Every finding on record at Lynbrook Restorative Therapy And Nursing

Based on observation, record review, and interviews the facility did not ensure that all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. This was identified for one (1) (Resident #77) of two (2) residents reviewed for antibiotic use. Specifically, on 02/01/2026 Resident #77 was receiving the antibiotic Vancomycin intravenously through a peripherally inserted central catheter (a long, thin tube inserted into a vein in the arm and threaded to a large vein near the heart, used for delivering long-term intravenous treatments) in the right upper arm. The resident's name, time/date of administration, and staff member identification were not indicated on the medication vial, normal saline bag, or the intravenous (IV) tubing.The finding is:The facility policy titled Intravenous Medication Infusion and Therapy/Hydration, effective 05/2020, documented to administer intravenous medications as per the physician's order and maintain intravenous lines. All licensed nurses are to ensure that intravenous medications and/or therapy are administered to the right resident, via the right route, right dosage, and right frequency and duration. Intravenous medications that come from the pharmacy have pharmacy labels. If the pharmacy label comes off mistakenly, an intravenous sticker label can be used to ensure the intravenous medication is properly labeled. Intravenous medications and fluids (for hydration therapy) that come from the in-house emergency supply are to be labeled with the intravenous sticker labels.Resident #77 was admitted with diagnoses including diabetes mellitus, peripheral vascular disease, and major depressive disorder. The 01/07/2026 admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 11, indicating the resident had moderate cognitive impairment. The resident received intravenous medication while a resident.A physician's order dated 12/31/2025 and renewed on 01/27/2026 documented vancomycin 1 gram/250 milliliter in 0.9% sodium chloride intravenous, infuse 1 gram by intravenous route every 12 hours, every day at 9:00 AM and 9:00 PM, for six weeks for diagnosis of extradural and subdural (brain area) abscess (pus collection in the brain).During an observation on 02/01/2026 at 12:25 PM, Resident #77 was in bed receiving the antibiotic vancomycin via the peripherally inserted central catheter line to the right arm. The medication vial, the normal saline bag, and the tubing were not labeled with the resident's name, the time and date of the intravenous antibiotic was started or the initials of the nurse who started the intravenous antibiotic medication.During an observation and interview on 02/01/2026 at 12:28 PM, