Every finding on record at Highland Park Rehabilitation and Nursing Center

Based on observation, interviews, and record review conducted during survey, the facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents for one (Resident #58) of four residents reviewed for accidents. Specifically, on 01/20/2026 during transport, Driver #1 failed to secure safety straps appropriately, causing Resident #58 to fall during a sudden stop and suffer head abrasions, a left-hand laceration and a neck fracture (break). This resulted in actual harm to Resident #58 that was not Immediate Jeopardy. The facility completed corrective measures prior to the start of survey. Citation is issued as Past Non-Compliance.The findings include:The facility policy and procedure titled Facility Bus dated January 2006, documented the facility bus was available to provide residents with the means to attend outside activities and appointments that might not otherwise be available to them. Only designated employees would drive the bus; drivers would be in good standing and have a good driving record and valid license. The driver was to ensure all riders had seatbelts appropriately applied and must have a cell phone on them during all outings.Resident #58 had diagnoses including complete traumatic amputation at knee level of right lower leg and left lower leg, neuromuscular dysfunction of bladder (bladder with diminished sensation), and peripheral vascular disease (poor circulation of the lower extremities). The Minimum Data Set (a resident assessment tool) dated 12/17/2025 documented Resident #58 was cognitively intact, understands and was understood by others.The Comprehensive Care Plan dated 04/08/2025 documented Resident #58 had an activity of daily living self-care performance deficit related to bilateral above the knee amputations and required set-up assistance with wheelchair mobility. Resident #58 often refused assistance with care, reapproach, and update nurses as needed. On 05/28/2025, Resident #58's behavior status was documented as non-compliant.The facility investigation dated 01/20/2026 at 9:45 AM, documented Resident #58 was in the facility's transport van on their way to a scheduled appointment when the vehicle came to a quick stop when railroad crossing guards came down suddenly, causing Resident #58 to come out of their wheelchair onto the van floor. Resident #58 was transported to the emergency room for evaluation. Resident #58 was assessed in the emergency room, a computed tomography scan (CT) completed of their head and neck, and x-rays were taken of their left-hand. Resident #58 sustained a spinous process fracture of C5 (fifth cervical (neck) vertebrae) that did not require surgical intervention, a laceration on the left-hand which required eight stitches, abrasions on their head and right middle finger. Resident #58 returned to the facility with a soft cervical collar in place for comfort. Driver #1 was suspended pending investigation.Review of a statement completed by Driver #1 dated 01/20/2026 documented they had loaded Resident #58 into the wheelchair van and secured the wheelchair with the four-point straps. They then threaded the buckle through the wheelchair frame and over Resident #58's waist, having the shoulder part of the belt falling at Resident #58's mid-bicep (upper arm). Resident #58 indicated they did not want their arm pressed like a sling to their torso and extracted it so the shoulder strap fell under their right arm. Driver #1 adjusted the belt to be tighter around Resident #58's waist and left for the appointment. They were coming down a hill leading up to some railroad tracks and started pressing the brakes. The railroad crossing guards started to come down, so they hit the brakes to come to a full stop. Driver #1 heard a thump, looked back and did not see Resident #58 in their wheelchair so they pulled over immediately. As soon as emergency personnel were in care of Resident #58, Driver #1 called the facility and made staff aware of the incident.The Hospital After Visit Summary dated 01/20/2026 at 3:37 PM, documented Resident #58 was seen in the emergency room after sustaining a fall out of their wheelchair during a vehicle situation. Resident #58's left-hand was washed and repaired with stitches. The computed tomography scan of Resident #58's head showed there were no skull fractures or brain bleeds, and Resident #58 was at their baseline mentation. The computed tomography scan of Resident #58's spine showed a minimally displaced fracture of the right aspect of the bifid spinous process of C5 (a small crack on one side of the Y-shaped bony bump at the back of a vertebra, where the bone is shifted just a tiny bit), which was not a particularly unstable appearing fracture. Resident #58 was having some midline discomfort so a neck brace was ordered until follow up with orthopedic surgery. An addendum by the medical provider documented, discussed with spine consult service at local hospital who did not feel as though the fracture needed any further workup. They recommended using a cervical collar if still painful and outpatient follow-up. Resident #58 was discharged with an outpatient orthopedic follow up and instructions for suture removal in one week.During an interview on 07/28/2026 at 2:48 PM, Resident #58 stated during the fall on 01/20/2026, they had a seat belt strap across their shoulder, but it was under their shoulder, and they could not recall if there was a strap across their waist.During a telephone interview on 07/29/2026 at 12:36 PM, Driver #1 stated they secured Resident #58's wheelchair to the wheelchair van with the four-point harness anchor straps. They stated they then grabbed the seatbelt and threaded it through the arm of the wheelchair and over Resident #58's waist, the shoulder strap fell over Resident #58's shoulder. Driver #1 stated they could not recall if Resident #58 removed their arm from under the strap placing the strap under their arm pit, but if it was what was written in their statement then that was the case.During an interview on 07/29/2026 at 1:03 PM, the Director of Nursing stated they would have expected Driver #1 to ensure the seatbelts were placed properly prior to providing transportation to Resident #58, or any other resident. They stated proper placement was having the shoulder strap over their shoulder, and the lap belt portion across their waist securely. If they did not have the belts placed securely it would put residents at risk of injury.During an interview on 07/29/2026 at 1:10 PM, the Administrator stated at the time of the incident on 01/20/2026, Resident #58 slid out of their wheelchair, but had all seat belts in place and everything was functioning properly.During an interview on 07/29/2026 at 2:46 PM, the Director of Rehabilitation stated prior to the incident on 01/20/2026, there had been no issues they were aware of with Resident #58 during transportation. They stated if a seatbelt was worn how it was designed, over the shoulder and over the waist, then it should function correctly. The Director of Rehabilitation stated they were requested to assess Resident #58 following the fall on 01/20/2026 and initiated a five-point harness to be worn on transport due to them having to wear the cervical collar; they stated they assess all residents after falls and would only see residents for transportation issues on a case-by-case basis.During a telephone interview on 07/30/2026 at 11:00 AM, the Medical Director stated they would have expected Driver #1 to have secured Resident #58 into the wheelchair van appropriately, with the seatbelt over their shoulder and their waist. They stated Resident #58 was top heavy and their center of gravity was off, so if they had their seat belt on as it was designed, it would have probably kept them from falling out of their wheelchair during the incident. The Medical Director stated Resident #58 sustained some injuries in the fall, that did not require surgical intervention, and a cervical collar was recommended for comfort due to having midline pain after the incident, which was eventually discontinued.During an observation and follow-up interview on 07/30/2026 at 2:37 PM, Driver #1 reenacted how they secured Resident #58 into the wheelchair van on 01/20/2026. Driver #1 pulled the traditional looking seatbelt over their lap and stated when they placed the buckle over Resident #58's lap the shoulder strap fell to their mid-bicep. Resident #58 pulled their arm out and rested it over the belt, allowing the strap to sit under their arm pit. Driver #1 stated Resident #58 had a history of refusals, and they did not want to argue or upset the resident but should have let nursing staff know about the refusal so they could talk to the resident. Driver #1 stated appropriate placement of the seatbelt was over the shoulder and over the resident's waist and they should have ensured Resident #58's was placed like that on 01/20/2026.During an interview on 07/31/2026 at 11:21 AM, the Director of Maintenance stated prior to transporting any residents, all drivers were trained on how to properly fasten each seatbelt and harness, which included placing the belt across their lap and through the wheelchair arm rest, allowing the shoulder strap to fall over their shoulder, like a traditional seatbelt. They stated having the seatbelt on as it was designed to was supposed to deter injury; Driver #1 should not have left the premises until the belt was in place as designed or alerted staff of the refusal.10 New York Code Rules and Regulations 415.12(h)(1)The following corrective actions were implemented by the facility to correct the non-compliance as of 02/10/2026.-Driver #1 was suspended pending investigation and received discipline for the incident and sent for drug and alcohol screening on 01/21/2026, results were negative.-The facility transport van was placed out of service, and a full inspection of the vehicle was carried out on 01/21/2026 with no safety issues identified.-On 01/22/2026, 100% of van drivers had comprehensive competencies with return demonstration performed to include resident safety during transport and properly securing wheelchair and safety belts with no issues identified.-On 01/22/2026, 100% of van drivers were educated to not drive the vehicle if residents are not properly secured or residents refuse proper use of safety belts.-The facility created a new policy titled Vehicle Transportation with an effective date of 01/22/2026 documenting the driver would be thoroughly trained and pass competency evaluation using the competency form for each vehicle type to include knowledge of vehicle operation, preparation of vehicle for safe operation and comfort of passengers, safe movement and supervision of passengers, and ensure all safety devices were in place. The policy documented if a passenger was non-compliant with safety procedures or devices, ensure the passenger was safe and notify a supervisor immediately before proceeding further.-The Administrator interviewed all residents who had facility transport in previous seven days, and no issues were identified.-Transportation audits were conducted by the Director of Maintenance three times per week for four weeks to monitor the corrective actions and to ensure implementation of facility protocols to ensure resident safety while utilizing the transportation services transport.-These audits were reviewed weekly by the Administration and were reported during the monthly facility Quality Assurance Program (QAPI) meetings.

Based on observation, interview, and record review conducted during the survey, the facility failed to ensure that each resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for one (Resident #42) of three residents reviewed. Specifically, Resident #42 was not offered or provided the removal of their facial hair during care. The findings include:The facility policy and procedure titled Activities of Daily Living, Supporting dated April 2025 documented residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way, at a different time, or having another staff member speak with the resident may be appropriate.The facility policy and procedure title Shaving the Resident dated February 2018 documented the following information should be recorded in the resident's medical record: if the resident refused the treatment, the reason(s) why and the intervention taken. Notify the supervisor if the resident refuses the procedure.Resident #42 had diagnoses including adult failure to thrive (a state of gradual physical and mental decline), congestive heart failure (the heart cannot pump blood well leading to fluid buildup and shortness of breath), and hypertension (high blood pressure). The Minimum Data Set (a resident assessment tool) dated 06/30/2026 documented Resident #42 was understood, usually understands, and had moderate cognitive impairment. Resident #42 required substantial/maximal assistance with personal hygiene including shaving. Review of the Comprehensive Care Plan dated 11/28/2025 documented Resident #42 had a functional ability deficit and required assistance with self-care. Interventions included substantial/maximal assistance with personal hygiene. Resident #42 was at risk or had impaired cognitive function related to confusion. Interventions included encourage Resident #42 to participate in daily decision making with daily activities. There was no documented evidence that Resident #42 had a history of refusals of care.Review of the Kardex (a guide for staff to provide care) dated 07/31/2026 documented Resident #42 required substantial/maximal assistance with personal hygiene.Review of Resident #42's Nursing Progress Notes dated 06/27/2026 through 07/30/2026 lacked documented evidence that Resident #42 had refused grooming and hygiene.During an observation and interview on 07/27/2026 at 9:51 AM, Resident #42 was lying in bed and had many black and white hairs on their chin, that were approximately 0.5 inches long. They stated they did not like it and that they thought the staff would take care of it. Resident #42 was unable to recall if they had asked the staff to remove their facial hair.During a telephone interview on 07/27/2026 at 10:56 AM, Resident #42's Responsible Party stated that they visited Resident #42 on a regular basis. They stated that the first time they noticed Resident #42 had chin hair, they said What the heck is that?. They stated that Resident #42 did not have any facial hair prior to living at the facility and they think Resident #42 would not want to be seen with facial hair. It was expected that the staff would remove the facial hair without asking them.During an observation of morning care on 07/29/2026 at 9:17 AM, Resident #42 was lying in their bed. The facial hair remained on their face. Certified Nurse Aide #1 completed morning care on Resident #42 and did not attempt nor offer to remove the resident's facial hair.During an interview on 07/29/2026 at 9:37 AM, Certified Nurse Aide #1 stated that Resident #42 had facial hair, and they should have attempted, or at least offered, to remove Resident #42's facial hair. They stated that it should have been encouraged because it was a dignity thing. Certified Nurse Aide #1 stated that if there were enough staff, facial hair removal should be offered and attempted every day.During an interview on 07/30/2026 at 2:38 PM, Licensed Practical Nurse #1 stated that usually staff would offer the residents to be shaved on their shower days, but it should be offered any time that the staff noticed a resident had facial hair. They stated that even if a resident were to refuse, the certified nurse aide should let the nurse know so they could reapproach the resident and document it. They stated that Resident #42 was confused at times and would not always be able to communicate that they wanted the certified nurse aides to remove their facial hair. Licensed Practical Nurse #1 stated that Certified Nurse Aide #1 should have attempted or offered to remove Resident #42's facial hair because otherwise, they could be seen as unkempt or unclean.During an interview on 07/30/2026 at 2:40 PM, Licensed Practical Nurse #2 Charge Nurse stated generally, certified nurse aides should offer facial hair removal during care. They stated that at times Resident #42 could be adamant that they did not want something, but Certified Nurse Aide #1 did not alert Licensed Practical Nurse #2 Charge Nurse that Resident #42 was refusing any care including facial hair removal on 07/29/2026. They stated that facial hair removal should have been attempted or offered because it was considered part of personal care and if a resident did not want facial hair, the staff should help remove it for them.During an interview on 07/30/2026 at 2:42 PM, Registered Nurse #1 Unit Manager stated the expectation was that any time a staff member provided care, they should have offered facial hair removal. They stated that it was a dignity issue and that most people would want to be neat and clean. It was the responsibility of the certified nurse aides to make sure the residents were offered facial hair removal and the responsibility of the nurses and nurse manager to ensure the certified nurse aides were doing their jobs.During an interview on 07/30/2026 at 2:48 PM, Registered Nurse #2 Educator stated that certified nurse aides were trained and received annual competencies regarding complete morning care. They stated that a part of morning care was facial hair removal, and it was expected that certified nurse aides automatically offer residents to have their facial hair removed. They stated that Resident #42 was confused at times and Certified Nurse Aide #1 should have attempted or offered to remove their facial hair. If Resident #42 would have refused, then Certified Nurse Aide #1 should have reported to Licensed Practical Nurse #2 Charge Nurse. They would have reapproached Resident #42 and documented any refusals.During an interview on 07/31/2026 at 9:17 AM, the Director of Nursing stated the expectation was that grooming would be completed during morning care. Grooming included brushing hair, washing the face, brushing teeth, checking nails and offering to shave. They stated if the resident refused care, then it should have been reflected in the care plan, and a progress note should have been charted. The charge nurse should have also been notified so they could reapproach the resident if needed. The Director of Nursing stated that shaving should be offered at least once a week or more when it was noticed. Ultimately, the charge nurse and unit manager were responsible.10 New York Codes Rules Regulations 415.12(a)(3)

Based on record review and interviews conducted during the survey, the facility failed to ensure the nurse staffing information was posted daily and included the required information. Specifically, the facility did not post accurate nurse staffing data on 07/17/2026, 07/22/2026, and 07/23/2026.The findings include: The facility's policy and procedure titled Posting Direct Care Daily Staffing Numbers, dated August 2022, documented within two (2) hours of the beginning of each shift, the number of licensed nurses (Registered Nurses and Licensed Practical Nurses) and the number of unlicensed nursing personnel (Certified Nurse Aides and Nurse Attendants) directly responsible for resident care was posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. The information recorded on the form shall include: A 24-hour shift schedule, the actual time worked during that shift for each category and type of nursing staff, and the total number of licensed and non-licensed nursing staff working for the posted shift. Review of the facility's records revealed on:- 07/17/2026, during the 2:30 PM to 10:30 PM shift, the daily assignment sheets documented four (4) certified nursing aids; however, the Direct Care Daily Staffing sheet documented a resident census of 77 and five (5) certified nursing aids. - 07/22/2026, during the 2:30 PM to 10:30 PM shift, the daily assignment sheets documented six (6) certified nursing aids; however, the Direct Care Daily Staffing sheet documented a resident census of 78 and seven (7) certified nursing aids.- 07/23/2026, during the 2:30 PM to 10:30 PM shift, the daily assignment sheets documented three (3) certified nursing aids; however, the Direct Care Daily Staffing sheet documented a resident census of 78 and five (5) certified nursing aids. During an interview on 07/31/2026 at 9:24 AM, the Human Resources Coordinator/Staffing Scheduling Coordinator stated they did not know they could change the Direct Care Daily Staffing sheets and they were told not to because it was a legal document. They stated the staffing sheets for each unit and each personnel should correspond with the daily staffing assignments and will ensure this will occur from here on in. During an interview on 07/31/2026 at 10:25 AM, the Director of Nursing stated if the staffing changed, it was up to the Nurse Staff Supervisor to update the daily staffing sheet, so it reflected the updated personnel and staffing hours for that day. During an interview on 07/31/2026 at 11:11 AM, Licensed Practical Nurse #3 stated they never were told to change the Direct Care Daily Staffing sheet if there were changes in the schedule and thought it was up to the Staffing Coordinator to make the changes. During an interview on 07/31/2026 at 11:42 AM, the Administrator stated the Human Resources/Staff Scheduler Coordinator was trained by the previous staffing coordinator and should have known the Direct Care Daily Staffing sheet and the data must reflect staff absences due to callouts or illness. They stated updated sheets for call outs were the responsibility of the Staffing Coordinator to make sure it was accurate. They stated if the Staffing Coordinator was not in the building, the nursing supervisor should be doing it. They stated this was important because those sheets must be accurate shift to shift and date to date. They stated they were uncertain if the nursing supervisors were aware that they should be changing the sheets according to any staff changes but will have to do some training if needed. 10 New York Codes, Rules, and Regulations 415.13

Based on observation, interview, and record review conducted during the Standard survey completed 4/26/24, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for two (Resident #5 and #39) of two reviewed for skin conditions. Specifically, there was the lack of an assessment and treatment initiation for a newly developed and reported skin ulceration (#39) and the lack of follow up on the wound consultant recommendations (#5). The findings are: The policy and procedure titled Skin/Pressure Ulcer Prevention & Intervention Program revised 04/14 documented weekly skin evaluations will be done on every resident. When skin/pressure ulcers are identified a Registered Nurse will assess the wound, document in the medical record, start a new wound tracking sheets and notify the practitioner for treatment. Whenever a resident develops a new skin/pressure ulcer the resident will be placed on the 24-hour report for interdisciplinary awareness and follow up. 1. Resident #39 had diagnoses that included cellulitis (bacterial skin infection) of right lower limb, type 2 diabetes mellitus and cerebral infarction (occurs because of disrupted blood flow to the brain). The Minimum Data Set, dated dated dated [DATE], documented Resident #39 was cognitively intact, usually understood and understands. The Minimum Data Set also documented Resident #39 had no arterial or venous ulcers. The Care Plan Activity Report entered on 12/20/23, documented Resident #39 was at risk for impaired skin integrity as evidenced by mycotic nails (fungal infection); incontinence; rash and other nonspecific skin eruption (groin). Interventions dated 12/7/23 documented to monitor skin surfaces for changes every shift. The care plan did not include the resident had an ulcer to the top of their right foot. The Physician's Orders dated 12/1/2023 to 4/25/2024, documented to monitor Resident #39's skin, complete head to toe skin checks and to notify RN (registered nurse) of any skin impairment every week. Review of Resident Treatment Administration Record dated 3/1/24 through 3/31/24 and 4/1/24 through 4/23/24 revealed there were no treatment orders in place to Resident #39's right foot. Review of Medical Doctor Progress Note dated 4/4/24, Medical Doctor #2 documented a diagnosis of chronic peripheral venous insufficiency (decreased blood flow). The progress noted documented no rashes or skin ulcers. Review of Nursing Progress Notes revealed: -4/10/24, Registered Nurse #2 Unit Manager documented they were called to Resident #39's room due to an open area noted on top of Resident #39's right second toe. Nurse Practitioner #1 was notified and an order to cleanse the toe with soap and water, pat dry and apply band aid. -4/15/24, Licensed Practical Nurse #4 documented therapy reported that Resident #39's right leg was swollen. Registered Nurse (unidentified) was made aware. -4/24/24, Licensed Practical Nurse #3 documented an area measuring 3.5 centimeters by 2 centimeters was noted on top of Resident #39's right foot. Nurse Practitioner #1 was updated, and new orders were received. Review of Nursing-Weekly Skin Assessments dated 4/4/24 through 4/25/24 revealed Licensed Practical Nurse #3 documented that Resident #39's skin was intact. During an observation and interview on 4/23/24 at 10:48 AM, Resident #39's was observed sitting in a wheelchair wearing gray socks to both of their feet with no shoes. The top of Resident #39's right sock was wet with a dark ring noted in the fabric. Resident #39 stated they had an open area the size of a quarter on the top of their right foot. When asked if a treatment was being applied Resident #39 stated, No! During an observation and interview on 4/24/24 at 11:26 AM, Resident #39 was sitting in wheelchair in their room, and there was no sock on their right foot. There was a quarter size open pink ulcer with irregular edges on the lateral top right side of their foot. The ulcer was weeping serous (clear, watery) fluid and the floor under Resident #39's foot was wet. During an interview on 4/24/24 at 11:45 AM, Certified Nursing Assistant #2 stated Resident #39 had a sore on the top of their right foot that they noticed last Friday (4/19/24) and they had reported it to Licensed Practical Nurse #5 last week, and today before breakfast they reported it to Licensed Practical Nurse #3. During an interview and observation on 4/24/24 at 11:54 AM, Licensed Practical Nurse #4 stated they had observed an open ulcer on Resident #39's right foot last week. Licensed Practical Nurse #4 observed the ulcer and stated it was the same ulcer they had seen last week but now the ulcer was larger and draining clear fluid. Licensed Practical Nurse #4 stated they thought a treatment was initiated last week. Licensed Practical Nurse #4 reviewed Resident #39's Treatment Administration Record and stated there were no treatments ordered for Resident #39's right foot. During an interview on 4/24/24 at 12:03 PM, Licensed Practical Nurse #3 stated they were not aware of the ulcer to the top of Resident #39's right foot until today at 11:00 AM when Registered Nurse #1 informed them. They looked briefly looked at it and stated the ulcer was open and had drainage. Licensed Practical Nurse #3 stated they reported the ulcer to Registered Nurse #2 Unit Manager, who informed them that an accident/incident report had previously been completed. During an interview on 4/24/24 at 12:20 PM, Registered Nurse #2 Unit Manager stated they were made aware of the open area to the toe on right foot at least a week ago and completed an incident report. Registered Nurse #2 Unit Manager stated they notified Nurse Practitioner #1 and was advised to leave area open to air. During a telephone interview on 4/26/24 at 9:38 AM, Licensed Practical Nurse #5 stated a Certified Nursing Assistant report to them on Friday, 4/17/24, that Resident #39 had a sore on their right foot and wasn't sure if it was there before. Licensed Practical Nurse #5 stated Resident #39 told them they had the open ulcer for a week. Licensed Practical Nurse #5 stated the ulcer was on the top of Resident #39's right foot, not near their toes and was about 1 centimeter by 1 centimeter with no drainage. Licensed Practical Nurse #5 stated they notified Registered Nurse #2 Unit Manager so they could find out what to do with it, as there was no treatment in place. Licensed Practical Nurse #5 stated they observed Registered Nurse #2 Unit Manager look at the ulcer before giving them instructions to place ointment and a band-aid over it. During a telephone interview on 4/26/24 at 10:00 AM, Nurse Practitioner #1 stated they did not recall if Registered Nurse #2 Unit Manager informed them of any new skin concerns. Nurse Practitioner #1 stated they would have documented the skin concern in a progress note if they were made aware of it. Nurse Practitioner #1 stated they would have expected to be notified of any new skin concerns. During an interview on 4/26/24 at 10:59 AM, Registered Nurse #1 stated Resident #39's skin concern was reported to them either Tuesday (4/23/24) or Wednesday (4/24/24) by a Certified Nursing Assistant. Registered Nurse #1 stated they looked at Resident #39's right foot and noted an open ulcer to the lateral top part of their foot and it was wet in appearance and they referred the Certified Nursing Assistant to have the Unit Manager or Charge Nurse look at it. During a follow up interview on 4/26/24 at 11:14 AM, Registered Nurse #2 Unit Manager stated when they were made aware of the open area on the top of Resident #39's right foot on 4/24/24, they were thinking of a different area. Registered Nurse #2 Unit Manager stated staff did report the open ulcer to the top of the foot to them. They should have started an incident report, assessed the ulcer, notified the medical provider, and had the Wound Consultant Medical Doctor #1 see Resident #39 so a treatment could be initiated. During an interview on 4/26/24 at 12:07 PM, the Director of Nursing stated they would have expected an incident report and an assessment to be completed immediately. The Director of Nursing stated a treatment should have been implemented immediately to protect the resident from contaminates and to prevent infection. 2. Resident #5 had diagnoses including unspecified open wound of the buttock, type 2 diabetes mellitus, and bipolar disorder. The Minimum Data Set (MDS-a resident assessment tool) dated 2/25/24 documented Resident #5 understood, understands and was cognitively intact. It was documented that Resident #5 was at risk for developing pressure ulcers. The Care Plan Activity Report initiated 1/21/24 documented Resident #5 had skin concerns which included a rash and other nonspecific skin eruption. Interventions included to monitor skin per the medical doctor's order. Interventions dated 1/31/24 included to observe skin surfaces and assess for changes every shift; wound team will assess wounds weekly with measurements and description of wounds, and administer treatment as ordered by medical doctor. The Wound Consultant Medical Doctor #1 recommendations documented the following: -4/4/24 erythema (redness) bilateral buttocks, apply Calmoseptine then cover with non-stick dressing. Plan of care discussed with facility staff. -4/9/24 apply Calmoseptine, needs less adhesive dressing please. Plan of care discussed with facility staff. - 4/16/24 apply topical Calmoseptine once daily. Plan of care discussed with facility staff. The physicians' orders with a start date of 4/9/24 documented to wash Resident #5's right buttock with warm water and soap. Pat dry. Apply Calmoseptine (moisture barrier/skin protectant) and cover with border gauze twice a day to unspecified open wound of the buttock. On 4/24/24, an order was documented by Licensed Practical Nurse #3 to wash Resident #5's buttocks with soap and water, pat dry. Apply Calmoseptine to area and cover with border gauze twice a day. Review of Resident Treatment Administration Record dated 4/9/24 through 4/24/24 revealed the treatment was completed as ordered not per the Wound Consultants recommendations. During an interview on 4/23/24 at 8:32 AM, Resident #5 stated they had a pressure ulcer on their rear end. Resident #5 stated they had one on each buttock, one was opened and the other was closed. During an observation on 4/24/24 from 4:00 PM to 4:12 PM, Registered Nurse Supervisor #1 reviewed the treatment orders on Resident #5 Treatment Administration Record and gathered supplies. Registered Nurse Supervisor #1 washed hands applied gloves and removed the dressings to bilateral medial (inner) buttocks. While the bordered adhesive gauze was being removed the adhesive from the gauze dressing denuded (removed surface layer) the resident's skin and causing two new abrasions (surface layer of skin broken) to the left and right buttocks. The abrasions were less than 1 centimeters red and moist. Registered Nurse Supervisor #1 did not obtain measurements of new abrasions at that time. During an interview on 4/24/24 at 4:32 PM, Registered Nurse Supervisor #1 reviewed the wound consultant recommendations in the electronic medical record and stated the recommendations do not indicate the use of adhesive gauze. During an interview on 4/24/24 at 4:43 PM, Registered Nurse #2 Unit Manager stated they received the wound consultants progress notes a couple days after wound rounds and they were responsible to review. Registered Nurse #2 Unit Manager stated they weren't aware of Resident #5's wound consultant recommendations and should have been. During an interview on 4/25/24 at 2:03 PM, Wound Consultant Medical Doctor #1 stated recommendations to change a treatment were completed during wound rounds. Wound Consultant Medical Doctor #1 stated that Resident #5 was bothered by the adhesive dressing, caused discomfort, and that was why an adhesive dressing wasn't recommended. 10NYCRR 415.12

Based on interview and record review conducted during a Complaint investigation (Complaint #NY00315852) completed during the Standard survey on 4/26/24, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug used without adequate monitoring; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued. Specifically, for one (Resident #130) of six residents reviewed there was a lack adequate monitoring of a PT-INR (Prothrombin Time/International Normalized Ratio- a blood test to measure how long it takes for blood to form a clot) for a resident on anticoagulant therapy (medication that causes thinning of the blood) resulting in adverse consequences. The finding is: Review of the facility policy and procedure titled Anticoagulant Therapy revised on 3/19, documented that Prothrombin Time/International Normalized Ratio results would be faxed into the nursing office, faxed into the electronic medical record under the result section, and placed on the Warfarin (an anticoagulant medication) Therapy Sheet in the medical doctor's book. The policy and procedure documented the nurse would immediately give the lab results to the provider or make a follow up call if no response or no order were received. The policy and procedure documented that when a new anticoagulant order was received the order would be entered as a medication order and lab order as International Normalized Ratio level. Review of the facility policy and procedure titled Laboratory Test Documentation revised on 3/18, documented that the nurse would review the order in the electronic medical record and add the lab test with date to the lab calendar and the Laboratory Test Results Log. The policy and procedure documented that once the lab results were received the nurse would communicate the results to the provider and sign that it had been completed, as well as writing a note on the lab result sheet and entering a progress note in the electronic medical record. Resident #130 had diagnoses that included gastrointestinal hemorrhage (bleeding), anemia, and presence of prosthetic heart valve. The Minimum Data Set (a resident assessment tool) dated 4/10/23 documented the resident was understood, understands, and was cognitively intact. The Minimum Data Set documented that Resident #130 took an anticoagulant medication for seven days during the seven day look back period. Review of the Comprehensive Care Plan dated 4/3/23, documented that Resident #130 had a risk for bleeding and other complications secondary to the use of anticoagulants. Interventions included the resident would be monitored for signs and symptoms of bleeding, such as tarry or black stools, drop in hemoglobin or hematocrit (blood level that indicates the amount of iron that will aid the blood cell in carrying oxygen) or bruising to skin with injury. Interventions also included that Resident #130 would be assessed for signs and symptoms of a deep venous thrombosis (blood clot). Review of the hospitalization Discharge Summary Notes dated 4/3/23 at 8:30 AM, documented that Resident #130 was to have Warfarin 5 milligrams daily and to titrate the dose by following the Prothrombin Time/International Normalized Ratio level. Review of the Physician Orders dated 4/1/23 to 4/30/23, documented that Resident #130 had an order for Warfarin 5 milligram tablet once daily in the evening for the presence of a prosthetic heart valve. There was no change in Warfarin orders for Resident #130 from 4/3/23 to 4/30/23. The Physician Orders documented that Resident #130 was to have a Prothrombin Time /International Normalized Ratio laboratory drawn on 4/6/23. There were no further Prothrombin Time /International Normalized Ratio laboratory orders from 4/7/23 to 4/30/23. There was no therapeutic range included on the order. Review of a laboratory report dated 4/6/23 documented Resident #130's Prothrombin Time was 16.3 (normal 10.0-12.9) and International Normalized Ratio was 1.4 (therapeutic 2.0-3.0). Registered Nurse #3's initials and noted 4/7/23 were handwritten on the laboratory results. There was no further documented evidence that a Prothrombin Time/International Normalized Ratio was completed prior to Resident #130's hospitalization on [DATE]. Review of facility medical provider progress notes dated 4/9/23 at 3:35 PM, Physician Assistant #1 documented Resident #130 was on Warfarin 5 milligrams at bedtime and obtain a Prothrombin Time/International Normalized Ratio on Tuesday. On 4/15/23 at 10:38 PM, Medical Doctor #1 documented Resident #130 had valvular heart disease and to continue with Warfarin and check the International Normalized Ratio level. Review of Nursing Progress Notes dated 4/3/23 through 4/30/23 revealed: -On 4/30/23 at 1:05 AM, Licensed Practical Nurse #6 documented that Resident #130 had blood in their stool. -On 4/30/23 at 3:28 AM, Licensed Practical Nurse #6 further documented that Resident #130 had more blood in their brief and the provider was notified with new ordered to send Resident #130 to the hospital for evaluation. -On 4/30/23 at 10:37 AM, Licensed Practical Nurse #7 documented that Resident #130 was admitted to the hospital for a coagulation disorder. There was no documented evidence that a Prothrombin Time/International Normalized Ratio was completed, or a provider was notified of a Prothrombin Time/International Normalized Ratio level from 4/3/23-4/30/23. Review of the hospital History and Physical notes dated 4/30/23 at 1:18 PM, documented that Resident #130 presented to the emergency room with bright red blood in their rectum consistent with external hemorrhoids. Resident #130's International Normalized Ratio blood level was greater than 8.5 on 4/30/23 at 3:58 AM and active problems included: bright red bleeding per rectum-likely hemorrhoidal in the setting of coagulopathy (an impairment in the ability to form a clot in the blood), supratherapeutic (amount of a drug higher than usual to treat a disease effectively) International Normalized Ratio connected to Warfarin use without monitoring. During a telephone interview on 4/23/24 at 1:58 PM, Resident's #130 Health Care Proxy stated that the resident was sent to the hospital in April of 2023 due to bleeding. The Health Care Proxy stated that when Resident #130 arrived at the emergency room their International Normalized Ratio was at 8 and the emergency room doctor noted the facility was not monitoring Resident #130's International Normalized Ratio levels. During a telephone interview on 4/24/24 3:24 PM, Physician Assistant #1 stated they were a medical provider for Resident #130 and recalled that Resident #130 was admitted to the hospital for a supra therapeutic International Normalized Ratio of about 8. Physician Assistant #1 stated that Resident #130 had a lack of monitoring their Prothrombin Time/International Normalized Ratio during their April 2023 facility admission prior to hospitalization due to a lapse in communication between themselves, the physician, and the facility nursing department. Physician Assistant #1 stated that the lack of Prothrombin Time/International Normalized Ratio monitoring was an accident or an oversight and they did not note that during their independent reviews of Resident #130's medical record that the Prothrombin Time/International Normalized Ratio blood level was not being monitored. They stated that the nursing department did not initiate the Laboratory Test Log to aide in the blood level monitoring and they would have expected the nurses who administered the Warfarin to check the log prior to administration of the medication to ensure the correct dose was given. Physician Assistant #1 stated Warfarin medication monitoring should have been done by having an International Normalized Ratio blood level completed at least weekly or every two weeks until the resident's blood level stabilized. Physician Assistant #1 stated that Prothrombin Time/International Normalized Ratio monitoring was important because not monitoring a resident's blood level could lead to harm, bleeding, or blood clotting, if the blood level was not within therapeutic range. During a telephone interview on 4/24/24 4:30 PM, Registered Nurse #3 stated they were the former Unit Manager at the facility. Registered Nurse #3 stated that when a resident was on Warfarin they would notify the provider, ensure that International Normalized Ratio laboratory test was being completed and dose changed if needed. Registered Nurse #3 stated a resident would have Prothrombin Time/International Normalized Ratio blood level drawn based upon the medical provider admission orders then weekly after that. Registered Nurse #3 stated they did not recall Resident #130, or if they ever notified a medical provider of the 4/6/23 Prothrombin Time/International Normalized Ratio lab result but remembered something being wrong with their International Normalized Ratio level. During an interview on 4/25/24 at 4:01 PM, Registered Nurse Supervisor #1 (former Director of Nursing) stated Resident #130 had a PT-INT (Prothrombin time/International Normalized Ratio) drawn on 4/6/23 and the laboratory results were noted with the initials of Registered Nurse #3. Registered Nurse Supervisor #1 stated they were unsure if Registered Nurse #3 addressed the laboratory results (4/6/23) with a provider because there were no medical provider initials on the results and there was no nurse progress note. Registered Nurse Supervisor #1 stated there were no further orders or results for Prothrombin Time/International Normalized Ratio laboratory tests for Resident #130 prior to their hospitalization on [DATE]. Registered Nurse Supervisor #1 stated that Resident #130's International Normalized Ratio therapeutic range should have been between 2-3. Registered Nurse Supervisor #1 stated they expected when nurses administered medication, they also looked at laboratory results that affect the medication. 10 NYCRR 415.12(l)(1)

Based on observation, interview, and record review during the Standard survey completed on 4/26/24, the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes. Specifically, the facility was not in compliance with Section 915 of the 2020 Fire Code of New York State, which requires carbon monoxide detection in all rooms and sleeping areas with fuel-burning appliances, and on-going preventative maintenance of carbon monoxide detectors. This affected two (Unit A and Unit B) of two resident units. The findings are: According to the 2020 Fire Code of New York State, patient rooms in nursing homes are defined as sleeping units. In residential and commercial buildings that contain a fuel burning appliance, carbon monoxide detection shall be installed in all rooms, occupiable space, dwelling units, sleeping areas, and sleeping units that contain a fuel-burning appliance. Additionally, the 2020 Fire Code of New York State stated carbon monoxide detectors shall be maintained in good working order in accordance with Section 915 of this code, National Fire Protection Association (NFPA) 720 (Standard for the Installation of Carbon Monoxide Detection and Warning Equipment), and the manufacturer's instructions/recommendations. Review of the Carbon Monoxide Alarm User's Manual, of the battery operated carbon monoxide alarms that were installed in the building, documented, Regular Maintenance. This unit has been designed to be as maintenance free as possible, but there are a few simple things you must do to keep it in working properly. Test at least once a week. Clean the carbon monoxide alarm at least once a month: gently vacuum the outside of the carbon monoxide alarm using your household vacuum's soft brush attachment. A can of clean compressed air (sold at a computer or office supply store) may also be used. 1a. Observations on 4/22/24 between 9:53 AM and 2:53 PM revealed plug-in style battery operated carbon monoxide alarms were installed in the corridors on Unit A. 1b. Observations on 4/23/24 between 7:57 AM and 3:25 PM revealed plug-in style battery operated carbon monoxide alarms were installed in the corridors on Unit B and the corridor between Unit A and Unit B. During an interview on 4/24/24 at 8:09 AM the Maintenance Director stated, all carbon monoxide detectors in the building were battery operated, the detectors were tested on ce a month, and the facility had documentation for the testing of the carbon monoxide detectors. The Maintenance Director further stated the facility was not vacuuming the carbon monoxide detectors. During an interview on 4/25/24 at 9:08 AM the Maintenance Director stated only one brand of carbon monoxide detector was installed throughout the building and the facility had no documentation for the cleaning of the carbon monoxide detectors. Review Carbon Monoxide testing logs revealed the building's carbon monoxide alarms were tested monthly from 5/22/22 through 3/25/24. Further review of the logs revealed the logs contained no documentation that the carbon monoxide alarms had been vacuumed monthly from 5/22/22 through 3/25/24. 42 CFR 483.70(b) 10NYCRR: 415.29(a)(2), 711.2(a)(1) 2020 Fire Code of New York State, Section 915: 915.3.1, 915.6

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY00298112) started 10/28/22 completed on 11/2/22, the facility did not ensure that all alleged violations including abuse are reported immediately, but not later than 2-hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the appropriate officials (including the State Survey Agency). Specifically, two (Residents #1 and 2) of 6 residents reviewed for abuse were involved in a resident-to-resident altercation and it was not reported timely to the Administrator and to the New York State (NYS) Department of Health (DOH) as required. The finding is: The facility policy and procedure (P&P) titled Abuse Investigation Protocol/ Resident to Resident Abuse dated 9/10/20 documented any resident /visitor/staff member may report any alleged or witnessed abuse to a nurse, supervisor, or department head. The Nursing Supervisor/Manager on duty who is coving the unit where the resident resides is notified, gathers statements from witnesses and residents involved, completes accident/ incident reports and notifies the Nursing Administration. The Director of Nursing (DON)/Assistant Director of Nursing (ADON) or designee determines if there is reasonable evidence of abuse, mistreatment, or neglect. A resident-to-resident contact that is witnessed or cannot be proven otherwise, must be reported to NYS Department of Health. The facility undated power point education provided by the DON titled Abuse Reporting documented; whoever is notified about the abuse, (department heads etc.) must contact the Director of Nursing/designee immediately. A full investigation must be conducted immediately, and case reported to the DOH within 2 hours (if serious injury) or within 24 hours of allegations of abuse or once an investigation has reached the threshold for abuse. Suspected Abuse, when discovered, any evidence of abuse must be reported to the charge nurse regardless of time lapse, the charge nurse will notify the nurse manager and/or DON of the alleged incident. The DON/Abuse coordinator will investigate the allegation. 1. Resident #1 had diagnoses including dementia, generalized anxiety disorder, and Parkinson's Disease. The facility form titled SS (Social Service) - Resident Interview completed 4/21/22 documented Resident #1 had moderate cognitive impairments. Review of the Care Plan Activity Report printed 10/31/22 and identified by the DON as the current comprehensive care plan (CCP) documented Resident #1 exhibited behaviors, and activities were documented to be as a source of danger and/or distress to oneself or to others. This was documented as evidenced by: accusations against staff, at times resistive to care, socially inappropriate behaviors, and verbal aggression directed towards others. Goals included that behavioral outburst will not pose a threat to self or others. Review of Resident #1's Progress Notes dated 6/26/22 electronically signed by Licensed Practical Nurse (LPN) #1 at 2:15 PM documented, just before breakfast resident picked up the wet floor sign and threw it at another resident (#2) which hit them in the face. There were no injuries noted and the aide who saw it happen separated the two residents. Resident #2 had diagnoses including schizophrenia, bipolar disorder and diabetes mellitus type 2. The facility form titled SS (Social Service) - Resident Interview completed on 6/1/22 documented Resident #2 was cognitively intact. Review of the Care Plan Activity Report printed on 10/31/22 and identified by the DON as the current CCP documented Resident #2 was at risk for victimization. Interventions included to monitor interactions, encourage to verbalize feelings, provide 1:1 visits with social services as needed. The Progress Notes dated 6/27/22 completed by Nurse Practitioner (NP) #1 documented, Resident #2 was involved in a resident-to-resident altercation over the course of the weekend and had a plastic wet floor sign thrown at them and was struck in the face by the other resident (#1). There were no injuries on physical exam, Resident #2 denies pain and discomfort. Review of Resident #2's Statement Form dated 6/27/22 at 9:45 AM signed by Registered Nurse (RN) #1 and co-signed by LPN #2 documented Resident #2 was sitting a chair by the nurses' desk when Resident #1 started yelling at Resident #2, punched Resident #2 on left side of their face near their eye, and then threw a wet floor sign at Resident #2 hitting them on the left side of their face near their eye. Review of the facility form titled Unusual Occurrence - Non-Falls dated 6/26/22 and timed 8:15 AM, documented a resident-to-resident altercation. Resident (#2) who got hit was sitting in the common area waiting for breakfast when Resident (#1) picked up the wet floor sign and threw it at Resident #2. The form was signed as completed by LPN #1 and documented that there was no reasonable cause to believe that abuse occurred or that an injury resulted from negligence of a caregiver. The form did not document that an RN was notified and was left blank. Review of facility Employee Statement Form dated 6/26/22 at 8:15 AM by Certified Nursing Assistant (CNA) #1 documented, they were bringing Resident #1 their breakfast tray. Resident #2 was sitting in the chair in front of the mirror and Resident #1 picked up a wet floor sign and threw it at Resident #2 hitting them in the face. CNA#1 documented they got between the residents and directed Resident #2 to the dining room for breakfast. There were no injuries to Resident #2, and the nurse was informed. Review of the Health Electronic Response Data System (HERDS): Nursing Home (NH) Incident Form revealed the DON reported the incident on 6/27/22 at 10:40 AM as any other reportable incident and documented that Resident #1 came out of their room and yelled at Resident #2 who was sitting in hallway, hit Resident #2 in the face with their hand, then picked up a wet floor sign and threw it at Resident #2 hitting them on left side of their cheek. There were no injuries noted. During a telephone interview on 11/1/22 at 1:58 PM, LPN #1 stated they didn't witness the incident and was told about the resident-to-resident altercation from CNA #1. LPN #1 stated they were unsure of the protocols of what to report and if there needed to be an Accident /Incident Report completed for Resident #2. LPN #2 stated they believed they had informed the DON of the incident because it was a resident-to-resident incident/ allegation of abuse because they documented the wet floor sign hit Resident #2 in the face. During an interview on 11/2/22 at 3:37 PM, LPN #2 stated they co-signed Resident #2's statement the day after the altercation. LPN #2 stated the resident-to-resident altercation should have been reported immediately to the DON, the NYS DOH, and an investigation initiated immediately. During an interview on 11/2/22 at 3:39 PM, the DON stated they were not contacted at the time of the resident-to-resident altercation between Resident #1 and #2, and was not made aware of the altercation until the following morning. The DON stated they should have been notified by LPN #1 immediately after the altercation. The DON stated they had reported the incident on 6/27/22 as soon as they knew, and it should have been reported within 2 hours of the allegation/incident on 6/26/22. During an interview on 11/2/22 at 3:47 PM, the Administrator stated the resident-to-resident altercation should have been considered an allegation of abuse and would have expected LPN #1 to have reported the incident to nursing administration. Additionally, the allegation/ incident should have been reported to the NYS DOH within 2 hours of the incident. 415.4 (b)(2)

