical provider was notified of the change in the resident's wound or that an assessment was completed. The 5/7/2023 History and Physical by attending physician #8 (Medical Director) documented the resident was admitted for rehabilitation and was post-operative and required wound care and restorative therapy. There was no documented evidence the wound was evaluated by attending physician #8. LPN #11's progress note on 5/13/2023 at 10:28 PM, documented the resident's wound had a mild odor, moderate drainage, and there was slough (dead tissue) present. There was no documented evidence LPN #11 reported the change in the resident's wound to the attending physician or that an assessment was completed. The 5/16/2023 Failure to Follow Order report completed by RN Manager #5 documented the resident reported to LPN #11 that their surgical wound dressing was not changed on 5/15/2023 and the resident asked for it to be changed prior to their surgical follow-up appointment. The dressing in place at that time was dated 5/14/2023 and there was a lot of drainage when the dressing was removed. There was foul odor that was no longer present after cleaning the wound. The center of the wound was dehisced and there was a quarter size section of loose slough. The sutures remained in place, but the skin was pulled out of them. The treatment was completed per order and the resident was transported to the surgical appointment. A call was later received from the surgeon's office reporting the resident was being admitted to the hospital (The 5/2023 TAR documented RN #2 signed as completing the resident's treatment on 5/15/2023). Statements obtained by the facility documented: - LPN #10 documented on 5/16/2023, the resident requested they perform a dressing change to their surgical wound as it was not done the prior day. The dressing on the wound was dated 5/14/2023. The wound had a foul odor and was saturated. The wound was open and looked to be infected. LPN #10 had RN Manager #5 look at the wound at that time and a new dressing was applied. - LPN #11 documented in an email to RN Manager #5 dated 5/16/2023 that on 5/8/2023, LPN #11 did not work and when they returned on 5/9/2023, the resident reported their treatment was not completed on 5/8/2023. On 5/12/2023, LPN #11 did not work and on 5/13/2023, the resident reported the dressing change was not completed on 5/12/2023. LPN #11 looked at the wound that day and there was a notable change. The sutures were intact, there was moderate drainage, a mild odor, and slough was present (The 5/2023 TAR contained documentation that LPN #14 signed as completing the resident's treatment on 5/8/2023). There was no documented evidence LPN #11 reported the change in the resident's wound when noted on 5/13/2023 and no documented evidence they reported that the resident's dressing was not changed as ordered on 5/8/2023 and 5/12/2023. There was no documented evidence the DON was aware of or investigated the resident's report that the treatment was not done on 5/8/2023 or that the treatment as not signed as completed on the TAR on 5/3/2023. The 5/16/2023 hospital records documented the resident was admitted for surgical wound complications including wound dehiscence (opening of an incision) and cellulitis (skin infection). The resident required debridement (surgical removal of dead tissue) on 5/18/2023 and was treated with antibiotics for the infection. The resident remained in the hospital until 6/9/2023 when they were discharged to another facility. During an interview on 8/11/2023 at 9:34 AM, RN Manager #5 stated shortly after admission, LPN #3 missed a dressing change for the resident, they did not recall the date, and there was no negative outcome. They stated the day before the resident's surgical appointment, they looked at the wound and the wound did not look good. They called the surgeon and notified them. They stated the next day, the resident went to the follow-up appointment at the surgeon's office and was admitted to the hospital. During an interview on 8/17/2023 at 8:28 AM, LPN #3 stated they did not recall Resident #2 and stated the resident was at the facility a long time ago. During an interview on 8/17/2023 at 8:44 AM, RN #2 stated they remotely remembered Resident #2 and did not recall any specifics of the resident's care. During an interview on 8/22/2023 at 8:31 AM, LPN #11 stated they did not recall if they reported to anyone when the resident told them their dressing change was not done on 5/8/2023. LPN #11 stated they did the dressing change on 5/11/2023; they were off on 5/12/2023 and when they returned on 5/13/2023 they found the dressing dated 5/11/2023 still in place. LPN #3 had been assigned to do the dressing change on 5/12/2023. They reported the incident to the RN Manager #5 on 5/13/2023. They stated the resident's surgical site looked bad, and had signs of infection, and a foul odor. During an interview on 8/29/2023 at 10:43 AM, the DON stated weekly wound rounds were completed by RN Manager #5 and the Charge Nurse who were both RNs. The DON was not aware wound rounds were not completed from 5/1/2023 through 5/13/2023 for this resident and did not know why they were not done. The expectation was wound rounds were documented and included measurements and what the area looked like. If a nurse did not have time to do a treatment, they were to document and notify the next shift so the treatment could be completed. Resident #2 had a wound care assessment completed on admission on 5/1/2023, and there was no further documentation that wound rounds were done for the resident. On 5/16/2023, LPN #11 brought to their attention Resident #2 reported their treatments were not being done and they completed an investigation. They obtained a statement from LPN #11, were not aware of any missed treatments for 5/8/2023, did not investigate that and was just aware of the 2 instances involving RN #2 and LPN #3. The DON re-educated RN #2 the day after the incident and LPN #3 the following week. No competencies were completed with the nurses on treatments/dressing changes following these missed treatments. During an interview on 9/7/2023 at 9:23 AM, RN #5 stated themselves or RN #6 completed wound rounds weekly. They stated if a wound had an odor that could indicate some form of infection and not completing a wound dressing change could result in an infection and inability to identify if a wound had worsened. They were not aware wound rounds were not being done weekly by RN #6 on the resident and if there was a reason for the wound rounds not to be done, or if the wound worsened, they expected to have been notified and the issues to be documented. They did not recall if they were notified by LPN #11 when Resident #2's surgical site had an odor on 5/11/2023 and if they were notified, they would have called the medical provider, assessed, and documented. They recalled that RN #2 missed a dressing change, and they assessed the site at that time. They did not know the date but recalled it was the day the resident was scheduled to see the surgeon. During an interview with RN #6 on 9/7/2023 at 1:17 PM, they stated they completed weekly wound rounds on residents with stasis or pressure ulcers and when they were not at the facility, wound rounds were completed by RN #5. RN #6 stated they were not doing wound rounds on any residents with surgical wounds so they did not see Resident #2. During an interview on 9/7/2023 at 9:32 AM, LPN #19 stated they completed treatments during the day shift and Resident #2's treatment was assigned to the evening shift so they did not observe the surgical wound. They documented on a treatment form during their shift they did not observe the area. They did recall at one-point Resident #2 requested their dressing be changed before they went out on an appointment and did not recall the date. They removed the dressing and noted the incision site had widened. There was no odor and the site looked good. They notified RN Manager #5 who assessed the wound and stated the area looked the same as when the resident was admitted . They did not notify the medical provider (attending physician #8) as RN Manager #5 stated the incision site looked the same. During an interview on 9/7/2023 at 9:46 PM, RN #14 stated they were the Supervisor and assisted with treatments when needed on the evening shift. Resident #2 was alert and oriented and had a surgical site after a BKA with a treatment. When providing a treatment, they documented the treatment as completed in the medical record and documented any abnormalities. If there were abnormalities, the medical provider would be notified. They did not recall if they completed the treatment on 5/8/2023 and if they did, it would be signed off as done. They did not see any decline in Resident #2's wound, it always looked the same, and they discussed that with RN Manager #5. They were not aware the resident reported their treatment was not completed on 5/8/2023 and was never asked any questions about that. During a telephone interview on 9/8/2023 at 9:16 AM, attending physician #8 (Medical Director) stated they did not recall if they were notified when the resident's surgical site had widened or had an odor. The surgeon or themselves should have been notified. They were not aware dressing changes were not completed by 2 nurses and could not comment if the infection could have been prevented if the dressing changes were completed or if the odor was identified and addressed when found. 2) Resident #7 had diagnosis including depression, anxiety, and a urinary tract infection (UTI). The 6/1/2023 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required supervision with most activities of daily living (ADLs), was at risk to develop pressure ulcers, had three Stage 2 (partial thickness loss of skin layers) pressure ulcers and one Stage 3 (full thickness loss of skin layers) pressure ulcer, and treatments included nutrition/hydration, pressure ulcer care, and applications of non-surgical dressings. The comprehensive care plan (CCP), initiated 6/2022, documented the resident had an ADL deficit and used a trapeze (device used by resident for positioning in bed) to assist with turning and repositioning. The resident was non-ambulatory and skin impairments including open wounds on the left back of the leg. The discharge plan was to return home after the wounds were resolved. Interventions included assess wound healing weekly, measure width and depth where possible, and document the status of the wound perimeter, wound bed, and healing progress. The improvement and decline were to be reported to the medical provider. The wound care team was to be consulted as needed. Staff were to provide standard skin care with lotions, creams, and prescribed medications as ordered. The 8/8/2023 attending physician #8's (Medical Director) comprehensive review documented the resident was alert and in good spirits. There were no changes in functional status or diagnoses. There was no documented assessment of the resident's wounds. The 8/2023 Treatment Administration Record (TAR) documented an order initiated on 6/24/2023, to the posterior left leg: wash with soap and water and use a sterile pad to pat dry. Apply petroleum dressing to open wounds and cover the calf with petroleum jelly ointment. Cover with a dry dressing and gauze daily. There was no documentation the treatment was completed as ordered on 8/1/2023, 8/2/2023, and 8/6/2023. The 8/9/2023 Skin and Wound Evaluation by RN #12 documented the resident had a pressure ulcer that was a Stage 2 on the left medial (middle) calf. There was 100% granulation tissue (new tissue), and redness at the site. The dressing was saturated and leaking and the wound was cleaned with soap and water. There were no measurements documented. The photographs taken by the facility on the same date were reviewed and showed the resident's whole calf was bright red in appearance. The 8/2023 TAR did not include documentation the treatment to the back of the resident's left lower leg was completed on 8/15/2023. The undated investigation completed by the Director of Nursing (DON) documented an unidentified person (identified by the surveyor as licensed practical nurse (LPN) #13) reported to the DON that the resident had open leg wounds and was being provided a treatment that was not ordered by a physician. The DON noted the resident had chronic wounds to their leg, buttocks, and back. The DON interviewed the resident. The Provision of Care Report dated 8/15/2023 by the DON documented a failure to follow orders for treatment to the resident's wounds as nurses provided a treatment that was not ordered. The report documented the resident was interviewed and they reported LPN #4 and registered nurse (RN) #12 discussed an alternate treatment for their leg wounds, asked the resident to purchase the treatment, and then applied it 4-5 times. The resident stated one of the nurses told them they saw it worked very well on a horse's wounds. The DON noted nurse practitioner (NP) #1 assessed the resident on 8/15/2023 and the wound appeared to have worsened from the last assessment on 8/5/2023 as there were more open areas and the wound was bleeding. The cream was found in the resident's room that day and removed. The DON researched the product and found the product (horse salve) was not approved for use on humans. The DON sent the information to the consulting pharmacist who also advised they should not use this product on the resident. A review of the TAR from the week before showed RN #12 signed as completing the resident's ordered treatment 4 times during the last week (The TAR contained no documentation that horse salve was ordered for the resident or administered). Interviews obtained by the facility documented: - The undated summary of an interview with LPN #4 documented they were interviewed by the DON, Administrator, and Human Relations. LPN #4 reported they knew of the treatment as it was used on their family's horses, and they wondered if it would help the resident. They mentioned the treatment to RN #12, discussed it with the resident who ordered horse salve, and it was used 4 or 5 times and kept in the resident's drawer. LPN #4 did not know if there was a medical order for the salve and they thought the medical provider was aware. LPN #4 explained on the first application of the treatment they assisted with applying it and did not sign anywhere for completing this treatment. - The untimed, undated summary of the interview with RN #12 written by the DON documented they heard of the horse salve treatment from LPN #4 and researched it online. They discussed it with the resident and mentioned it to the medical provider (NP #1) and then the resident purchased it. They applied it on 8/9/2023 and did not obtain an order. - Nurse practitioner (NP) #1's statement dated 8/21/2023 documented they were asked by RN #12 if they could research other treatment options for the resident. They were not approached again by RN #12 with any further information or for new orders for the resident. The 8/15/2023 NP #1's progress note at 12:46 PM, documented the skin on the resident's left lower leg was assessed. The back of the resident's leg had excoriation (raw, irritated skin) and several small open areas. The skin condition was compared with photos taken prior and there was deterioration. The treatment was to be changed that day to an antimicrobial treatment. The photographs taken by the facility at the same time were reviewed by the surveyor and the wound was observed to be consistent with NP #1's description. There was redness on the calf and areas that appeared raw and peeling. Measurements taken by the facility and documented with the photographs were 17.58 centimeters (cm); length was 11.29 cm and width was 2.66 cm. During an interview on 8/24/2023 at 8:55 AM, LPN #4 stated they were supposed to have an order for a treatment prior to applying it. The resident had wounds on their mid back, buttocks, and the left upper thigh and the left leg. They stated there was a treatment in place prior to the horse salve being used but they did not recall what it was. LPN #4 stated they had been taking care of a horse and used this product on the horse's leg and it worked well so they began talking about it with RN #12 who asked if it could be used on humans. RN #12 researched it and the resident got the product. They thought RN #12 discussed it with NP #1. LPN #4 first applied the horse salve on 8/7/2023 or 8/8/2023 at the direction of RN #12. RN #12 reapplied the horse salve the next day and there were no complaints of pain. They stated they did not think they applied the salve on 8/9/2023 but did not recall RN #5 was aware they were using this treatment. LPN #4 never looked for a treatment order as they were assisting RN #12 and RN #12 was the person signing for the resident's treatments. During an interview on 8/24/2023 at 9:46 AM, RN #12 stated when a new treatment was requested, they asked the medical provider for an order and then initiated the treatment. The resident was alert and oriented and had wounds on the back of the left calf with multiple open areas. The left calf had multiple open, superficial wounds with redness surrounding the entire area. The area's appearance varied from day to day and there might have been some bleeding at times when removing the dressing. They did not know if there was bleeding at the site on 8/8/2023. A couple of weeks prior, there was no bleeding. RN #12 worked with LPN #4 who used the horse salve with huge results on a horse. RN #12 and LPN #4 talked to the resident about it and decided it might work. RN #12 looked up the ingredients of the salve. The resident obtained the salve on 8/8/2023 and LPN #4 applied it. RN #12 mentioned the salve to NP #1, did not know when they did this, and NP #1 was not aware they trialed the salve. RN #12 applied the salve on 8/9/2023, only to the open areas, completed the treatment and signed for it. LPN #4 applied the salve on 8/8/2023 and RN #12 applied it on 8/9/2023. On 8/9/2023, the area appeared to have more granulation (healthy) tissue, no bleeding, and the resident had no pain. RN #12 did not measure the area at that time. On 8/10/2023, they observed more redness in the wound and there was still granulation tissue. They took photos of the wound and did the weekly wound check. they stated the areas were not deeper, and they were not sure if they were bigger as they did not compare them to previous measurements. RN #2 stated after that weekly wound check on 8/10/2023, they did not continue to apply the salve as they did not see an improvement in the wound. They stated they did not tell anyone there was a change in the wound. RN #2 stated if they had seen progress in the wound, they would have obtained a medical order for the horse salve. During an interview on 8/24/2023 at 10:44 AM, NP #1 stated approximately 2 weeks ago they were approached by RN #12 wanting to research different creams for Resident #7's left calf wound. They stated RN #12 never reapproached them after that and they were notified by the DON the horse salve was applied to the resident on 8/14/2023. NP #1 assessed the resident on 8/15/23 and compared the wound to the previous photos. The wound had bleeding, had deteriorated, and the area was larger. NP #1 stated when they and the DON saw the resident the resident had complained of stinging and burning to the wound. NP #1 stated they would not expect RN #12 to implement a treatment without an order. During an interview on 8/28/2023 at 10:43 AM, the DON stated on 8/14/2023, they were alerted by LPN #13 the resident had been talking about the horse salve and the DON spoke to the resident immediately after being informed. The resident verified the horse salve had been applied 3-4 times by LPN #4 and RN #12. The DON did not ask any other staff if they were aware of the horse salve being used. The DON had photos of the leg wound before and after the horse salve was used and the leg wound had deteriorated. The DON and NP #1 saw the resident on 8/15/2023 and measured the wounds. There were 2 sets of measurements documented on 8/15/2023 for the same wound because within a few hours of the DON and NP #1 assessing the resident, the RN Manager #5 assessed the resident. RN Manager #5 measured the wounds separately and the DON and NP #1 measured the whole wound area. The DON stated the wound size was larger, not deeper the resident had complaints of pain and stinging when the dressing was completed. Once the dressing was removed, the pain and stinging stopped. During an interview on 8/30/2023 at 9:19 AM, LPN #13 stated they last did a dressing change for the resident a long time ago. In 8/2023, either on a Saturday or Sunday, they were not sure of the date, certified nurse aide (CNA) #15 told them the nurses were applying a horse salve to the resident's legs. LPN #13 talked to the resident who informed them LPN #4 and RN #12 were trying a new salve on their legs and the resident thought the wound was getting worse. LPN #13 left the facility that night without telling anyone. The following night, LPN #13 told RN #16 who texted the DON and let the DON know. During a telephone interview on 8/30/23 at 11:58 AM, RN #16 stated they were approached by LPN #13 over the weekend of 8/13/2023 and LPN #13 reported they were told by CNA #15 that Resident #7 was getting a horse salve on their leg wound. CNA #15 asked the resident how many nurses knew about this but LPN #13 told RN #16 they were not sure if that was correct or just a rumor. RN #16 stated they sent an email to RN Manager #18 and the DON that night explaining what was going on. They did not talk to the resident and did not look at the area. During a telephone interview on 9/8/2023 at 9:16 AM, attending physician #8 (Medical Director) stated they did recall the incident regarding Resident #7 and would never have approved a horse salve being used. They would expect proper assessment, proper wound care, and this treatment was done without their consent. They did not recall what the wound looked like when they saw the resident after the salve was applied and stated the resident did not have pain. 10 NYCRR 415.12