Based on observation, interview, and record review conducted during a Standard survey started on 3/28/22 and completed on 4/1/22, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living (ADL's) received the necessary services to maintain grooming and personal hygiene. Specifically, one (Resident #35) of two residents reviewed for ADL's had long jagged and dirty fingernails on both hands. The finding is: A facility policy and procedure (P&P) titled Care of Fingernails/Toenails last review date 10/1/21 documented the facility is to maintain the resident's nail bed clean, to keep nails trimmed and to prevent infection. The documented purpose was to maintain resident's dignity, prevent injury and to prevent infection. Nail care includes daily cleaning and regular trimming of the nails. A facility P&P titled ADLs last review date 10/1/16 documented to provide ADL care to all residents based on assessment of needs and to ensure all resident's needs are met in a timely manner. 1. Resident #35 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-a resident assessment tool) dated 2/9/22 documented Resident #35 was severely cognitively impaired, was rarely/never understood, and rarely/never understands. In addition, Resident #35 required total assistance of one for personal hygiene. The care plan activity report generated 4/1/22 documented Resident #35 required total assistance of one for ADL's/care. Documented interventions included Resident #35 would have all their needs anticipated. Review of the Progress Notes dated 3/15/22 through 3/31/22 for Resident #35 revealed there was no documented evidence of nail care provided or that Resident #35 refused care. Review of the Resident CNA (certified nurse aide) Documentation Record dated March 2022 for Resident #35 revealed tasks of skin check/care and personal hygiene was performed at least daily from 3/24/22 through 3/31/22. During intermittent observations on 3/28/22 at 12:39 PM and 3:44 PM, 3/30/22 at 12:19 PM, 3/31/22 at 10:27 AM and 1:04 PM, and 4/1/22 at 7:52 AM revealed Resident #35's fingernails on both hands were long (over the tips of the fingers), dirty with brown debris, jagged and had chipped nail polish. During an interview on 3/31/22 at 12:07 PM, CNA #1 stated it was the responsibility of the CNAs to trim residents' fingernails, if the resident was not a diabetic. Additionally, CNA #1 stated that fingernails should be checked daily; trimmed when long and cleaned when dirty. During an interview on 3/31/22 at 12:16 PM, Licensed Practical Nurse (LPN) #1 stated the CNAs were responsible for cleaning and trimming residents' fingernails on the residents' shower days. Additionally, LPN #1 stated that if a resident was refusing nail care, the CNA should report it to the nurse, and the refusal of care should be documented. During an interview on 4/1/22 at 9:23 AM, Registered Nurse (RN) #1 that Resident #35's showers were scheduled and posted for the 2 pm -10 pm shift on Tuesday's and Thursday's. RN #1 stated the expectation was that on a residents' shower day the CNA would perform head to toe washing, including washing the residents' hair, groom male and females' facial hair and to clean/trim residents nails. Additionally, RN #1 stated that any refusals of care should be brought to the nurse on duty's attention. During a follow interview and observation on 4/1/22 at 10:37 AM, RN #1 stated Resident #35's fingernails were in rough shape and should have been trimmed. During an interview on 4/1/22 at 10:49 AM, the Director of Nurses (DON) stated that fingernails were to be cared for on a residents' shower day and as needed in between if soiled. Nail care not being performed was a dignity issue, infection control issue and residents can cause injury to themselves or someone else if nail care was not provided. 415.12 (a)(3)

Based on interview and record review conducted during the Standard survey started on 3/28/22 and completed on 4/1/22 the facility did not ensure that the resident's representative and the Office of the State Long Term Care Ombudsman was notified of the transfer/discharge of each resident. Specifically, one (Resident #51) of one resident reviewed for hospitalization was transferred and discharged to the hospital on 3/28/22 and the facility did not contact resident's representative and send a copy of the discharge notice to the Office of the State Long Term Care (LTC) Ombudsman. The findings are: Review of the policy and procedure (P/P) titled Discharge: Notification to the Ombudsman dated 9/22/21 documented it is the policy of the facility to notify the ombudsman of all facility-initiated discharges from the facility on a monthly basis. Additionally, monthly the Social Worker will send a list of names, date of transfer and destination of all residents transferred to the hospital. During an interview on 4/1/22 at 12:30 PM the Director of Nursing stated they did not have a policy regarding discharge/ transfer notification. 1) Resident #51 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-resident assessment tool) dated 3/1/22 documented Resident #51 was severely cognitively impaired, sometimes understood and sometimes understands. Review of Progress Notes dated 3/28/22 revealed Resident #51 left the facility for a follow-up appointment at the orthopedics (ortho) office for a right hip surgical site. There was no further documented evidence in the electronic medical record that Resident #51 was transferred or discharge to the hospital. Continued review the electronic medical record revealed there was no documented evidence regarding notification to the resident's representative and Ombudsman that Resident #51 was discharged to the hospital. During an interview on 4/1/22 at 12:03 PM, Registered Nurse (RN) #2, Unit Manager (UM) stated Resident #51 went to an ortho appointment on 3/28/22 and from there the resident was transferred to the hospital and admitted . RN #2, UM stated they did not notify the residents family as they had assumed that the doctor's office would have notified them because they sent the resident to the hospital. RN #2, UM stated if the resident was sent to the hospital from here (this facility) they would have notified the family. During an interview on 4/1/22 at 12:22 PM, the Director of Nursing (DON) stated they would not expect the facility to have notified the family that Resident #51 was admitted to the hospital because they were out at an ortho consult and the resident was sent to the hospital directly from their office. It would be up to the doctor's office to do it. During an interview on 4/1/22 at 12:40 PM the Social Worker (SW) stated, I have not notified the Ombudsman that Resident #51 was transferred to the hospital. At 1:18 PM the SW stated they were the only one responsible for notifications to the Ombudsman .The SW stated they were not aware it needed to be done for hospital transfers or emergencies. On 4/1/22 at 1:22 PM an attempt was mad to contact the facility Ombudsman via telephone and a voice message was left. During an interview on 4/1/22 at 1:48 PM, the Business Office Manager stated Resident #51 was discharged from the facility to the hospital on 3/28/22. 415.3(h)(1)(iv)(d)

Based on observation, interview, and record review conducted during the Standard survey started on 3/28/22 and completed on 4/1/22 the facility did not post on a daily basis the following information: facility name, current date, total number, and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift and resident census in a prominent place readily accessible to residents and visitors. The finding is: Review of the facility policy and procedure titled Daily Staffing Sheets dated 11/21/17 documented it is the policy of the facility to determine the appropriate staffing on a unit based on the census, acuity, shift and needs of the residents. Staffing Coordinator/ Nursing Supervisor prepares staffing based on the pre-determined pars, census and acuity of the unit, and post daily staffing sheets in a prominent location in the facility. During observations made on 3/28/22 through 4/1/22 between 8:00 AM to 3:00 PM revealed the daily staffing sheets were posted in the staff break room by the time clock behind a door which needed a code to enter. This area was not a visible area readily accessible to residents and visitors. During an interview on 4/1/22 at 8:47 AM, the Human Resource Director stated the staffing coordinator was not here today (4/1), but the daily staffing sheets were posted near the employee time clock which was in the employees break room. At the time of the interview an observation was made, and the daily staffing sheet was in the employees' breakroom by the time clock. The employee's breakroom door was locked, and a secure code needed to be entered to gain access to the room. During an interview on 4/1/22 at 9:38 AM, the Director of Nursing (DON) stated the daily staffing sheets had previously been posted on the bulletin board in the hallway near the entrance. I did not realize the staffing coordinator had moved it to the breakroom by the time clock. I will have to do some educating as it has to be posted in an area where residents and visitors can see.

Based on interview and record review conducted during the Standard survey completed on 6/21/19, the facility did not ensure the resident's right to choose activities, schedules (including sleeping and waking times), and health care and providers of health care services consistent with his or her interests, assessments, and plan of care; and make choices about aspects of his or her life in the facility that are significant to the resident. One (Resident #53) of one resident reviewed for choices had an issue involving the revocation of smoking privileges without evidence of unsafe smoking. The finding is: A facility policy titled Resident Safe Smoking with review date of 4/2019 revealed: This facility promotes a smoke-free environment. Grandfathered residents (admitted prior to 10/4/13) who continue to smoke are required to abide by all safety regulations of this facility; failure to do so may result in temporary or permanent loss of smoking privileges. Grandfathered residents must be independent with smoking process. They must be able to safely hold and light a cigarette without the assistance of staff. The comprehensive care plan team will meet to discuss and develop an individualized care plan that addresses and concerns and/or preferences (sic). Any resident found to be non-complaint with the smoking rules and regulations may temporarily or permanently lose their smoking privileges. The disciplinary action will be on level with the severity and risk of safety r/t (related to) the non-compliant action. 1. Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated 5/15/19 documented the resident is understood, understands, and is cognitively intact. In addition, the MDS documented no impairment of functional limitation in range of motion (limited ability to move a joint that interferes with daily functioning (particularly with activities of daily living) or places the resident at risk of injury of the upper extremities nor lower extremities. The Care Plan Snapshot last reviewed/revised 2/15/19 revealed: Problem: Resident is a tobacco smoker. She has a long history of tobacco usage. Goal: Resident will follow all the non-smoking rules as per facility policy. She will only smoke in designated smoking areas. She was grandfathered in to the policy as she has been in the facility since 2011 and has smoked on the property the entire time. Approach: Her compliance with both the smoking policy and the non-smoking policy will be monitored on an ongoing basis. Resident is a smoker. Cigarettes and lighter are kept in the clean utility room. She requests them when she desires to smoke. Signs self out and wheels self to designated area outside. Wears smoking apron. The Care Plan Snapshot last reviewed/revised 2/27/19 revealed: Problem: Resident enjoys daily individual leisure time activities such as watching TV, visiting in lobby with others, going outside to sit and smoke. Goal: Resident will continue to engage in individual activities as evidenced by activity log through next review date. Approach: Staff and volunteers take resident out to smoke 3-4 times daily and assist her with set-up and smoking apron. During an interview on 6/17/19 at 12:56 PM, Resident #53 stated she was grandfathered for smoking and the smoking privileges were taken away about a month ago. The Resident Progress Notes dated 3/28/19 included the following: A meeting was held with Administration, interdisciplinary team, and resident to discuss the safety concerns of resident smoking outside. It had been determined that the resident was no longer safe to smoke outside independently. It was also expressed that there were concerns regarding the resident lighting a cigarette and having an open flame. Review of a Smoking Schedule assessment completed by an Registered Nurse (RN) dated 9/10/18 revealed it was incomplete and lacked documention of unsafe smoking behaviors. Resident Progress Notes dated 1/4/19 through 3/28/19 revealed no documented unsafe smoking behaviors. Review of the nursing 24-hour reports dated (MONTH) 2019 through (MONTH) 2019 revealed no documented unsafe smoking behaviors. During an interview on 6/20/19 at 9:02 AM, the Director of Social Work stated, The former Administrator had indicated that in her talks with corporate it had been decided it was not safe for Resident #53 to go out alone. They wanted her to always have supervision due to safety and to change to flameless due to smoking and risks. I don't know what occurred to make her unsafe. During an interview on 6/20/19 at 9:37 AM, the Director of Activities stated, The new corporate administrators came to the facility, after they left the Administrator stated corporate informed her there was no longer smoking at the facility. The grandfathered residents were no longer grandfathered in per our policy. 415.5(b)(i)(3)

Based on observation, interview and record review conducted during the Standard survey completed on 6/21/19, the facility did not ensure that residents who have not used [MEDICAL CONDITION] drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record and residents who use [MEDICAL CONDITION] drugs receive gradual dose reductions (GDR) and behavioral interventions, unless clinically contraindicated, in an effort, to discontinue these drugs for two (Resident #12, 37) of five residents reviewed for [MEDICAL CONDITION] medications. Specifically, Resident #12 had an issue that involved a physician's orders [REDACTED].#37 had issues that involved the administration of [MEDICATION NAME] without documentation of behaviors or a specific condition to support the use of the medication. In addition, there was no medical work-up prior to the start of the medication. The findings are: 1. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-a resident assessment tool) dated 3/27/19 documented the resident had severe cognitive impairment and received antipsychotic medication. The date of the last GDR was documented as 8/13/18. Review of a facility policy and procedure (P&P) titled Gradual Dose Reduction of Medication with a revision date of 4/2/18 revealed efforts to reduce dosage or discontinue psychopharmacological medications will be ongoing, as appropriate, for the clinical situation. Review of the hospital discharge Med List With Last Dose Given form dated 5/25/18 revealed the resident received [MEDICATION NAME] 75 mg Q (every) HS (at bedtime) with the last dose documented as administered on 5/24/18 at 9:34 PM. An Admission History and Physical physician progress notes [REDACTED]. It documented the Physician placed him back on [MEDICATION NAME]. The Physician Visit Note dated 2/23/19 documented an assessment/plan that resident is on [MEDICATION NAME] for patient safety to prevent harm to himself and others and helps with his agitation and [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. -[MEDICATION NAME] 75 mg QHS 5/26/18 through 5/27/18 -[MEDICATION NAME] 50 mg QHS 5/27/18 through 8/13/18 -[MEDICATION NAME] 25 mg QHS 8/13/18 through 6/20/18 -[MEDICATION NAME] 12.5 mg QHS 6/21/19 Open Ended A Social Work (SW) Progress Note dated 4/8/19 documented the interdisciplinary team (IDT) met with the facility Pharmacy Consultant to review the resident's medications. The Committee recommended a GDR of [MEDICATION NAME] to be reviewed as a possibility by the Attending Physician. Review of a Summary of Recommendations dated 4/8/19 revealed the committee discussed the resident's stable behaviors and recommended to reduce [MEDICATION NAME] 25 mg QHS to 12.5 mg QHS. The form ink stamped Medication Regimen Review, Pharm D was initialed and dated by the Pharmacy Consultant on 5/3/19. Review of a Note to Attending Physician/ Prescriber dated 4/8/19 revealed the Physician agreed to the committee recommendation, signed and dated the form on 4/13/19. The form ink stamped Medication Regimen Review, Pharm D was initialed and dated by the Pharmacy Consultant on 5/3/19. The Medication Administration Record [REDACTED]. Nursing Progress Notes dated 4/2/19 through 5/31/19 revealed no documentation regarding [MEDICATION NAME] decrease to 12.5 mg QHS as recommended by the committee and approved/ordered by the Physician. Review of the 24-Hour Report dated 4/1/19 through 4/30/19 revealed no documentation of Note to Attending Physician/ Prescriber being signed by the Physician on 4/13/19; that the [MEDICATION NAME] had been reduced, or that the order had been implemented. The comprehensive Care Plan dated 6/19/19 revealed the resident had [DIAGNOSES REDACTED]. A planned intervention included to provide the resident with medications per MD (Medical Doctor) order. During an interview on 6/20/19 at 12:30 PM, Registered Nurse (RN) #2 Unit Manager (UM) reviewed the Note to Attending Physician/ Prescriber dated 4/8/19 and stated that Physician #2 agreed to the committee recommendation on 4/13/19 and signed it on 4/13/19 when he came in. During an interview on 6/20/19 at 12:43 PM, the Director of Social Worker (SW) stated the facility has monthly behavior meetings with the facility Pharmacist, SW, and RN UM present. After the meeting, the Pharmacist will send any recommendations to the facility to be reviewed with the Attending Physician and if he agrees the Charge Nurse would be responsible to implement the order, notify the family and document in the resident's record. At 12:45 PM, the SW reviewed the Note to Attending Physician/Prescriber and stated Physician #2 comes in on Saturday's and he agreed to the recommendation on 4/13/19. Pharmacy signed the recommendation on 5/3/19. During an interview on 6/20/19 at 1:18 PM, LPN #2) stated Physician #2 comes in every Saturday on the day shift. If he has a new order for a resident it is the responsibility of the Charge Nurse to enter the order into the computer, so it is implemented; There is no order in the computer, so it wasn't done. During an interview on 6/21/19 at 6:15 AM, RN #3 Supervisor stated she worked as Charge Nurse on Unit B on 4/13/19. She stated, Physician #2 had a folder for what he needs to review and sign when he comes in. He can come in to the building and do whatever and you wouldn't even know he has been in the building. Typically, when there is new order the Charge Nurse would put the order in the computer, write a progress note regarding medication change and call the family. I can't remember that far back. I did not know he had signed the recommendation is the only thing I can say. During an interview on 6/21/19 at 8:52 AM, RN #4 (former B wing UM) stated Physician #2 had a folder on the unit for when he comes in to see his patients. If he has a new order it would be the responsibility of the Charge Nurse on duty to enter the order in the computer, so it is implemented. If it was a weekend, I wouldn't have known about a new order. I don't recall. During a telephone interview on 6/21/19 at 9:57 AM, Physician #2's office RN #5 relayed a message from Physician #2 that when he signed the Note to Attending Physician/Prescriber on 4/13/19, that is considered a new order for the resident. He would expect the new order to be implemented that following Monday 4/15/19. During an interview on 6/21/19 at 12:59 PM, the Director of Nursing (DON) stated, there is no system in place for confirming a new order has been taken off from the Note to Attending/Prescriber. I would expect staff to put the order in the computer, write a note and notify the family right away when a new order is received from the Physician. Right now, there is no process for double checking. 2. Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented that the resident was severely cognitively impaired, sometimes was understood and sometimes understands. Section [NAME] (Behavior) documented the resident had no potential indicators of [MEDICAL CONDITION], hallucinations, or delusions. There were no physical behavioral symptoms exhibited, however verbal behavioral symptoms occurred. The resident was not at significant risk for physical illness or injury; there was no significant interference with the resident's care, participation in activities or social interactions and there was no impact on others. Section N (Medications) documented the resident did receive an antipsychotic medication for the past seven days. Review of a facility P&P titled Psychotherapeutic Drug Policy review date 6/2015 revealed the purpose of the policy is to ensure that a resident who receives psychoactive drugs will be reflected in the initial assessment and ongoing assessments of the needs of the resident concerning the effectiveness and the need to decrease dosages when indicated. The ordering physician must specify and document [DIAGNOSES REDACTED]. Behaviors are to be monitored and charted on the psychoactive drug monitoring sheet, along with alternate methods for treating the condition or symptoms prior to initiating the psychoactive medication. Review of the Physician order [REDACTED]. The order did not include any type of medical evaluation or non-pharmacological interventions. -4/1/19 documented an order for [REDACTED]. -5/4/19 documented an order to increase [MEDICATION NAME] 50 mg twice daily at 10:00 AM and 4:00 PM, for dementia without behavioral disturbance. The order did not include any documentation of rational for increasing the dose, or any non-pharmacological interventions put into place. -6/11/19 documented an order to decrease [MEDICATION NAME] 37.5 mg once daily and on 6/17/19 documented an order to decrease and remain on [MEDICATION NAME] 25 mg once daily for dementia without behavioral disturbances. The order did not include any type of medical evaluation or non-pharmacological interventions. Review of the Care Plan dated 5/25/19 documented the resident received an antipsychotic medication related to a [DIAGNOSES REDACTED]. On 6/19/19 at 8:18 AM Resident #37 was observed in the dining room for breakfast. She was well-groomed, nicely dressed wearing sunglasses, and seated in Geri-chair. One staff assisted with eating; being supportive and verbally cueing the resident to eat and drink. The resident ate very little, and had no behavioral concerns noted at this time. At 10:20 AM the resident was observed in music therapy resting in Geri-chair with no noted behaviors exhibited at this time. During an interview on 6/19/19 at 10:31 AM, Certified Nurse Aide (CNA) #4, stated regarding Resident #37, I have to ask if she wants to eat every time I offer her a bite or a drink because she gets upset, she can't see; often times she won't take a bite. Continued observation on 6/19/19 at 12:21 PM revealed Resident #37 was observed in the dining room for lunch seated in Geri-chair, one staff assisting the resident to eat. Staff verbalized encouragement that the resident hold her own cup. The resident was observed doing very well holding her own cup and drinking from a straw. No behavioral concerns identified at this time. 6/20/19 at 7:25 AM Resident #37 was observed receiving AM care by CNA #3 and Licensed Practical Nurse (LPN) #2. The resident was very vocal calling out that she did not want to get cleaned up, however both staff members were effective using diversional conversation and supportive reasoning. Staff continuously reoriented the resident in a gentle manner, while using positive reinforcement and thorough explanations. During an interview on 6/20/19 at 10:10 AM, when asked what behaviors Resident #37 displayed prior to be started on [MEDICATION NAME] LPN #2 stated that the resident was very loud in the dining room. She would have conversations with herself asking and answering her own questions as if she were two people. The non-pharmalogical intervention was to remove her from the immediate area; and there was no medical work up prior to starting the [MEDICATION NAME]. When asked regarding any behavioral documentation, LPN #2 replied I wish I had an answer, I know it is documented in here somewhere. During an interview on 6/20/19 at 10:27 AM, the DON stated, that clear behavioral charting needed attention. We have identified as a Leadership Team that behavioral notes need to be worked on in this facility. During a telephone conversation on 6/21/19 at 12:08 PM when asked regarding his clinical expectations of staff prior to starting a resident on an antipsychotic medication, Physician #1 stated, I have high expectations, and the staff need to be clear in their assessments, it's one thing if it's a momentary behavioral problem as opposed to continued behaviors. When asked what the clinical indications for use are Physician #1 stated, We use it for residents who are [MEDICAL CONDITION] or have generalized anxiety disorders with behavioral problems. I would expect a full medical exam prior to starting a resident on an antipsychotic. The whole shebang including renal/kidney function, whole lab panel, inclusive of CBC (complete blood count), 12 lead EKG (electrocardiogram)-checking if there was a prolonged Q-T (a heart rhythm disorder that can cause serious irregular interval heart rhythms) and, especially in older people checking for any [DIAGNOSES REDACTED] (movement disorder in which a person's muscles contract uncontrollably), signs of infection and [DIAGNOSES REDACTED] (lack of certain white blood cells.) 415.12(1)(2)(i-ii)

Based on interview and record review conducted during an Abbreviated Survey (Complaint #NY 534) completed on 4/16/18, the facility did not provide and document sufficient preparation and orientation to residents to ensure a safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand. One (Resident #1) of three residents reviewed for discharge preparation did not have services in place at the time of discharge, to assist with medication set-up. The finding is: Review of a facility policy and procedure entitled Discharge Planning Procedure to Other Facility or Home dated 1/1995 revealed the social worker will be responsible for coordinating outside resources such as Public Health, Financial Assistance, Home Health Care and Transportation. 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 9/27/17 revealed resident is understood, understands and is cognitively intact. The MDS documented that the resident requires extensive assistance with bed mobility, transfers, dressing, personal hygiene and is independent with ambulation on and off the unit. Review of the Comprehensive Care Plan (CCP) dated 9/17/17 revealed the resident requires one assist with dressing, grooming, and oral care related to weakness. Further review of the CCP revealed Resident #1 has a history of being noncompliant with his medications and occasionally refuses his medications. A Physician order [REDACTED].#1 to be discharged home today. Review of a Resident Progress Note dated 9/19/17 from 9:42 AM to 1:16 PM revealed the Social Worker (SW) met with Resident #1 to discuss his discharge plans and a referral was made to a home health agency for skilled nursing services, a home health aide (HHA) and a SW to secure help at home for his discharge. A Resident Progress Note date 9/19/17 from 1:18 PM to 2:36 PM revealed the SW spoke with two home health care agencies who were unable to accept Resident #1 due to his past history or because they did not service the area where he lived. Review of a Community Referral Application dated 9/21/17 revealed Resident #1 was non-compliant with medication, treatments, fluid restrictions and has no friends or local family. Further review of the Community Referral Form revealed the section for Risk Factors documented non-adherence to treatments or medication(s) or difficulty managing medications was checked. Review of a Resident Progress Note dated 9/25/17 at 12:52 PM revealed the resident was accepted by a Management Service Organization (MSO) for Home Care Services. The Discharge Summary/ Plan of Care dated 9/27/17 documented that Resident #1 was discharged to home on 9/27/17 via a van accompanied by staff and requires set-up assistance with medication administration. Review of a Resident Progress Note dated 9/27/17 at 2:42 PM revealed Resident #1 was discharged to home; groceries were purchased and put away for him; his laundry was started; garbage was emptied; lunch was given to him; his fish were fed; and his discharge papers were faxed to his primary Physician and the MSO. There was no documented evidence that Home Care Services were arranged for medication management. During an interview on 3/23/18 at 11:00 AM, the Director of Social Work stated that Resident #1 was discharged to home with a Case Management Program, which provides referrals to find services in the community that they don't provide themselves. When asked whether the facility should ensure that services are in place prior to discharge for a resident who is discharged home needing assistance with medication set-up, the Social Worker replied Yes. During an interview on 3/23/18 at 11:45 AM, the Director of Nursing stated she was familiar with how an MSO operates. When asked if the facility should ensure that services are in place prior to discharging a resident home who needs assistance with medication set up, the DON stated yes. A telephone interview with the Referral Coordinator for the MSO on 4/9/18 at 9:04 AM revealed that Resident #1 was referred to a care managed agency on 9/27/17 for enrollment to receive home care services. During a telephone interview on 4/9/18 at 9:14 AM, the Administrative Care Coordinator for the care managed agency stated they received a referral from the MSO for Resident #1 in mid-September; he was only in the outreach program and they were unable to enroll him as he passed away at the end of September. She stated she did not believe the resident was set up with any other agency at the time. Medication management was not arranged for Resident #1 after he returned home. Interview with the Director of Social Worker on 4/10/18 at 2:15 PM revealed it was not standard practice of the facility to indicate Medication Set up on the home discharge instructions. The Director of Social Work was aware Resident #1 was set up with the MSO at the time of discharge, but was unaware if services were in place for medication set-up at the time of discharge. 415.11(d)(3)

Based on interview and record review conducted during an Abbreviated Survey (Complaint #NY 534) completed on 4/16/18, the facility did not provide a discharge summary to residents that includes, but is not limited to, the following: a recapitulation of the residents stay that includes, but is not limited to diagnoses, course of illness/ treatment or therapy, pertinent lab work, radiology, and consultatation results; reconciliation of all pre-discharge medications with the resident's post discharge medications (both prescribed and over the counter); and a post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and post-discharge medical and non-medical services. Specifically, two (Residents #1, 2) of three residents reviewed for discharge summaries were discharged to home without a recapitulation of the resident's stay; a final summary of the resident's status; a medication list of the medications the resident was taking prior to discharge and at the time of discharge; and a post discharge plan of care. The findings are: Review of a facility policy and procedure entitled Discharge Planning Procedure to Other Facility or Home dated 1/1995 revealed the Social Worker will be responsible for coordinating outside resources such as Public Health, Financial Assistance, Home Health Care and Transportation. The resident and or responsible party will be given the name and number of all appropriate state and local protection and advocacy agencies. The Charge Nurse/ Nurse Manager will be responsible for obtaining all medical records materials such as copies of history and physical, DNR papers, lab work, medical discharge summaries, and transfer forms required for orderly transfer. Including prescriptions if discharge is to home. 1. Resident # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 9/27/17 revealed the resident is understood, understands and is cognitively intact. The MDS documented that the resident requires extensive assistance with bed mobility, transfers, dressing, personal hygiene and is independent with ambulation on and off the unit. Review of the comprehensive Care Plan (CCP) dated 9/17/17 revealed the resident requires one assist with dressing, grooming, and oral care related to weakness. Further review of the CCP revealed Resident #1 has a history of being noncompliant with his medications and occasionally refuses his medications. A Physicians Order Report dated 8/30/17- 9/27/17 revealed an order dated 9/27/18 to discharge home today. Review of a Physician Dictation form dated 9/16/17 revealed Resident #1 was seen for a medical necessary visit regarding itching in the groin area. There was no documentation regarding the plan for the resident to be discharged home on[DATE]. Review of the Discharge Summary/ Plan of Care dated 9/27/17 revealed Resident #1 was discharged to home on 9/27/17 via a van accompanied by staff; requires set-up assistance with medication administration; had managed care services in place; and documents given upon discharge included a Medical Orders for Life Sustaining Treatment Form (MOLST). Review of the Discharge Summary/ Plan of Care and the entire medical record revealed no documented evidence of a recapitulation of the resident's stay; a final summary of the resident's status; a medication list of the medications the resident was taking prior to discharge and at the time of discharge; or a post discharge plan of care. Review of a Resident Progress Note dated 9/27/17 at 2:42 PM revealed resident was transported home by staff; he was given his discharged med list and MOLST form; and was reminded to adhere to his fluid restriction and diet. During an interview on 4/10/18 at 1:10 PM, the Registered Nurse (RN #1) Unit Manager stated that upon discharge, the residents are sent home with the Discharge Summary Plan of Care report and the current Medication/ Treatment flow sheet. When asked if the current Medication/ Treatment Flow sheet that was in the medical record was sent home with the resident the RN UM stated, No we print it before they are discharged and it just shows the current medication and not the discharged medications. The interview revealed that the facility was unable to produce the medication list that was sent home with Resident #1 upon discharge. Interview with the Director of Nursing (DON) on 4/10/18 at 1:45 PM revealed she was unable to produce a list of medications sent home with Resident #1 as their electronic computer system is unable to display and/or print the resident's active medication orders after the resident has been discharged . 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #2 is usually understood, understands and is severely cognitively impaired. Further review of the MDS revealed Resident #2 requires the extensive assistance of two for bed mobility, transfers, and toileting and requires extensive assistance of one for hygiene and dressing. Review of the comprehensive Care Plan dated 3/1/18 revealed Resident #2 has the support of her husband with whom she lives with and she and her spouse are hopeful that she will be able to return home when she completes her therapy with services to be determined. Review of a Physician order [REDACTED]. Review of a Physician Dictation dated 3/3/18 revealed Resident #2 was seen for a thirty-day visit; has difficulty walking; labs (laboratory tests) were rechecked; and continue with present therapy. There was no documentation of a plan to discharge the resident to home on 3/6/18. Review of the Discharge Summary/ Plan of Care dated 3/6/18 revealed Resident #2 will be going home with her spouse via car; all her medications are ready; home care services are in place; there were no recommendations from the Physician; and documents given upon discharge included a medication/ treatment flow sheet and a MOLST form. Review of the Discharge Summary/ Plan of Care and the entire medical record revealed no documented evidence of a recapitulation of the resident's stay; a final summary of the resident's status; a medication list of the medications the resident was taking prior to discharge and at the time of discharge; or a post discharge plan of care. Review of a Resident Progress Note dated 3/6/18 at 3:00 PM revealed discharge medications were reviewed and MOLST given. All belongings taken with resident, skin intact, and discharged to home at this time with husband. Interview with the Registered Nurse (RN #1) Unit Manager on 4/10/18 at 1:10 PM revealed upon discharge, the residents are sent home with the Discharge Summary Plan of Care report and the current Medication/ Treatment flow sheet. When asked if the current Medication/ Treatment Flow sheet that was in the medical record was sent home with the resident, the RN UM stated, No we print it before they are discharged and it just shows the current medication and not the discharged medications. The interview revealed that the facility was unable to produce the medication list that was sent home with Resident #2 upon discharge. Interview with the Director of Nursing (DON) on 4/10/18 at 1:45 PM revealed she was unable to produce a list of medications sent home with Resident #2 as their electronic computer system is unable to display and/or print the resident's active medication orders after the resident has been discharged . 415.11(d)(1,2)