Based on record review and interview during the abbreviated survey (NY00320465) the facility failed to ensure a resident's total program of care, including medications and treatments, was reviewed by the medical provider for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1 had a history of seizures and was admitted to the facility with hospital discharge orders for seizure medications. The medications were not included on the facility admission orders and the resident did not receive anti-seizure medications for 6 days. The resident subsequently had a seizure requiring hospitalization . This resulted in actual harm to Resident #1. Findings include: The facility policy Admission Process for New Residents dated 10/1/2020 documented the facility would complete a thorough nursing interview and assessment for all residents newly admitted . The interdisciplinary team (IDT) would obtain an accurate medical history of the resident and gather the necessary data to formulate a plan of care. The Nurse Manager/Charge Nurse would ensure the physician's orders were obtained and verified, appropriately documented, and implemented. Resident #1 had diagnoses including epilepsy (seizure disorder). The 7/19/2023 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment and required limited assistance with most activities of daily living (ADL). The 7/13/2023 registered nurse (RN) #6's progress note at 12:52 PM, documented the resident was admitted for short-term rehabilitation. The 7/13/2023 hospital medication list documented the resident received the following medications in the hospital and was to continue taking them: lacosamide (anti-seizure medication), 150 milligrams (mg) one tablet, twice daily (BID), and lamotrigine (anti-seizure medication), 25 mg two tablets BID for seizures. The 7/13/2023 admission orders signed by nurse practitioner (NP) #1 and RN Manager #5 did not document orders for lacosamide or lamotrigine. The 7/13/2023 comprehensive care plan (CCP) documented the resident had a seizure disorder and staff were to monitor and document the resident's seizure activity. The 7/2023 Medication Administration Record (MAR) did not document orders for lacosamide, 150 mg one tablet, twice daily (BID), or lamotrigine, 25 mg two tablets BID. The 7/19/2023 at 11:17 AM, progress note by RN #6 documented the RN was called to the resident's room. The resident was in the recliner with full body tremors and saliva coming from the mouth. The resident's skin and face were blue for approximately 30 seconds and the resident had a pulse. A code blue was called, and the code team took over the resident's care. The resident was transported via stretcher to the emergency department (ED). NP #1 was made aware, and the resident's family was notified. The 7/19/2023 investigation completed by the Director of Nursing (DON) documented Resident #1 was admitted to the facility for short-term rehabilitation on 7/13/2023 and had a diagnosis of a seizure disorder. On 7/19/2023, Resident #1 had seizure activity, was transferred to the hospital, admitted with seizures, and required anti-seizure medication. The resident had not taken their anti-seizure medication since admission to the skilled nursing facility on 7/13/2023. The DON documented there was a discrepancy in the medication orders. The orders for lacosamide 150 milligrams (mg) one tablet, twice daily (BID), and lamotrigine 25 mg two tablets BID for seizures were not entered into the resident's medical record. After review, the DON noted 4 of 7 pages of the resident's orders from the hospital were entered into the resident's chart. The missing pages were found in the shredding bin in the medical provider's office (NP #1). The resident's primary care provider in the community (attending physician #21) was contacted and confirmed long-term use of anti-seizure medication and requested the orders be followed. The 7/19/2023 at 5:28 PM, hospital record documented the resident was admitted to the hospital due to a seizure and anti-seizure medication was restarted. During an interview on 8/11/2023 9:34 AM, RN Manager #5 stated when a resident was admitted , the nurse received report before the resident came to the unit and the hospital medication list was sent to NP #1's office. When the resident arrived at the facility, they called NP #1, and NP #1 came to the unit with the admission orders. During the investigation by the DON, RN Manager #5 was made aware the resident's orders did not include all pages of the medication list from the hospital and one of the pages of orders did not make it to the resident's chart by NP #1. During an interview on 8/11/2023 at 11:15 AM, the DON stated a hospital discharge summary was sent from the hospital to the skilled nursing facility prior to the resident's admission. NP #1 was responsible to review the medication orders. The resident had orders for anti-seizure medications on admission and they were documented on the last 2 pages of the discharge paperwork from the hospital and were not ordered on admission to the skilled nursing facility. On 7/19/2023, the resident had a seizure and was transported to the hospital. NP #1 reviewed the discharge orders and did not see the seizure medications when the resident was initially admitted . In a follow-up interview on 8/28/2023 at 10:43 AM, the DON stated after the resident was sent to the hospital following the seizure, the resident's family was called, and they reported a history of seizures. When they looked into this, they identified NP #1 did not fully review all discharge orders from the hospital. The DON stated they found the rest of the resident's hospital discharge orders in the shredding bin in the medical provider's office. NP #1 was a contract employee who worked for the hospital so it would be up to the hospital to initiate counseling or provide education to NP #1 and the DON did not initiate any counseling or re-education for NP #1. During an interview on 8/24/2023 at 10:49 AM, NP #1 stated they were trained by the hospital on medication and treatment orders and did not receive any training at the nursing facility unless a read and sign paper was provided. They did not see Resident #1 on admission until they were sent to the hospital with the seizure and after that, it was identified the resident had a seizure disorder and received anti-seizure medications in the hospital. When the resident was initially admitted , they reviewed the paperwork and left out a page with medications on it. As a result, they did not order seizure medications for the resident on admission. The resident went without seizure medications from the day of admission to the day of the seizure and they did not know the dates. During an interview on 9/8/2023 at 9:16 AM, the Medical Director stated they were made aware of the issue with the resident's missing medications after the fact. They did not know the exact date and spoke with NP #1 after the incident about accuracy. The Medical Director stated they also reviewed the discharge orders as NP #1 reported to them and this time, that did not occur. During a telephone interview on 9/11/2023 at 4:37 PM, attending physician #21 stated the resident had been their patient since 2015 and had a history of seizures. The resident received two anti-seizure medications including lacosamide and lamotrigine and had been on these medication for a while after multiple medications being trialed. The resident also had a neurologist involved int their care. At the time of the incident, the resident was discharged from the hospital to the skilled nursing facility and attending physician #21 was not available to see the resident at that time. After the resident had the seizure, they received a call from the DON, and they told the DON to continue the resident's anti-seizure medications. Attending physician #21 stated if the resident received their anti-seizure medications, they would not have a seizure. 10 NYCRR 415.15(b)(2)(iii)

Based on record review and interview during the abbreviated survey (NY00316770), the facility did not ensure alleged violations were thoroughly investigated and did not prevent further potential abuse/neglect while the investigation was in process for 1 of 7 residents (Resident #2) reviewed. Specifically, Resident #2 reported their wound treatments were not completed as ordered on 3 occasions and the investigation was not thorough and complete. The facility did not identify all involved staff and did not immediately implement a plan to protect residents and prevent reoccurrence. Findings include: The facility policy Investigation-Resident Abuse dated 3/1/2019 documented if there was reasonable cause to believe a person receiving care had been physically abused, neglected, or mistreated, the facility would conduct a thorough investigation. The investigation would be carried out immediately, all witnesses would be interviewed, and a record of the interviews would be in written form. The investigation of potential abuse would include a plan to prevent reoccurrence. The facility policy Administration of Required Treatments revised 5/19/2023, documented nursing staff would administer all treatments as ordered by the physician/medical provider. The nursing staff were to administer the treatment and document in the computerized system. The nursing staff were to communicate with the oncoming shift if there were circumstances that prevented the treatment from being done. Failure to complete treatments would be investigated as neglect with failure to provide care. Resident #2 had diagnoses including peripheral vascular disease (PVD, impaired blood flow), diabetes, and a below the knee amputation (BKA) of the left leg. The 5/7/2023 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance with most activities of daily living (ADL), had a surgical site that required wound care, and received applications of a non-surgical dressing, ointments, and medications. The 5/1/2023 wound assessment completed by registered nurse (RN) Manager #5 documented the resident was admitted to the facility with a left lower leg surgical wound from a BKA with 21 sutures present. The wound was assessed, and a treatment was ordered. The 5/2023 Treatment Administration Record (TAR) documented: - on 5/1/2023, to the left BKA surgical site, cleanse