Based on observation, interview, and record review conducted during a Standard survey completed on 3/23/18, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two (Residents #1, 48) of 22 residents reviewed for quality of care. Specifically, the interdisciplinary team did not ensure that the management of a resident's care at the end of life maintained the resident's dignity and comfort (#48). Additionally, staff did not obtain laboratory (lab) work for a resident readmitted to the facility after a stay in the hospital stay and did not monitor vital signs while the resident was on antibiotic therapy (#1). The findings are: 1. Resident #1 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician's Readmission History and Physical note dated 2/6/18 revealed the resident returned from the hospital with a [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of the 24-Hour Reports from 2/6/18 to 2/8/18 revealed the resident's name was not under the Labs Drawn section of the report. There were no notations in the unit appointment calendar with the resident's name for labs to be obtained on 2/6/18 through 2/8/18. There were no notations of the resident's name in the lab requisition book on 2/6/18 through 2/8/18. A Nurse Practitioner (NP) Acute Visit Note dated 2/26/18, under the Assessment/ Plan section, documented the patient will need some routine lab work as she has not had any follow up since discharge (from the hospital). Interview with LPN #1 on 3/21/18 at 1:51 PM revealed that the nursing staff writes in the appointment calendar what lab work the resident needs. Regular lab days are on Tuesdays and Thursdays and the lab technician looks at the lab requisition book to see which labs are to be drawn that day. Interview with the RN (#1) Unit Manager on 3/21/18 at 1:55 PM revealed that lab work orders should be written on the 24-Hour Report. The midnight shift is supposed to put the lab order on the appointment calendar, for the residents who are supposed to get labs drawn that day. RN #1 called the hospital where the lab work is processed. The hospital verified there was no lab work drawn for Resident #1 on 2/8/18. Interview with the Director of Nursing (DON) on 3/23/18 at 8:49 AM revealed that she expected her nursing staff to put the order into the computer, write a progress note about the order, and then put it in the lab calendar. She also expected her night shift nursing staff to write in the lab requisition book, which residents need lab work done. b.) Review of a policy and procedure entitled Vital Signs/Baseline Vital Signs dated 7/26/16 revealed that the facility should take vital signs upon admission, monthly, or if a change in condition of the resident occurs. Review of a Brunner & Suddarth's textbook of Medical Surgical Nursing, 10th edition by S. Smelter and B. Bare, pages 529 - 532 revealed the nursing process for a resident being treated for [REDACTED]. This includes but is not limited to monitoring the individuals respiratory status, vital signs, potential complications and efficacy of treatment. The comprehensive Care Plan (CCP) dated 3/6/15 last revised on 3/12/18 documented the resident's cardiac/respiratory status was identified at risk due to a history of pneumonia with an approach to check vital signs as needed and per policy and to monitor resident for changes in vital signs. Review of the Resident Progress Notes dated 1/21/18 through 1/25/18 revealed the following: - 1/21/18 at 6:01 AM - Certified Nurse Aide (CNA) noted that the resident felt warm. The resident's vitals taken at that time included a temperature of 101.8 Fahrenheit (normal is 98.6 F) and pulse 108 (normal 60 to 100 beats per minute). The resident's face was noted to be flushed and her skin was warm. A Progress Note at 9:52 AM revealed that the physician was notified of the resident's condition. New orders were received for an injection of [MEDICATION NAME] (antibiotic) 1 gram and [MEDICATION NAME] (antibiotic) 500 milligrams twice a day for five days. - 1/22/18 at 12:00 PM - The resident's vital signs (vitals) were taken and blood pressure was 155/48 (normal 120/80), pulse 68, respirations 18 (normal 12-20), temperature 98.8 F, and oxygen saturation (measurement of oxygen in the blood) on room air was 98 percent (%) (normal 95% - 100%). - 1/23/18 at 6:30 AM - The resident's vital signs were noted to be stable. The Vitals Report revealed vital signs were recorded on 1/21/18, 1/22/18, and 1/23/18. There were no vital signs recorded on 1/24/18 or 1/25/18. The 24-hour Reports from 1/21/18 to 1/25/18 revealed vital signs were taken on 1/21/18 on all shifts, 1/22/18 on the midnight and afternoon shift, 1/23/18 on the day shift, and there were no vital signs noted on 1/24/18 or 1/25/18. Interview with a Licensed Practical Nurse (LPN #4) on 3/23/18 at 7:25 AM revealed that vitals should be taken every shift for the duration of the antibiotic. Interview with LPN #5 on 3/23/18 at 7:37 AM revealed that vitals should be taken on every shift for the length of the antibiotic. She stated, if the antibiotic is scheduled for five days, we should take vitals for five days. Interview with LPN #3 on 3/23/18 at 7:42 AM revealed that vitals should be taken every shift when a resident is on antibiotics and if the vitals are worsening nursing staff would contact the physician. Interview with the Registered Nurse (RN#1) Unit Manager on 3/23/18 at 8:45 AM revealed that she expected staff to chart in the progress notes any adverse reactions to the antibiotics and to chart vital signs as long as a resident is on the antibiotics. Interview with the Director of Nursing (DON) on 3/23/18 at 8:49 AM revealed that she expected her staff to obtain vital signs on every shift for the duration of the antibiotics. Interview with the RN Infection Control Nurse on 3/23/18 at 9:21 AM revealed that if a resident is on antibiotics they should be checking vitals every shift and documenting on them. 2. Resident #48 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed that the resident was admitted on [DATE] with severe cognitive impairment, sometimes understands, and is usually understood. The facility's policy and procedure (P&P) entitled End of Life Care dated 8/12/16 revealed that Nursing and Social Work staff are responsible to perform an assessment of a resident approaching the end of life to identify symptoms and ways to optimize comfort, relieve suffering and promote dignity. The P&P documented that management of care at the end of life is to relieve suffering and provide the best quality of life for the resident and his/her family. ADL's (activities of life) will be assessed and the care plan adjusted as the resident needs change and increase as they draw nearer to the end of life care. Review of MD (medical doctor) Orders dated 3/9/18 revealed an order for [REDACTED]. The Care Plan History (comprehensive care plan) dated 3/9/18 documented that the resident had a MOLST (Medical Orders for Life Sustaining Treatment) form which indicated that the resident is on Comfort Measures (conservative, supportive measures to be provided at the end of life) only, Do Not Resuscitate (DNR - to withhold emergency lifesaving measures in the event an individual stops breathing or heart stops)/ Do Not Intubate (DNI) (to withhold the insertion of a breathing tube into the airway in the event an individual stops breathing), not send to the hospital, no feeding tube, no IV (intravenous) fluid, and no antibiotics. Care Plan approaches included to respect advanced directive decision, monitor for non verbal cues and unmet needs. A Social Work Resident Progress Note dated 3/12/18 at 11:27 AM revealed that two family members reviewed the resident's 48-Hour Care Plan. There was no specific information regarding end of life care. Review of a Resident Progress Note, written by a Licensed Practical Nurse (LPN), dated 3/12/18 revealed the family requested that the resident receive [MEDICATION NAME] before staff turn him. Review of a Significant Change MDS Resident Progress Note by the Social Worker dated 3/16/18 at 2:06 PM revealed the resident was lethargic; will wake to verbal /physical stimuli; had difficulty understanding others; was unable to communicate his needs; sleeps more, moves slowly and is on Comfort Care and is actively dying. Additional review of the Care Plan History revealed no documented evidence that the care plan was revised to reflect the resident's active dying status. Observation on 3/19/18 at 12:05 PM revealed the resident was transported into the assist dining room in a Geri-chair while the resident was sleeping. At 12:22 PM, a Certified Nurse Aide (CNA #4) approached the resident to feed him; however, the resident remained asleep when the CNA called his name. The CNA took a spoonful of food to the resident's lips and the resident winced, did not accept the food and went back to sleep. The CNA was observed attempting to feed the resident several times over the next 10 minutes with the same result; the resident ate and drank nothing during the lunch meal. Observation on 3/21/18 from 6:27 AM to 9:40 AM revealed the resident remained asleep in bed. At 9:40 AM, CNA #5 entered the room with a breakfast tray to attempt to assist the resident with breakfast. The CNA called the resident's name multiple times and the resident did not respond or wake up. The CNA left the resident's room and removed the breakfast tray. Additional observation on 3/21/18 at 11:15 AM revealed CNA #3 was washing the resident's abdomen, the resident remained asleep and winced when the CNA touched the resident or turned and positioned him. During the observation on 3/21/18 at 11:15 AM, CNA #3 became very upset and cried while stating she was told by nursing staff that she must get the resident up for lunch. The CNA stated she has informed them of his condition (similar to this observation) and they continue to tell her to get the resident out of bed with the mechanical lift to the Geri-chair. The surveyor asked the CNA to check with nursing staff prior to getting him up. The CNA approached the Charge LPN (#6) who stated that the resident had to get up in the Geri-chair for lunch. The CNA found the Registered Nurse (RN #1) UM who stated on 3/21/18 at 11:28 AM that the resident had to get up for lunch to expand the resident's lungs and prevent pneumonia. There is no documentation of this plan in the Resident Progress Notes, the Care Plan History or in the resident's medical record. The RN UM stated the resident is not uncomfortable so it is all right for the CNA to transfer the resident from bed to the Geri-chair to try and feed the resident lunch. The surveyor asked the RN UM if the family was informed of the resident's lack of eating, drinking and general condition over the last couple of days and the RN UM stated they knew the resident was like this when he returned from the hospital on [DATE]. Additional observation on 3/22/18 at 11:44 AM revealed CNA #3 provided incontinence care for the resident. The resident did not respond to the CNA's voice and remained asleep during the task, kept his eyes closed and grimaced when he was touched or turned and positioned. The RN UM was present during this observation. During an interview on 3/22/18 at 11:48 AM, CNA #3 stated the resident was like this yesterday; however, yesterday he opened his eyes from time to time, today he is not responding to voice at all. During an interview on 3/23/18 at 11:30 AM, the Acting Administrator stated she was the Director of Nursing when the resident returned from the hospital and stated that in morning report she instructed staff to get the resident out of bed if he tolerated it for one meal; however, she expected staff to use their judgement. The Acting Administrator stated the resident had little to no food and fluid intake for the last several days and she would make sure the RN UM called the responsible party/family to let them know. 415.12

Based on interview and record review conducted during a Complaint Investigation (#NY 617) conducted during an Abbreviated Survey completed on 12/30/16, the facility did not ensure that each resident receives adequate supervision and assistive devices to prevent accidents. One (Resident #1) of two residents reviewed for mechanical lift transfers had issues. Specifically, the lack of a complete RN assessment to determine sling size and the Comprehensive Care Plan and Resident Profile did not address or include instructions regarding the sling size to be used. The findings are: 1. Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS-a resident assessment tool) dated 10/5/16 revealed the resident was cognitively intact, required total assist for transfers. Additionally, the resident was 59 inches tall and weighed 175 pounds. Review of the Comprehensive Care Plan (CCP) with a revision date of 10/11/6 revealed a plan to transfer the resident with a Maxi Lift (mechanical lift) and the assistance of two people. There was no sling size identified on the Care Plan. Review of the Resident Profile (guide used by staff to provide care) printed on 10/31/16 revealed the resident transfers with a Maxi Lift (mechanical lift) and the assistance of two people. The profile did not include instructions for the size of the sling or which loops to be used during the transfer. Review of a Quality Assurance/ Protected Information Accident/ Incident investigation dated 10/31/16 revealed two certified nurse aides (CNA #5 and #8) transferred Resident #76 to the bed from the chair in the resident ' s room using a Hoyer lift (mechanical lift). While transferring the resident, the sling broke and the resident fell to the floor. The resident landed with her shoulders against the back of the lift and she hit her head on the floor sustaining a laceration on the back of her head approximately the size of a softball. The investigation documented that a Licensed Practical Nurse (LPN #3) was notified immediately. Pressure, ice and gauze was applied and 911 was called. Review of the Employee Statement written by CNA #5 dated 10/31/16 at 8:30 PM revealed: The resident was being transferred by herself and another aide when the sling broke and the resident fell , the sling broke on her left side. She fell on to her back on top of the legs on the lift. Review of an Employee Statement written by CNA #8 dated 10/31/16 at 8:30 PM revealed: CNA #5 and CNA #8 were transferring resident into the bed and the sling broke and she went to report it to the nurse. The sling loops were positioned with the hooks on the green loop towards the head and her arms and the purple loop towards her legs. The sling broke on her left side, she landed on her back on the top of the legs of the lift. Review of an Employee Statement written by LPN #3 dated 10/31/16 revealed the LPN was called to the resident ' s room, when she arrived the resident was lying on her back on the floor with her shoulder blades resting on the lift legs. Bright red blood was coming from the back of resident's head. Gauze and ice were applied to the resident ' s head and 911 was called. Interview with Registered Nurse (RN #2) Unit Manager on 12/14/16 at 10:20 AM revealed, she is responsible for recording the size of the sling on to the resident ' s plan of care. The width of sling may vary from resident to resident. The CNA's are the one who determine the width of the resident and choose which sling is best appropriate. Some residents are larger than other residents and maybe require a larger girth sling. The Nurses are in- serviced yearly on how to identify damaged slings, but could not remember the last in-service prior to 10/31/16. During an interview with LPN #2 on 12/14/16 at 10:16 AM she stated the sling size is on the Resident Profile. It's always been on the Care Plan. I'm not sure who determines the sling size. I believe it is the Unit Manager. During a telephone interview on 12/14/16 at 11:24 AM, a company representative for the sling manufacturer stated that determining the size of the sling for a patient is based on the height and weight of the resident, but it does not necessarily mean they have to use one certain size for some one. It all depends on the weight distribution of the patient. Not all patients are proportioned the same and some have wider girths requiring a different size sling. During a telephone interview on 12/15/16 at 2:39 PM, CNA #8 stated the Maxi Lift was broken on 10/31/16 and the Nurse gave the staff permission to use the Hoyer lift to assist the resident back to bed. The lifts are full body lifts and are compatible. The Maxi sling was replaced with the Hoyer sling while the resident was up in her wheel chair. We hooked the straps up. I was guiding the resident. We were less than a foot away from the bed and the straps broke on the left side and she fell down. The loops did not break; it was where the actual strap was stitched into the fabric. Interview with the Director of Rehabilitation Services on 12/15/16 at 3:00 PM revealed therapy will determine the transfer status of a resident upon admission and the Unit Manager determines the appropriate sling size based on the height and weight of the resident. Both style lifts are full body lifts and are compatible. The staff had to utilize the Hoyer lift opposed to the Maxi lift because the Maxi lift was broken and had been removed from service. During a telephone interview on 12/16/16 at 8:33 AM, CNA #5 stated that her and another CNA received permission from LPN #3 to transfer the resident into bed with the Hoyer lift instead of the Maxi lift. The Maxi lift had been removed from service earlier during the day as it was broken. CNA #5 stated she went into then clean linen room to grab a sling to replace it with the one that the resident had under her in the chair. We replaced the Maxi lift sling with the Hoyer lift sling while the resident was sitting in the chair. We hooked the green loops at the top of her head and hooked the legs on the purple loop down toward the bottom. CAN #5 stated they chose the green loops on the top straps and purple loop on the bottom strap because this would have the resident maintained in an upright position. I had the controls in my hand and the other girl had the resident's legs. We were a foot from the bed before the sling broke. The resident fell to the floor and I immediately went to get the nurse. She stated she had a refresher in-service after the incident occurred but could not recall the last time she had been in-serviced on sling size or use. During an interview on 12/16/16 at 9:35 AM, the DON stated staff are in serviced yearly and sling in-services are included in the mandatory in-services for all direct care staff. Monthly audits were completed by the Director of Housekeeping/Laundry. Those slings will hold up to 450 lbs. The aides all told me they were checking the slings, and stated she was aware that the slings were undated and unlabeled prior to the incident and implemented a new system to identify the slings by number and date as a result of the incident. I guess our previous system was ineffective. During an additional telephone interview on 12/30/16 at 12:31 PM, CNA #5 stated she went into the clean linen room and grabbed a Hoyer lift sling. Hoyer lift slings are full body slings. I grabbed a large sling, based on the resident's weight, one that did not have a commode hole in the middle of it. That is how I knew which one to choose. Maxi lift slings are different than Hoyer lift slings. Hoyer lift slings are a full body sling and a Maxi lift sling, the slings come up around the thighs. During an additional telephone interview on 12/30/16 at 2:32 PM, CNA #8 stated the RN Unit Managers are the ones who determine the correct sling size and the size is put on the Resident Profile, That is how I know what sling to use. We are trained yearly on slings with part of our mandatories (in-servicing). During a telephone interview on 12/30/16 at 11:37 AM, the Director of Nursing (DON) stated the RN's assess for the appropriate sling size based on height and weight. They are the only one who can assess. During a telephone interview on 12/30/16 at 11:50 AM, the RN #2 Unit Manager stated the RN Unit Managers are responsible for sizing the sling upon admission. If a resident is admitted on the weekend, the RN Supervisor is responsible for choosing the correct size of the sling and will address it on the Care Plan based on the resident's height and weight. Additionally, RN #2 Unit Manager stated, I have only been here for five months and was recently trained a few weeks ago on sling sizing per the Policy & Procedure and per the Manufacturer Guidelines. I was not trained prior to then. During a telephone interview on 12/30/16 at 12:45 PM, the Administrator stated that per the manufacturer guidelines the slings are universal and are able to be used with any manufacturer lifts. The RN's are responsible for determining the size of the sling upon resident admission. On the weekend the RN Supervisor would be accountable for sizing of the appropriate sling based on resident height and weight. In summary, Resident #76, sustained injuries from a fall after a mechanical lift sling broke. There was no formal assessment for determining sling size and the instructions for sling size was not included on the Comprehensive Care Plan or the Resident Profile. 415.12(h)(1)

Based on observation, interview and record review conducted during the Standard survey completed on 12/16/2016, the facility did not ensure that a resident with an indwelling catheter (a tube inserted into the bladder to drain urine) received the appropriate care and services to prevent urinary tract infections [MEDICAL CONDITION]. One (Resident #6) of two residents observed for indwelling catheters had issues involving infection control practices were not maintained during care. Specifically, improper glove use and hand hygiene. The findings are: 1. Resident #6 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 10/5/16 revealed the resident has moderate cognitive impairment, is usually understood and usually understands. The resident has an indwelling Foley catheter, and has a history of a UTI within the last 30 days. During an observation of morning care on 12/14/16 at 10:27 AM, Certified Nurse Aide (CNA #7) positioned the resident on his left side to remove the bed pan from underneath him. CNA #7 then took a wash cloth and wiped the resident's buttocks. The wash cloth was visibly soiled with a small amount of brown fecal matter. CNA #7 folded the washcloth over and again wiped the resident's buttocks with the wash cloth, until resident was clean. CNA #7 then positioned the resident on his back. CNA #15 (who was assisting) left the room to gather more clean linens. CNA #15 returned to the room and handed CNA #7 the clean washcloths. CNA #7 proceeded to wash resident's perineal area (area between the anus and genitalia), genitals, including the Foley catheter tubing, without changing her gloves or washing her hands. After personal care was completed, CNA # 7 disposed of her soiled gloves into the trash can under the sink area, opened the door with her right hand, touching the doorknob without washing her hands. During an interview on 12/14/16 at 11:17 AM, CNA #7 stated she was unaware that she did not change her gloves and wash her hands between cleaning the resident's buttocks and genital area. CNA #7 stated she should have changed her gloves and washed her hands in between care and touching the door knob. I was nervous. During an interview on 12/16/16 at 9:30 AM, the Director of Nursing (DON) stated the CNA should have changed her gloves and washed her hands after cleansing the residents buttocks of fecal matter and prior to providing pericare and Foley care. He (the resident) has a history of UTI's. I will monitor his vital signs, place the resident on 24 hour report and get an order for [REDACTED].>Review of the facility policy and procedure entitled Catheter Care reviewed date 11/30/15 revealed the purpose of this procedure is to prevent invasion of micro-organisms into the drainage system and prevention of urinary tract infection. Hands are to be washed before and after caring for catheter, tubing or drainage bag. Review of a policy and procedure entitled Hand-Washing reviewed 12/16/15 revealed handwashing is the single most important action you can take to prevent the spread of infection. Always wash hands between care of residents, and after handling contaminated articles. Review of a policy and procedure entitled Incontinent Care date 9/15/14 revealed to avoid feces in the urinary area. 415.12(d)(1)

Based on interview and record review conducted during a Complaint Investigation (Complaint #NY 103) conducted during a Standard survey completed on 12/16/16, the facility did not immediately consult with the resident's Physician when there is a significant change in the resident's physical status. One (Resident #123) of one resident reviewed for notification of change had issues with lack of documented evidence that the Physician was notified when the resident complained of a headache after having a fall with head injury. 1. Resident #123 had [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - a resident assessment tool) dated 9/14/16 revealed the resident was cognitively intact, understood and understands. Review of the resident's comprehensive Care Plan dated 9/9/16 revealed the resident was care planned for being at risk for falls. Review of a Resident Progress Note dated 9/15/16 and timed 2:24 AM written by the Licensed Practical Nurse (LPN #1) revealed, the resident was found on the floor with the mattress on top of her. The resident said that she hit her face on the bedside table. The resident does have a 2 centimeter (cm) laceration on the left side of her top lip. 1 cm laceration to the inside. Bleeding noted, stopped with pressure and a wet wash cloth. 4 cm bruise noted to right wrist. No further injuries noted. ROM WNL ( range of motion, within normal limits). Neuro (neurological) checks WNL. RN notified will continue to monitor. Review of a Observation Report dated 9/15/16 revealed the resident's vitals were taken: - 2:35 AM - the resident's pulse rate was noted to be 123 beats per minute (normal 60 - 100 beats per minute) - 3:13 AM - the resident's pulse rate was noted to be 120 beats per minute Review of a Resident Progress Note dated 9/15/15 and timed 5:54 AM revealed, Resident complaining of a headache, refusing to take anything for pain. Further review of the Observation Report dated 9/15/16 and timed 5:39 AM revealed the resident's vitals were taken and the resident's pulse rate was noted to be 100 beats per minute. Review of a Resident Progress Note dated 9/15/16 and timed 4:16 PM written by a Registered Nurse (RN #2) revealed, 1:15 PM therapy came to me stating resident noted to have right side facial droop with drool on left side. Also not able to form words and mumbling. Writer into assess resident. Remain with slight right sided facial droop, speech and thought process slow and slight slurred. Pupils equal and reactive. Grips left stronger then right. Arm drift, resident able to lift both arms but right not as far as left. Vital signs: temperature - 99.0 (98.6 degrees fahrenheit), heart rate - 91 and respirations - 23 (12-20), blood pressure - 112/63 (top number that's between 90 and 120, and a bottom number that's between 60 and 80). At 1:45 the MD (medical doctor) was notified and an order was received to send the resident to the emergency room (ER). At approximately 2:10 PM the resident left the facility for the ER. Review of undated document entitled Signs and Symptoms (a facility guideline of when to call the on - call Physician or Nurse Practitioner (NP)) revealed the provider should immediately be contacted for a fall; when a resident has a fall with any suspected serious injury, any hip pain, or more than minor pain elsewhere or a fall with only insignificant injury. Review of the Situation Background Appearance Review (SBAR) and Progress Note for RNs/LPN/LVNs dated 9/15/16 initiated and signed by LPN #1, revealed the section entitled Review and Notify is blank. Interview on 12/15/16 at approximately 10:00 AM with RN #2 revealed that she would expect her staff to contact the Physician after the resident had a fall and complained of a headache. Interview on 12/15/16 at approximately 10:30 AM with the Director of Nursing (DON) revealed that she expects that if the resident complained of any new symptom after a fall, to contact the emergency department provider at the local hospital and follow their directions. Interview on 12/15/16 at approximately 10:50 AM with LPN #1 revealed that she should have called the provider when the resident complained of a headache and followed the provider's instructions. Interview on 12/15/16 at approximately 3:00 PM with the resident's Physician revealed that the provider expects the staff to contact the provider or the emergency department provider at the local hospital if there is a change in condition of the resident. Review of the facility policy and procedure entitled Reporting Change in Resident Condition dated 7/6/15 states, if there is a change in condition the nurse will complete an SBAR prior to calling the provider. The Physician or Provider will be informed of the data on the SBAR and the wishes of the resident, family and health care proxy. All communication will be documented in the progress notes. 415.3(e)(2)(ii)(b)

Based on interview and record review conducted during a Complaint Investigation (Complanit #NY 103) conducted during a Standard survey completed on 12/16/16, the facility did not ensure that each resident receives the necessary care and services to maintain the highest practical physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Specifically, one (Resident #123) of 23 residents reviewed for quality of care had an issue with the lack of a Registered Nurse (RN) assessment for the resident who complained of a headache after a fall with a head injury. 1. Resident #123 had [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - a resident assessment tool) dated 9/14/16 revealed that the resident was cognitively intact, understood and understands. Review of a Resident Progress Note dated 9/15/16 and timed 2:11 AM revealed that the RN on call (Director of Nursing) received a call that the charge nurse answered the call light and found the resident on the floor next to her bed with the mattress on top of her. She had sustained an injury to her lip and bruising. Instructed to start neurological checks and complete a Situation Background Appearance and Review (SBAR). Review of a Resident Progress Note dated 9/15/16 and timed 2:24 AM written by the Licensed Practical Nurse (LPN #1) revealed, the resident was found on the floor with the mattress on top of her. The resident said that she hit her face on the bedside table. The resident does have a 2 centimeter (cm) laceration on the left side of her top lip. 1 cm laceration to the inside. Bleeding noted, stopped with pressure and a wet wash cloth. 4 cm bruise noted to right wrist. No further injuries noted. ROM WNL (range of motion, within normal limits). Neuro (neurological) checks WNL. RN notified will continue to monitor. Review of the Situation Background Appearance Review (SBAR) and Progress Note for RNs/LPN/LVNs dated 9/15/16 initiated and signed by LPN #1, revealed that the section entitled Review and Notify is blank. Review of the Observation Report dated 9/15/16 revealed the resident's vitals were taken: - 2:35 AM - the resident's pulse rate was noted to be 123 beats per minute (normal 60 - 100 beats per minute) - 3:13 AM - the resident's pulse rate was noted to be 120 beats per minute Review of a Resident Progress Note dated 9/15/15 and timed 5:54 AM revealed, Resident complaining of a headache, refusing to take anything for pain. Further review of the Observation Report dated 9/15/16 and timed 5:39 AM revealed the resident's vitals were taken and the resident's pulse rate was noted to be 100 beats per minute. Review of a Resident Progress Note dated 9/15/16 and timed 4:16 PM written by a Registered Nurse (RN #2) revealed, 1:15 PM therapy came to me stating resident noted to have right side facial droop with drool on left side. Also not able to form words and mumbling. Writer into assess resident. Remain with slight right sided facial droop, speech and thought process slow and slight slurred. Pupils equal and reactive. Grips left stronger then right. Arm drift, resident able to lift both arms but right not as far as left. Vital signs: temperature - 99.0 (98.6 degrees fahrenheit), heart rate - 91 and respirations - 23 (12-20), blood pressure - 112/63 (top number that's between 90 and 120, and a bottom number that's between 60 and 80). At 1:45 the MD (medical doctor) was notified and an order was received to send the resident to the emergency room (ER). At approximately 2:10 PM the resident left the facility for the ER. Interview on 12/15/16 at approximately 10:00 AM with RN #1 she stated that there is a RN on call during the midnight shift but not in the building. She also stated that the DON is usually on call during the week and she and the other RN rotate the weekends. She stated that she expects her nursing staff to contact the RN if there is a change in condition and a need for an assessment. Interview on 12/15/16 at approximately 10:30 AM with the DON revealed that she expects her nursing staff on the midnight shift to complete an SBAR and to contact the provider or the emergency department provider at the local hospital if there is a change in condition. Interview on 12/15/16 at approximately 10:50 AM with LPN #1 revealed that she could not recall if she told an RN about the resident's headache. 415.12