with NS, dry, apply a petroleum dressing and a 4 x 4 (gauze) and cover with gauze and an ACE wrap daily. - On 5/1/2023 and 5/2/2023, the treatment was signed as completed by licensed nurses. - On 5/3/2023, the treatment was documented as not completed and to see the nurse's note. There was no corresponding nurse's note received. - On 5/4/2023 through 5/7/2023, the treatment was documented as completed as ordered by licensed nurses. - On 5/8/2023, the treatment was completed by licensed practical nurse (LPN) #14. - On 5/9/2023, the treatment was completed by LPN #11 - On 5/10/2023 and 5/11/2023, the treatment was completed by LPN #14. - On 5/12/2023, the treatment was completed by LPN #3. - On 5/13/2023 and 5/14/2023, the treatment was completed by LPN #11. - On 5/15/2023, registered nurse (RN) #2 documented they completed the ordered treatment. The 5/16/2023 Failure to Follow Order report completed by registered nurse (RN) Manager #5 documented the resident reported to LPN #11 that the dressing to their surgical wound was not changed on 5/15/2023. LPN #11 noted the dressing that was in place at that time was dated 5/14/2023 and there was a lot of drainage when the dressing was removed. There was foul odor when dressing removed that was no longer present after cleaning the wound. The center of the wound was dehisced (incision re-opened) and there was a quarter size section of loose slough (dead tissue). The sutures remained in place, but the skin was pulled out of them. The treatment was completed, and the resident was transported to a surgical appointment. A call was later received from the surgeon's office reporting the resident was being admitted to the hospital. The 5/18/2023 Follow Up for Resident #2, signed by the Director of Nursing (DON) documented: - On 5/16/2023, the resident was scheduled for a surgical follow-up and asked LPN #10 if they could change their dressing as the dressing change was not done the day before. LPN #10 removed the old dressing that was dated 5/14/2023. The TAR documented RN #2 completed the resident's treatment on 5/15/2023. - Upon further review, it was noted that on 5/12/2023, LPN #3 did not complete the resident's treatment as RN #5 was made aware by LPN #11 when they removed a dressing dated 5/11/2023 on 5/13/2023. - Disciplinary action and re-education were given to RN #2 and LPN #3. The facility policy for assessments was to be review or revised as needed. LPN #11 documented in an email to RN Manager #5 dated 5/16/2023, that on 5/9/2023 and 5/13/2023, the resident reported their dressing change was not completed the prior day. On both occasions, the dressing on the resident was dated for the day prior to the date the resident said the treatment was not done. The 5/16/2023 hospital records documented the resident the resident was admitted for stump complications including the wound dehiscence and cellulitis (skin infection). The resident required debridement (surgical removal of dead tissue) on 5/18/2023 and was treated with antibiotics for the infection. The resident remained in the hospital until 6/9/2023 when they were discharged to another facility. The 5/16/2023 Notice of Disciplinary Action Form for RN #2 documented a written counseling as the resident stated their dressing was not changed on 5/15/2023. RN #2 signed the TAR as completing the treatment on 5/15/2023. The corrective action included the expectation was that treatments would be completed as ordered for proper care of residents. The form was signed by RN #2 and RN Manager #5 on 5/18/2023. The 5/16/2023 Notice of Disciplinary Form for LPN #3 documented a written counseling for falsification of records. On 5/12/2023, LPN #3 signed the TAR that the treatment was completed, the resident stated it was not done, and the dressing was dated 5/11/2023 when removed on 5/13/2023. The corrective action included the expectation was that treatments would be completed as ordered for proper care of residents. The form was not signed as reviewed by LPN #3 or RN Manager #5. During an interview on 8/11/2023 at 9:34 AM, RN Manager #5 stated Resident #2 arrived at the facility after a below the knee amputation and shortly after, LPN #3 missed a dressing change on the resident. There was no negative outcome at that time. The day before the surgical appointment on 5/15/2023 they looked at the wound and found the wound did not look good. They called the surgeon and filled them in on the wound. The following day the resident went to the follow up appointment at the surgeon's office and was admitted to the hospital. The DON investigated the issue and found RN #2 did not change the resident's dressing as ordered. During an interview on 8/17/2023 at 8:28 AM, LPN #3 stated if the treatment was done, they signed the TAR and if they did not do it, they did not sign the TAR. They did not recall Resident #2 and stated 5/2023 was a long time ago. They did not recall being counseled or re-educated on not completing a dressing change or falsification of records. During an interview on 8/17/2023 at 8:44 AM, RN #2 stated they identified falsification of records as documenting on something being done when it was not done. The facility process for signing off treatments was they signed for a treatment after the treatment was completed and not before. They remotely remembered Resident #2 and did not recall any specifics of the resident's care. During an interview via telephone on 8/28/2023 at 10:43 AM, the DON stated: - When they completed their investigation into the resident's treatments, they were not aware that wound rounds had not been completed for the resident. They expected staff to complete weekly wound rounds and document them. The resident had a wound assessment on admission and on 5/1/2023 and no other wound rounds were documented until 6/2023. - If a nurse did not have time to do a treatment, they were supposed to document that per policy and notify the next shift so the treatment could be completed. - On 5/16/2023 LPN brought to eh DON's attention the resident reported their treatments were not being done. - When asked to identify the initials of the person who documented they did the treatment on 5/8/2023, the DON reviewed the TAR and stated that was LPN #14 and that was a day the resident reported their treatment was not done. The DON stated the 5/8/2023 incident was not investigated. - When the DON did the investigation, they were aware of 2 instances of the resident's treatment not being done involving RN #2 and LPN #3. They were not asked for statements as they could write a statement on a disciplinary form. - LPN #3 was not issued the discipline form yet, suspension or re-education by RN Manager #5. - The DON re-educated RN #2 the day after the incident. - Neither LPN #3 nor RN #2 completed treatment competencies after the incident. 10NYCRR 415.4(b)

Based on record review and interview during the abbreviated survey (NY 646) conducted on 12/28/21, the facility failed to provide or obtain radiology or other diagnostic services to meet the needs of its residents for 1 of 4 residents reviewed (Resident #3). Specifically, a STAT (emergent) x-ray of the right ankle was ordered for Resident #3 on 7/13/2021 and it was not completed until 7/15/2021. When the results were obtained, Resident #3 was identified with fractures of the right ankle. Findings include: The undated facility protocol for STAT(emergent) orders documented: - The provider enters the order into the medical record and was to call the unit and notify the nurse of the STAT order. - The nurse was to review the order in the computerized medical record system; document STAT on the written order in the laboratory binder on the unit, and was to call radiology and notify them of the STAT order. Resident #3 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was independent with activities of daily living (ADL). The 7/9/2021 registered nurse (RN) #12's progress notes documented the resident had a fall earlier that morning. The 7/10/21 at 7:52 AM, licensed practical nurse (LPN) #16's progress note documented the resident's right outer ankle and top of right foot were bruised. A message was left for nurse practitioner (NP) #10. The 7/13/2021 NP#10's order documented the resident was to have a right ankle x-ray completed STAT. The 7/15/2021 at 11:47 AM, RN #15's progress note documented the physical therapy aide reported redness to the resident's right lower leg. RN #15 assessed the resident and noted redness to the right ankle, several inches around the ankle, and to the top of the right foot. [CONDITION(S)] (swelling) was also present. RN #15 documented they reported the assessment to NP #10 and documented that RN #12 reported to them an x-ray was being processed. The 7/15/21 at 12:35 PM, RN #12's progress note documented an order was received from NP #10 for a right ankle x-ray to be done STAT. RN #12 called and faxed the order to radiology. The 7/15/2021 x-ray report documented the resident had an oblique impacted fracture through the lateral malleolus (ankle bone) as well as a chip fracture through the medical malleolus of the right ankle. The 7/16/2021 facility incident report documented: - the type of incident was delay of care. - on 7/13/2021, a STAT right ankle x-ray was ordered by NP #10 for the resident. - There was no verbal communication between nursing staff and NP #10 confirming the order. - On 7/14/2021, NP #10 noted the x-ray had not been completed and mentioned it to the Director of Nursing (DON). - On 7/15/2021, NP #10 noted the x-ray was still not completed and notified RN #12, who obtained the x-ray. Statements obtained by the facility and included with the incident report documented: - LPN #11 documented on 7/13/21, LPN #5 approached them and asked if there was an x-ray ordered, would it be green in the computer if it was completed. LPN #11 told LPN #5 if it was green in the computer it was not done. LPN #11 documented they were then called by a resident with an immediate need, tended to that resident, and did not follow-up on the conversation with LPN #5 any further. - LPN #5's statement documented on 7/13/2021, they verified a STAT right ankle x-ray order for Resident #3. After verification, the order did not show up as red in the computerized system. LPN #5 asked LPN #11 about the documentation in the computerized system and LPN #11 stated they did not know and did not know how to proceed. LPN #5 continued with their work, forgot about the x-ray, and should have followed-up. - RN #12's statement documented on 7/13/2021, they did not receive an order, verbal or written, from NP #10 to perform a right ankle x-ray for the resident. On 7/15/2021, RN #12 received a telephone call from NP #10 stating a right ankle x-ray needed to be done as it was ordered STAT on 7/13/2021. RN #12 called imaging and faxed the