Based on observation, interview, and record review conducted during the Standard survey completed on 12/16/16, the facility did not ensure that residents who are unable to care out activities of daily living (ADL's) received the necessary services to maintain good personal hygiene. One (Resident #89) of five residents observed for personal care had issues involving the certified nurse aide (CNA) washing the resident's groin and genitals with a washcloth that was previously used to wash the resident's feet. The findings is: 1. Resident #89 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 10/26/16 revealed the resident has severely impaired cognition and rarely or never understands. Further review of the MDS revealed the resident is totally dependent on one person for bathing and requires the extensive assistance of one person for personal hygiene and dressing. Review of the current comprehensive care plan dated 5/18/2016 revealed the resident requires assistance of one with bathing, encourage resident to assist with care as much as possible. During an observation of the resident's shower on 12/15/16 at 11:23 AM, the Certified Nurse Side (CNA #2) assisted the resident to wash his upper body and back while the resident sat in a shower chair with a toilet seat. CNA #2 then soaped the wet washcloth and washed the resident's thighs, lower legs and feet. Using the same washcloth, CNA #2 washed the resident's groin, male genitalia, then reached under the shower chair and washed the resident's peri area (the area between the rectum and genitalia) and buttocks. After washing the area, CNA #2 placed the brown stained washcloth on the floor of the shower. CNA #2 retrieved a dry, clean washcloth from a table in the shower room, wet and soaped the washcloth and re-washed the peri area and exposed buttock by reaching under the shower chair. CNA #2 placed the second washcloth on the floor of the shower and rinsed the soap off the resident's entire body. During an interview with the Registered Nurse (RN #1) Unit Manager (UM) on 12/16/16 at 8:28 AM, the RN UM stated that staff should not wash the resident's genitalia and peri area with a washcloth that was used to wash the resident's feet. During an interview with CNA #2 on 12/16/16 at 8:42 AM, CNA #2 stated she should not have washed the resident's groin, genitalia, peri care with the same washcloth used to wash the resident's feet but should have used a clean washcloth instead. 415.12(a)(3)

Based on observation, interview and record review conducted during the Standard survey completed on 10/25/13, the facility did not immediately consult with the resident's physician when there was a significant change in the resident's physical condition with a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment.) Specifically, one (Resident #42) of 19 residents reviewed for notification of change lacked timely physician notification of a resident's ongoing gastrointestinal symptoms not relieved with the most recent treatment orders. The Physician was not notified of the ongoing symptoms from 10/14/13 to 10/20/13. The resident continued to have a firm, distended abdomen with decreased oral intake and ongoing complaints of nausea, vomiting and pain. On 10/22/13, the Nurse Practitioner (NP) evaluated the resident, who was then transferred to the hospital and underwent abdominal surgery. This resulted in actual harm that is not immediate jeopardy. The finding is: 1. Resident #42 has [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS - an assessment tool) dated 7/31/13 revealed the resident is cognitively intact, understands and is understood. The MDS documented that the resident's mood included feeling depressed, tired, bad about herself, and having a poor appetite. The MDS also documented that the resident received scheduled pain medication. Review of a Resident Progress Note dated 10/8/13 at 8:30 AM revealed a Licensed Practical Nurse (LPN #1) documented that the Nurse Practitioner (NP) ordered a flat plate x-ray of the resident's abdomen due to complaints of a tender and distended abdomen. Review of a Radiology Report dated 10/8/13 revealed the x-ray of the abdomen showed "severe ileus pattern." A Resident Progress Note dated 10/8/13 at 3:25 PM documented that new medical orders from the resident's physician included a clear liquid diet until further notice, obtain a urinalysis (laboratory analysis of urine) and urine culture/ sensitivity (identifies bacteria and susceptibility to antibiotics), and administer a [MEDICATION NAME] suppository (laxative medication) 10 mg (milligram) one time rectally at 4:00 PM. Review of a Resident Progress Note, written by the Registered Nurse (RN) Unit Manager (UM) dated 10/9/13 at 10:07 AM revealed that the NP was in and reviewed the results of the abdominal x-ray. The RN Manager documented that the NP ordered a soapsuds enema (SSE). Review of a Vitals Report, dated 9/22/13 to 10/22/13 revealed the resident had a medium amount of loose brown stool on 10/8/13 and a medium amount of liquid brown stool on 10/9/13. Review of a Resident Progress Note dated 10/12/13 at 10:10 AM revealed RN #2 documented that new orders were received to [MEDICATION NAME](antibiotic medication) 500 mg one tablet twice daily by mouth for seven (7) days. The RN documented that the resident's abdomen remained firm, bowel sounds were hypoactive (slow activity) and the physician was aware. At 1:18 PM, RN #2 documented that the resident complained of nausea with no emesis (vomiting), was tolerating the liquid diet and that the physician was in to see the resident. Review of an Event Report for the physician's Acute Care Visit on 10/12/13 revealed that the physician reviewed the x-ray and laboratory results. The physician documented that the resident had an ileus and a urinary tract infection and was slightly dehydrated. The Physician documented that the resident was started on an antibiotic on 10/12/13 and "We will see how she responds to that." "If she is not responding to this and her symptoms persist, we will hospitalize her for further evaluation." Additional review of the Vitals Report dated 9/22/13 to 10/22/13 revealed on 10/11 there was no bowel movement (BM); on 10/12, a small BM; on 10/13, a medium BM; on 10/14, no BM, and 10/15, a small BM. Additional review of the Vitals Report revealed the resident's dietary intake recorded for 10/15/13 and 10/16/13 included the following: - 10/15/13 breakfast- none, lunch- refused, dinner- 51-75% (percent) - 10/16/13 breakfast- none, lunch 1-25%, dinner- none. Further review of Resident Progress Notes dated 10/13/13 to 10/15/13 revealed the following: - On 10/13/13 at 11:03 AM, RN #1 documented that orders were received to discontinue Cipro, begin Keflex (antibiotic medication) 500 mg three (3) times a day by mouth and that the resident may have diet as tolerated. - On 10/14/13 at 2:40 PM, RN #2 documented, "abdomen firm and distended, hypoactive (slow activity) bowel sounds." - On 10/15/13 at 3:09 AM, RN #3 documented the resident's abdomen remained distended and firm, with no complaints of nausea or vomiting. - On 10/15/13 at 9:46 AM, RN #2 documented that the resident "refused breakfast, abdomen remains distended, bowel sounds hypo(active), no emesis. VSS (vital signs stable- temperature, pulse, respirations, blood pressure), encouraged to ambulate, refuses." - On 10/15/13 at 1:48 PM, RN #2 documented, "refused lunch, taking liquids." - On 10/15/13 at 9:10 PM, RN #4 documented, "small amount of emesis (vomiting) noted around 4:00 PM. VSS (Vital signs stable). Bowel sounds were hypoactive throughout. Abdomen slightly distended and uncomfortable upon palpation. Complains of pain being a seven (7) on a scale of 1 to 10. Fluids offered and accepted well." During an interview on 10/25/13 at 12:41 PM, RN #4 recalled that (on 10/15/13) the resident "had quite a problem with abdominal distention; she was in a lot of pain; and the family was quite concerned with her condition and felt like nobody was doing anything except giving her suppositories and enemas." The RN stated that she attempted to contact the physician and that the physician's voice mail was full. The RN stated that the resident received scheduled pain medication, her discomfort "subsided somewhat" and that she informed the next shift. Additional review of the Resident Progress Notes and 24-Hour Nursing Report for the evening and night shifts on 10/15/13 revealed no documented evidence that the resident's pain level of seven (7) and the episode of emesis were communicated between nursing shifts or to the resident's physician. Review of the Vitals Report dated 9/22/13 to 10/22/13 revealed that the resident ate 25 percent or less of each meal for eleven (11) of thirteen (13) meal intakes recorded from 10/16/13 through 10/20/13 and the resident did not have a bowel movement on 10/17, 10/18 and 10/19/13. Additional review of Resident Progress Notes and 24-Hour Nursing Reports dated 10/16/13 to 10/19/13 revealed no documented evidence that the physician was informed of the resident's poor dietary intake and of the lack of a bowel movement. Review of Resident Progress Notes dated 10/16/13 to 10/20/13 revealed the following: - On 10/16/13 at 7:51 AM, RN #2 documented, "medium BM, bowel sounds decreased in lower abdomen, abdomen remains distended and firm, took only fluids for breakfast..." - On 10/16/13 at 9:31 PM, RN #4 documented, "resident continues to feel abdominal discomfort. She refused to eat dinner this evening. Bowel sounds were hypoactive throughout and abdomen slightly distended. Abdominal discomfort noted upon palpitation. Complained of feeling nauseous, especially after eating, drinking or taking medications." - On 10/17/13 at 3:41 AM, RN #3 documented, " ...abdomen remains distended." - On 10/18/13 at 8:03 PM, RN #5 documented, "(the resident) refused dinner. She accepted fluids poorly this shift." - On 10/19/13 at 2:51 PM, RN #2 documented, "appetite poor despite encouragement, refused to get out of bed, states she just doesn't feel well. VSS." - On 10/20/13 at 9:59 AM, RN #2 documented, "complaints of nausea, abdomen remains distended, bowel sounds hypo (active), appetite poor, afebrile, will speak with (the physician) tomorrow regarding no appetite, nausea." - On 10/20/13 at 6:55 PM, LPN #3 documented that the "resident's sister was insistent on sending (the) resident to ER (emergency room ). (The physician) called and updated on condition. New orders obtained, give [MEDICATION NAME] suppository per rectum now, give fleets enema in am (morning) and update him with results ..." Interview with LPN #3 on 10/24/13 at 4:40 PM revealed that on the evening of 10/20/13, a family member came in and was insistent that the resident be sent to the ER. The LPN stated she was aware that the resident had an ileus and she did not think the resident was any different than she had been. The nurse reported that the patient was given a [MEDICATION NAME] as the physician ordered. During an interview on 10/25/13 at 2:00 PM, the resident's Physician stated that when the nurse called him on 10/20/13 regarding the family's concern for hospitalization , he recalled being told that "Nothing was different." The Physician stated that he ordered blood work for the following day which showed some dehydration and possible hemolysis (destruction of red blood cells in a blood sample). Continued review of the Resident Progress Notes revealed: - On 10/21/13 at 2:26 PM, LPN #4 documented, "abdomen soft, remains distended ..." - On 10/21/13 at 10:35 PM, RN #4 documented, "small amount of emesis note ...Complaints of nausea noted ...." On 10/21/13 at approximately 10:30 AM, the surveyor approached the resident who was lying in bed, to request an interview. The head of the bed was elevated to 60 degrees. The resident was observed intermittently closing her eyes, muttering and moaning. The resident declined the interview, saying she was tired and did not feel well. Review of a Resident Progress Note, written by RN #2, dated 10/22/13 at 7:44 AM revealed "Abdomen remains distended. Bowel sounds hypoactive, crying, complaints of pain in abdomen. (Facility NP) in and examined, orders to send to (local hospital) ER." An untimed Resident Progress Note dated 10/22/13 documented that the resident was transferred to the hospital and at 1:30 PM, the RN UM documented, "verbal report from the ER, resident admitted with ileus." During an interview on 10/24/13 at approximately 4:00 PM, the RN Charge Nurse was asked why she did not call the physician from 10/13/13 to 10/21/13, when the resident continued to display ongoing abdominal symptoms. The RN stated that when she did rounds with the physician (on 10/12/13), he stated the urinary tract infection could make the bowels sluggish and he wanted to give the medication a chance to work; "if she didn't get better they would have to take her to the hospital." The RN stated that the resident was eating and drinking, and she was moving her bowels. Interview with the facility NP on 10/25/13 at 8:33 AM revealed that he saw the resident at the facility's request on 10/8/13 and ordered the abdominal flat plate. The NP saw the resident again at the staff's request the morning of 10/22/13 when he determined her condition was much worse and he sent her to the ER. Interview with the Night RN Charge Nurse/ Supervisor on 10/25/13 at 12:15 PM revealed the resident's abdominal problems began with distention, nausea and emesis. The RN recalled she was told the resident had a possible ileus. The RN stated she was informed that the physician was aware of the resident's condition and she knew that the day staff was conversing with him. Interview with the RN Evening Supervisor on 10/25/13 at 2:45 PM revealed she knew that the resident had abdominal discomfort. The RN stated that the physician and nurses were handling it. She couldn't recall having to assess the resident. Interview with the resident's Physician on 10/25/13 at 2:00 PM revealed that the resident had a significant history of [MEDICAL CONDITION] and constipation. The Physician stated that around 10/9/13, the resident had an abdominal flat plate which suggested ileus. The Physician stated he ordered labs (laboratory tests), suppositories and enemas. He stated he saw the resident again on the "19th" and her abdominal problems were getting worse, abdomen distended, non-tender, denied nausea and he recalled that the nurses said she was taking fluids well, although her appetite was down. The Physician stated he tried enemas and suppositories again and the resident had small results with no increase in pain. The Physician stated the next day, the resident was sent to the hospital, she had a possible bowel obstruction and required surgery for [REDACTED]. Re-interview with the Physician on 10/25/13 at approximately 3:00 PM, after the facility was unable to locate a 10/19/13 physician visit note, revealed he was mistaken. The Physician reported that he saw the resident on 10/12/13. When questioned what he would have wanted the nurses to monitor and inform him of, the Physician stated "unrelieved pain and continued abdominal problems without relief." The Physician stated he was not called from 10/12/13 until 10/20/13 when the nurse called him with an update. The Physician stated that during the 10/20/13 telephone call, he asked if the resident had pain and he was told "no". 415.3(e)(2)(ii)(b)