order. - On 7/16/2021, the Administrator documented they interviewed NP #10 who stated on 7/13/2021, they followed-up with Resident #3 regarding a fall that occurred on 7/9/2021. The resident's right ankle was extremely swollen at that time and NP #10 ordered a STAT right ankle x-ray at 11:52 AM on 7/13/2021. NP #10 stated they expected to receive the results by the end of that day. NP #10 reported they spoke to the DON on 7/14/2021 as the results were not available. - On 7/16/2021 at 11:12 AM, the DON documented in an email to the Administrator and RN #13 that on 7/14/2021, NP #10 told the DON they ordered an ankle x-ray on the resident and it was not done. It was ordered STAT the prior day. The DON further documented they did not follow-up as they left early that day for personal reasons. On 12/28/2021 at 8:49 AM, NP #10 was interviewed via telephone and stated when an x-ray was ordered, they entered the order into the medical record and the nurse processed the order and contacted radiology. On 7/13/2021, NP #10 assessed Resident #3 and found the right ankle had increased swelling. They entered the x-ray order at that time. The following day, on 7/14/2021, NP #10 checked for the results of the x-ray and they were not in the record so they talked with the DON about the x-ray not being completed. On 7/15/2021, NP #10 did not find the results of the x-ray and talked to RN #12 who obtained the x-ray. On 12/28/2021 at 11:06 AM, NP #10 was re-interviewed and stated when an x-ray was ordered STAT they expected the x-ray to be done the day it was ordered. On 12/28/2021 at 9:50 AM, LPN #5 stated during an interview via telephone, on 7/13/2021, they saw the x-ray order and verified it in the computerized medical record system. LPN #5 stated the order was entered that day at 12 PM so they assumed the x-ray had been completed. LPN #5 stated they asked another nurse on the unit about the order and they were not sure about the process. LPN #5 did not contact a Supervisor for direction and did not notify the next shift about the x-ray order. LPN #5 stated they were not sure of the process for x-rays as most x-rays were completed on the day shift and they usually worked evenings. On 12/28/2021 at 11:22 AM, the DON stated a STAT order meant the x-ray was to be completed as soon as possible. The facility did not have a policy for STAT orders however did have a protocol. On 12/28/2021 at 12:07 PM, RN #15 was interviewed and stated when a new order was initiated, the medical provider would let the nurse know there was a new order. After being notified, the nurse would confirm the order. After the order was confirmed, there was a binder on the unit for lab and x-ray order and the nurse needed to complete the forms and follow the protocol to implement lab and x-ray orders. 483.50(b)(2)(1)(11)

Based on observations, record review and interview during the recertification and abbreviated surveys (NY 452) conducted from 12/15/21-12/17/21 the facility failed to make prompt efforts to resolve grievances the resident may have for 1 of 1 resident (Resident #13) reviewed. Specifically, the resident and the resident representative requested the resident's personal laundry be done by the resident representative and the facility denied the request. In addition, when the facility began permitting resident representatives to do laundry again, there was no documented evidence staff followed-up with the resident representative regarding the change in the policy. Findings include: The facility policy Resident Personal Laundry reviewed 10/2020 documents when clothing is removed from the resident it will be placed in the laundry bags in the hallway. Once full they are put in the dirty utility room. The Housekeeping Linen Personnel will be responsible for sorting resident's laundry and returning the clean linen to each resident's room. Washer/dryer is available on second and third floors for emergency use to ensure that residents have clean clothing. The policy did not include procedures for personal laundry done by resident representatives outside the facility. The facility COVID-19 Plan updated 10/2021 did not include procedures for handling of resident personal laundry. Resident #13 was admitted to the facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/7/2020 MDS documented it was very important to the resident to take care of personal belongings. The comprehensive care plan (CCP) initiated 5/19/20 documented the resident had potential for adjustment issues during the current pandemic and DOH (Department of Health) guidelines. Interventions included the resident would be encouraged to speak about their concerns and would continue to speak to family members on the phone, iPad, and window visits. Interdisciplinary progress notes from 9/1/20-12/31/20 did not include documented discussions of the resident/resident representative preference for doing the resident's personal laundry or where the resident's laundry would be done. During an interview with the resident on 12/15/21 at 9:54 AM, the resident stated their family member was not currently doing their personal laundry and it was being sent out to an outside laundry service. The resident stated their family member had been doing their laundry before COVID-19, but the facility staff never told the resident why the family member could no longer do the laundry. The resident stated they would like to have their laundry done by their family member. The resident stated even now since the family member could come for visits, they were not allowed to do the laundry. The resident's closet was observed with a sign reading Please send Laundry to {outside laundry company} The closet contained multiple shirts, pants and fleece jackets all marked with the resident's name. During a telephone interview with the resident's family member on 12/16/21 at 11:50 AM, they stated before COVID-19 they could do the resident's laundry. They stated when visitation was on hold, they asked the facility if staff could bring the resident's laundry to the front door to be picked up by the family member and they were told that would not be allowed. The family member stated if they did the laundry only one person would be touching the laundry versus multiple people at the laundry service. The family member stated there was nothing wrong with the laundry service but when they did the resident's laundry, they took special care of the clothes and some items did not go in the dryer, so they wanted to do the laundry themselves. The family member stated they were unsure how often the resident's laundry was done. During an interview with certified nurse aide (CNA) #2 on 12/16/21 at 1:29 PM, they stated the resident's laundry was sent out to the laundry service because the resident was there for long-term care. Clothes would go out in the evening and came back on Mondays, Wednesdays, and Fridays in the resident hamper. The CNA stated before COVID-19 the resident's family member took the resident's laundry home to do but then the laundry was kept confined to the facility during COVID-19. The CNA stated the family member had been in to visit and had not mentioned the laundry since visitation resumed. During an interview on 12/17/21 at 10:24 AM, the Director of Nursing (DON) stated they would probably be the best person to speak with related to laundry. The DON stated families could take laundry home if they wished to wash them for the residents. During COVID-19 they were not allowing families to bring laundry home. The DON stated there were currently no COVID-19 positive residents in the building and they had reopened so families were able to do laundry again. During an interview on 12/17/21 at 10:41 AM with registered nurse (RN) Unit Manager #4 they stated prior to the COVID-19 pandemic, the resident's family member was doing the resident's laundry. When there was no visitation, they implemented a plan for the facility to do all residents' laundry. The Nurse Manager stated the resident had not mentioned their preference for the family member to do the laundry. During a follow-up interview with the resident's family member on 12/17/21 1:28 PM, they stated they spoke to the Administrator about the laundry a couple of times. The family member stated the social workers tried to help and then the Administrator made the decision not to allow them to do the resident's laundry. The family member stated the were not aware that they could do laundry again and had not been told or updated. During an interview with social worker #5 on 12/17/21 at 1:42 PM, they stated they were aware of the family member's request to do the resident's laundry. The family member had spoken to a lot of people about it. The social worker stated during COVID-19 and times of no visitation, the facility was not allowing family members to take laundry home to reduce contact and exposure for infection control purposes. There were a few people that were set up for taking laundry home because those residents had anxiety. Now the families were able to take laundry home again. The social worker stated the directive came from Administration. The facility Administrator was unavailable for interview during the recertification survey. 10 NYCRR 415.3(c)(1)(i)

Based on record review and interview during the COVID-19 Focused Infection Control Survey conducted 11/30/2020, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of COVID-19. Specifically, for 1 of 3 employees (certified nursing assistant, CNA #1) reviewed, weekly testing for COVID-19 was not conducted. Findings include: New York State Executive Order (EO) 202.30 (dated May 10, 2020), as modified by EO 202.40 (dated June 9, 2020), as codified at 9 NYCRR 8.202.30 and 8.202.40, documented The Operator and Administrator of all nursing homes and all adult care facilities, which are located in regions that have reached Phase Two of reopening, must test or make arrangements for the testing of all personnel, including all employees, contract staff, medical staff, Operators and Administrators, for COVID-19, once per week. The 10/6/20 Nursing Home Staff Testing Requirements facility policy documented all staff who are or will be on site at the facility, including contracted staff, volunteers, administrators and the operator, will be required to be tested weekly to comply with New York State Department of Health (NYSDOH). In accordance with the Executive order, those that refuse to participate in required testing will not be permitted to work or provide any services at the facility until such time as they comply with the requirement. The 10/12/20 facility Precautions for Source Control and Preventing Spread of COVID-19 policy documents all nursing home staff will be tested weekly. The facility will monitor staff testing utilizing a weekly schedule which delineates all nursing staff scheduled to work for a designated week. An email from the Vice President of Nursing Services dated 11/30/20 documented the facility currently had two COVID-19 positive residents and one person under investigation. CNA #1 was observed on 11/30/20 at 10:15 AM in the hallway of a resident unit wearing a surgical mask and goggles. When interviewed at 10:20 AM, CNA #1 stated, she was tested for COVID-19 weekly. CNA #1 had no documented COVID-19 testing results for the month of 11/2020 when results were requested by surveyors on 11/30/20. During an interview on 11/30/20 at 2:23 PM, the Administrator stated CNA #1 had been on medical leave from 10/24/20 to 11/21/20. CNA #1's timesheet documented she worked the 2 PM-10 PM shift on 11/21, 11/22, 11/26 and 11/27; the 6:00 AM-6:00 PM shift on 11/29; and the 6:00 AM- 2:00 PM shift on 11/30/20. During an interview on 11/30/20 at 3:11 PM, the employee health licensed practical nurse (LPN) # 5, Administrator, and the Director of Nursing (DON) stated that CNA #1 returned to work on 11/21/20 and was not tested for COVID-19 until the date of survey, 11/30/20. During a follow up interview on 11/30/20 at 3:17 PM, the employee health LPN #5, the Administrator, and the DON stated that CNA #1 had returned to work for 9 days without being tested for COVID-19. The Administrator stated the expectation was that the employee should have been tested prior to returning to work. The DON did not know why the employee had not been tested . During an interview with the Vice President of Nursing Services on 11/30/20 at 3:30 PM she stated she is provided with a staff schedule and a report for the previous day of COVID-19 testing and checks for testing. The employee name is yellowed out once testing is completed. She was responsible for ensuring the nursing staff had been tested . She stated she did not think she was aware CNA #1 had returned from her leave of absence. If an employee brings in a note for medical clearance, they must be tested before they are put on the schedule. She recalled hearing that CNA #1 was told she had to be tested before working. When she looked at the schedule, CNA #1's name was crossed off. She stated somehow CNA #1 fell through the cracks and they needed to develop a way to capture leave of absences to ensure employees were tested . During an interview with the DON on 11/30/20 at 3:45 PM she stated CNA #1 had been out on medical leave. It was the responsibility of the employee health nurse to determine when the employee could return to work. She thought the employee health nurse would check to see if employees were tested before returning to work. She stated she expected employees to be tested and have a negative result before returning to work from a leave of absence. CNA #1 had told her she got out of her routine and forgot to get tested . They no longer kept a list, and everyone was responsible for their own testing. 10 NYCRR 415.19(a)(1) 10 NYCRR 400.2

Based on observation, record review, and interview during the abbreviated survey (NY 660), the facility did not ensure the right to request, refuse, and/or discontinue treatment and to formulate an advance directive for 1 of 3 residents reviewed (Resident #5). Specifically, Resident #5 had a do not resuscitate order (DNR, allow natural death in the event the heart stopped) and received cardiopulmonary resuscitation (CPR, chest compressions). Findings include: The facility's Advance Directive policy, dated [DATE], documented it was the facility policy to ensure that a resident's choice about advance directives be respected. The facility's Inter-Institutional Transfer of DNR policy, updated ,[DATE], documented if a resident had a DNR order, their bracelet would have a red insert and if a resident had a full code order (CPR), the bracelet would have a white insert. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was severely cognitively impaired. The Medical Orders for Life Sustaining Treatment (MOLST), dated [DATE], documented a DNR order. The physician order [REDACTED]. The comprehensive Care Plan (CCP) dated [DATE] documented Resident #5 had a MOLST and did not want to be resuscitated. The facility's incident report dated [DATE] at 4:10 AM, documented: - Resident #5's call bell sounded and certified nurse aide (CNA) #8 arrived at the room and found the resident on the floor, lying face down. CNA #8 yelled for assistance. - Registered nurse (RN) #9 and CNA #7 responded and saw Resident #5 on the floor, without oxygen in place, and the resident had snoring like respirations. - RN #9 documented the resident's code status indicator bracelet was white, CPR was initiated by CNA #7 while RN #9 went to obtain the crash cart. When RN #9 was out of the room he reviewed the resident's MOLST and determined the resident had a DNR order. Chest compressions were stopped, and the resident expired within a few minutes. - The Supervisor was made aware of the resident's death. - The facility interviewed staff and found a resident's rights violation of the CCP. - There was no documentation if the facility checked Resident #5's bracelet when investigating this incident. When interviewed on [DATE] at 12:00 PM Staff Educator RN #11 stated all nurses and CNAs were CPR certified and were recertified every 2 years. Staff were educated annually on determining resident code status. The most recent annual training occurred on [DATE] and [DATE] and CNA #7 and 8 both attended. When interviewed on [DATE] at 12:52 PM, CNA #7 stated on the night of [DATE] she provided care for Resident #5 around 11:00 PM at the start of her shift. CNA #8 found Resident #5 on the floor while she was on break and RN #9 for her help. She responded to the room with RN #9 and CNA #8 already in the room. The resident was not responding or breathing. RN #9 stated he was going to get the cart and notify the supervisor and the resident had an order for [REDACTED].#8 asked her if she knew CPR, she stated yes, and she initiated CPR. She performed a few compressions not even 10 when RN #9 came to the room and reported Resident #5 had a DNR order. When interviewed on [DATE] at 7:05 AM CNA #8 stated she was certified in CPR and received education on resident code status prior to the incident. On the night of the incident she heard Resident #5's call bell and went to answer it. The resident was on the floor face down and she attempted to wake Resident #5. RN #9 came to the room and attempted to arouse the resident and was unable to. RN #9 and she both looked at the bracelet and thought it was white. RN #9 stated he was going to check the resident's code status. CNA #8 arrived in the room and she asked CNA #8 if she knew how to do CPR and she stated she did. She began moving the bed into the hallway to make room and was not present when CNA #8 began compressions. She did not tell CNA #8 to start CPR. She and the supervisor entered the room followed by RN #9. When they entered the room CNA #8 stated she did CPR on Resident #5. RN #9 told her no she's a DNR. When interviewed on [DATE] at 8:06 AM RN #9 stated on [DATE] he was told by CNA #8 Resident #5 was on the floor unresponsive. When he entered the resident's room, he assisted CNA #8 with the resident, rolled the resident over and found the resident unresponsive, with a decreased breathing pattern, and turning blue around the lips. He told CNA #8 he wanted to check the residents code status. He did not check the resident's bracelet or the door for the red dot as he wanted to be sure of the resident's code status and did not trust the bracelet or the dot on the door. When he left the residents room, CNA #8 began removing items from the resident's room to make sure there was room for the crash cart. The resident was still breathing when he left the room and he did not check for a pulse. He asked CNA #7 to go to Resident #5's room. He went to the resident's chart, checked the MOLST which documented the resident had a DNR order. When he returned to the resident's room, he observed CNA #7 performing CPR, he told her to stop because the resident's code status was DNR. He stated CNA #7 jumped the gun and should have waited until he confirmed the residents code status before starting CPR. 10NYCRR 415.3(e)(1)(ii)

Based on observation, record review and interview, during the abbreviated survey (NY 930), the facility did not ensure correct installation, use, and maintenance of side rails for 8 of 8 residents (Residents #,[DATE]) reviewed for side rails. Specifically: - Resident #1 had an air-filled specialty mattress and side rails. The facility did not attempt to use appropriate alternatives prior to installing the side rails, did not assess the resident for entrapment risk from the side rails, did not review the risks and benefits of side rails with the resident or resident representative and obtain informed consent prior to installation of side rails. Subsequently, on [DATE], the resident was found with her body out of the bed and her head wedged between the side rail and the mattress. The resident had no pulse or respirations and was pronounced dead. - Residents #2, 3, 4, 6, and 7 had no care planned measurable objectives and interventions for side rail use. - Residents #,[DATE] had no documentation of alternative interventions attempted prior to side-rail implementation. - Residents #2, 3, 4, 5, 6, 7 and 8 had no review of the risks/benefits of side rail use and no informed consent was obtained prior to side rail use. - Residents #3, 4, 5, 6, 7 and 8 had no side rail assessment. - Resident #2 had an incomplete side rail assessment. This resulted in Immediate Jeopardy/Substandard Quality of Care for Residents #,[DATE]. Findings include: The facility's Side Rail Policy last reviewed by the facility on ,[DATE], documented the side rails form will be used for resident assessment of side rail use. The purpose is to provide the least restrictive environment that promotes safety and comfort for all residents. An ongoing assessment of the need for side rails will be made through the care plan by the Interdisciplinary Team. Upon admission, nursing will determine resident's choice for side rail and/or Side Rail assessment form as needed and document findings. The team will review side rail choice with resident, document interventions for decreased use if appropriate and develop alternatives as needed. 1) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Admission Minimum Data Set (MDS) assessment was in progress and not completed at the time of the abbreviated survey. The [DATE] hospital discharge summary documented the resident had a fall with a left [MEDICAL CONDITION] and was status [REDACTED]. During her course of treatment, she had ventilator-dependent [MEDICAL CONDITION], new onset [MEDICAL CONDITION] (heart rhythm disorder), progressively worsening debility and deconditioning, and worsening dementia. The resident was discharged to the facility for short term rehabilitation. The [DATE] registered nurse (RN) #11's admission assessment documented the resident was alert to self only, disoriented to time and place, she was confused and had a history of [REDACTED]. She had a Stage II (partial-thickness skin loss) pressure ulcer on her buttocks and was totally dependent for bed mobility, transfers and eating. The assessment did not document if the resident was assessed for side rails. The [DATE] physician note documented the resident had significantly decreased level of alertness, was difficult to arouse, did not follow commands and uttered only a few intelligible words. The plan was to work on strength, endurance and functional mobility skills. The [DATE] physical therapist (PT) #2's initial evaluation and plan of treatment documented the resident had impaired functional mobility, strength and balance due to recent illness, hospitalization , surgery and immobility for 2 weeks. Skilled therapy was indicated to promote safety awareness, minimize falls, increase lower extremity range of motion and strength, and improve ability to perform functional mobility with reduced risk of falls. The assessment did not document the resident needed side rails. The [DATE] comprehensive care plan (CCP) documented the resident had impaired cognition and a left [MEDICAL CONDITION] related to a fall. The care plan did not document the resident had side rails. On [DATE] at 11:02 PM, licensed practical nurse (LPN) #1 progress note documented she entered the resident's room at 10:05 PM to do a treatment and saw the resident hanging off the bed with her neck in the side rail. The resident was cold and had no movement. The nurse called out for help, registered nurse Supervisor (RNS) #3 came in and they placed the resident on the floor. She had no pulse and there was no response from a sternal rub (application of painful stimulus to the center of the chest). CPR (cardiopulmonary resuscitation, chest compressions) was started and a Code Blue was called. When the Code Team arrived, they worked on the resident for 30 minutes before pronouncing her dead. On [DATE] at 9:35 AM, the bed the resident had occupied was observed with 2 plastic side rails in the up position. The side rails were from the head of the bed and extended ,[DATE] length of the bed towards the foot of the bed. RN Manager #5 reported the bed had remained empty since the incident. On [DATE] at 1:20 PM, RNS #3 stated in a telephone interview she responded when LPN #1 called for help on [DATE]. RNS #3 found the resident's head wedged between her alternating air mattress and the side rail, and RNS #3 had to physically pull the resident's head out. She stated the facility was assessing residents to determine if they were safe to use side rails and side rails were usually given to residents who could independently move about in bed. She stated she was not sure if the resident was safe to use side rails because she had not had any previous interactions with the resident. She stated she knew the resident must have required total assistance because she had seen a Hoyer lift in the resident's room before. On [DATE] at 1:45 PM, LPN #1 stated in a telephone interview the resident could not move in bed alone, she required assistance of 2 to be turned and did not recall if the resident was able to grab the side rail to assist with positioning. She stated she believed residents were assessed for side rail use upon admission and most residents on the unit had their side rails up. On [DATE] at 2:00 PM, certified nurse aide (CNA) #4 stated in an interview she worked with the resident a few times including the evening of [DATE]. She stated the resident could use the side rail to hold onto when she rolled the resident but could not use it independently to reposition herself in bed. On [DATE] at 9:25 AM, RN Manager #5 stated in an interview the facility had a side rail assessment form that was in the process of revision, but it had been pushed aside for other tasks. She stated the old assessment was used to determine if the side rails were the least restrictive device, but it did not address if the resident could safely use side rails. She stated since the form was no longer in use, nursing continued to assess for side rails but did not document the assessments. She was not sure if the resident could safely use side rails when she was admitted because she did not do the resident's admission. She stated side rail use was supposed to be in the care plan. On [DATE] at 10 AM, the Director of Nursing (DON) stated in an interview she was in the process of revising the side rail assessment form. She stated she started reviewing it over the past 3 months and since then the assessments were not being completed for residents. She stated when she worked on the resident's investigation, she did not identify a side rail assessment had not been completed. She stated she did not realize nursing was not completing the assessments after she decided to review and revise the old form and had she been timelier, things may have turned out differently. On [DATE] at 12:20 PM, PT #2 stated in an interview the facility had no real policy addressing the use of side rails and prior to the incident on [DATE], she was not involved with side rail assessments. She had worked at other facilities where they tried alternatives such as lowering the bed or using floor mats before considering side rails. Since the incident on [DATE], the facility talked about PT doing the side rail assessments, talked about the risks and benefits of some residents' side rails as a team, did not review the risks versus benefits with residents' family members, but since this was all in the planning phase, nothing formal had been put into place yet. Since Resident #1 was no longer at the facility, the team did not discuss the risks versus benefits of her side rails as that started after the [DATE] incident. She had not been directed to obtain informed consent for side rail use. When she did therapy assessments for bed mobility, she informed the nurse of her findings and that information was entered into the computer and pulled over to the CNA care guide. She stated she had initially assessed Resident #1 for therapy when she was admitted and worked with her daily. The resident had an air mattress, was very limited at first and required hand over hand guidance to hold onto the rail when being turned. The resident could not turn or move about in bed on her own. On [DATE] at 2:40 PM, a follow-up interview was done with RNS #3. RNS #3 stated when she found the resident, she was face down between the lowest part of the side rail (towards the middle of the left side of the bed) and the mattress. She stated the resident's head was twisted some so her face was more toward the mattress than the side rail. She again stated that her head was definitely wedged and she did not have much difficulty pulling it out. On [DATE] at 3:15 PM, nurse practitioner (NP) #7 stated in an interview the resident was confused at times, could not turn on her own and required extensive assistance of two people. She stated she expected side rails to be assessed and only used when a resident could assist with bed mobility and able to participate with turning and positioning. 2)The facility did not ensure Resident #2 had care planned measurable objectives and interventions for side rail use, review the risk and benefits of side rails with the resident or resident representative, attempt alternative measures prior to side rail implementation, and obtain informed consent prior to installation of side rails. Resident #2 had an incomplete side rail assessment. Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident's Admission Minimum Data Set (MDS) assessment was in progress but not completed at the time of the abbreviated survey. The [DATE] hospital discharge summary documented the resident sustained [REDACTED]. She was discharged to the nursing home for rehabilitation. The [DATE] registered nurse (RN) #11's admissions assessment documented the resident was confused, weak, had a history of [REDACTED]. The assessment did not document if the resident was assessed for side rails. The [DATE] physical therapist (PT) #2's initial evaluation and plan of treatment documented the reason for the referral was a recent fall with injuries. The resident's functional mobility assessment for bed mobility was total dependence with attempts to initiate. The resident required side rails for safety with siderolling and supine (lying flat) to sit transfer. The assessment did not document the resident was assessed for entrapment risk. The undated direct care instructions documented the resident required assistance of 1 with rolling in bed assistance of 2 to boost in bed. The [DATE] comprehensive care plan (CCP) documented the resident was at high risk for falls related to deconditioning due to rhabdomyolysis. Interventions included ensuring proper footwear, anticipate needs and physical therapy evaluation and treat as ordered. The care plan did not document the resident required side rails. On [DATE] at 2 PM, certified nurse aide (CNA) #4 stated in an interview that someone in physical therapy told her not to use side rails with the resident on the day of her admission. She stated when she saw that another CNA had put the side rails up later that day, she went back in the room and put them down. On [DATE] at 2:15 PM and at 3:59 PM, the resident was observed in bed in her room with both side rails up. The side rails were 2 plastic side rails from the head of the bed and extended ,[DATE] length towards the foot of the bed. On [DATE] at 10 AM, the Director of Nursing (DON) stated in an interview she was in the process of revising the side rail assessment form. She stated she started reviewing it over 3 months ago and since then the assessments were not being completed for residents. On [DATE] at 9:25 AM, RN Manager #5 stated in an interview the facility had a side rail assessment form that was in the process of revision, but it had been pushed aside for other tasks. She stated the old assessment was used to determine if the side rails were the least restrictive device but did not address if the resident could safely use side rails. She stated since the form was no longer in use, nursing continued to assess for side rails but did not document on it. She stated side rail use was supposed to be in the care plan. On [DATE] at 9:35 AM, CNA #8 stated in an interview she could find out if a resident required side rails by looking at the care plan or care guide. On [DATE] at 12:20 PM, PT #2 stated in an interview the facility had no real policy addressing the use of side rails and prior to the incident with Resident #1, she was not involved with side rail assessments. She had worked at other facilities and they tried alternatives such as lowering the bed or using floor mats before considering side rails. Since the incident on [DATE], the facility talked about PT doing the side rail assessments but were still in the planning phase, and nothing formal had been put in place yet. She stated after the incident on [DATE], the team discussed the risks versus benefits of some residents' side rails but did not have these discussions with residents or residents' family members. She had not been directed to obtain informed consent for side rail use. When she completed an assessment for bed mobility, she would inform the nurse of her findings and that information was entered into the computer and pulled over to the CNA care guide. She assessed Resident #2 upon admission, and the resident was capable to use bed rails and needed them for transfers. Resident #2 was alert to self and could follow some direction. On [DATE] at 8:30 AM, the Administrator provided a facility wide list of residents who used side rails. Resident #2 was assessed as no longer requiring side rails and was not on the list. On [DATE] at 3:15 PM, nurse practitioner (NP) #7 stated she expected side rails to be assessed and only used when a resident could assist with bed mobility and able to participate with turning and positioning. 3) The facility did not ensure Resident #4 had care planned measurable objectives and interventions for side rail use, documentation of alternative interventions attempted prior to side-rail implementation, a review of the risks/benefits of side rail use and no informed consent was obtained prior to side rail use, and a side rail assessment. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DATE] Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired and she required extensive assistance of two with bed mobility and transfers. The MDS documented the resident did not have a side rail. The [DATE] comprehensive care plan (CCP) documented the resident required assistance with activities of daily living (ADLs). Interventions included a side rail to enable resident with repositioning. The resident's record did not document a side rail assessment from ,[DATE] to ,[DATE]. On [DATE], the facility provided a current list of residents with side rails. Resident #4 was listed as having side rails. On [DATE] at 8:30 AM, the Administrator provided an updated list of residents in the facility with side rails. Resident #4 was no longer listed as having side rails. On [DATE] at 8:06 AM, the resident's bed was observed with no side rails attached to the bed. On [DATE] at 10 AM, the Director of Nursing (DON) stated in an interview she was in the process of revising the side rail assessment form. She stated she started reviewing it 3 months ago and since then the assessments were not being completed for residents. On [DATE] at 12:20 PM, PT #2 stated in an interview the facility had no real policy addressing the use of side rails and prior to the incident, she was not involved with side rail assessments. She had worked at other facilities and they tried alternatives such as lowering the bed or using floor mats before considering side rails. Since the incident on [DATE], the facility talked about PT doing the side rail assessments but were still in the planning phase, and nothing formal had been put in place yet. She stated since the [DATE] incident, they talked about risk verses benefit of side rails as a team but did not have these discussions with residents or residents' family members. She had not been directed to obtain informed consent for side rail use. When she completed a therapy assessment for bed mobility, she would inform the nurse of her findings and that information would be entered into the computer and pulled over to the CNA care guide. On [DATE] at 8:11 AM, certified nurse aide (CNA) #9 stated in an interview the resident was not alert and oriented and required extensive assistance and kind of used the side rails to brace herself during care. Staff had to turn and position the resident as she could not do it on her own. If a resident was no longer capable to use side rails during care, she would report it. She stated the resident had her side rails removed because she was no longer using them. On [DATE] at 8:16 AM, registered nurse (RN) Charge Nurse #10 stated in an interview all nurses were responsible to ensure side rails were assessed and documented in the care plan. If a licensed practical nurse (LPN) found issues with side rail use, they would report to the RN and the RN would be responsible for follow up. They were currently working on updating the care plans for side rail use, notifying families and completing assessments. On [DATE] at 3:15 PM, nurse practitioner (NP) #7 stated she expected side rails to be assessed and only used when a resident could assist with bed mobility and able to participate with turning and positioning. _____________________________________________________________________________________ Immediate Jeopardy was removed on [DATE] at 4:15 PM prior to exit based on the following corrective actions taken. The facility: - Assessed all current residents for side rail use and removed side rails for residents not capable of using them. - Ensured the least restrictive intervention would be trialed before initiating side rails for all current residents. - Educated all current residents/resident representatives on the risks/benefits of side rail use. - Obtained informed consent for side rail use for all current residents. - Educated staff on any revisions to the facility's policy/procedure related to side rail use to include side rail assessments completed on admission, quarterly and for significant changes, least restrictive interventions attempted first, risk/benefits of side rail use, and obtaining informed consent prior to implementing side rails. 10NYCRR 415.29

Based on interview and record review during the abbreviated survey (NY 930), the facility did not ensure a quality assurance and performance improvement (QAPI) program that put forth good faith attempts to identify and correct quality deficiencies as well as opportunity for improvement for 8 of 8 residents (Residents #1, 2, 3, 4, 5, 6, 7 and 8) reviewed for side rails. Specifically, the facility did not identify recurrent noncompliance with their side rail policy and implement a QAPI Plan. Findings include: Refer to F700 - Bedrails 1) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Admission Minimum Data Set (MDS) assessment was in progress and not completed at the time of the abbreviated survey. The [DATE] physician's orders did not document the resident required side rails. The [DATE] nursing admission assessment documented the resident was alert to self only, disoriented to time and place, was confused and had a history of [REDACTED]. She had a Stage II (partial-thickness skin loss pressure ulcer on her buttocks and was totally dependent with bed mobility, transfers and eating. The assessment did not document if the resident was assessed for side rails. The [DATE] physical therapist (PT) #2's initial evaluation and plan of treatment documented the resident had impaired functional mobility, strength and balance due to recent illness, hospitalization , surgery and immobility for 2 weeks. Skilled therapy was indicated to promote safety awareness, minimize falls, increase lower extremity range of motion and strength, and improve ability to perform functional mobility with reduced risk of falls. The assessment did not document the resident needed side rails. The [DATE] comprehensive care plan (CCP) documented the resident had impaired cognition and a left [MEDICAL CONDITION] related to a fall. The care plan did not document the resident had side rails. On [DATE] at 11:02 PM, licensed practical nurse (LPN) #1 progress note documented she entered the resident's room at 10:05 PM to do a treatment and saw the resident hanging off the bed with her neck in the side rail. The resident was cold and had no movement. The nurse called out for help, registered nurse Supervisor (RNS) #3 came in and they placed the resident on the floor. The resident had no pulse and there was no response from a sternal rub (painful stimuli applied to the breast bone). CPR (cardiopulmonary resuscitation, chest compressions) was started and a Code Blue was called. When the Code Team arrived, they worked on the resident for 30 minutes before pronouncing her dead. 2) Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident's Admission Minimum Data Set (MDS) assessment was in progress and not completed at the time of the abbreviated survey. The [DATE] admissions assessment documented the resident was confused, weak, had a history of [REDACTED]. The assessment did not document if the resident was assessed for side rails. The [DATE] physical therapist (PT) #2's initial evaluation documented the resident's safety awareness was impaired, her sitting balance was fair and standing balance was poor. The resident was totally dependent for bed mobility with attempts to initiate, and she required side rails with side rolling and supine (lying flat on back) to sit transfers. The [DATE] physician's order did not document the resident needed side rails. 3) Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DATE] Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired and she required extensive assistance of two with bed mobility and transfers. The MDS documented the resident did not have a side rail. The [DATE] physician's order did not document the resident needed side rails. The resident's record did not document a side rail assessment from ,[DATE] to ,[DATE]. On [DATE] at 10 AM, the Director of Nursing (DON) stated in an interview she was in the process of revising the side rail assessment form. She stated she started reviewing it over 3 months ago and since then the assessments were not being completed for residents. On [DATE] at 2:35 PM, the Medical Director stated in an interview he expected residents to be assessed for side rail use and he expected there to be a physician order if they required them. On [DATE] at 3:30 PM, the Administrator was interviewed and stated the facility identified and corrected quality deficiencies through audits and reports from staff. He was made aware 3 months ago, after a discussion with a Nurse Manager, the side rail policy and assessment tool should be reviewed and revised to look at best format for assessment. They were not currently auditing side rails. After the incident with Resident #1 he became aware that side rails were not being assessed and he discovered the DON was not completing tasks related to the revision of policy and the assessment tool. He stated it was never brought to his attention and she should have let him know so they could have come up with a plan. 10NYCRR 415.27(a-c)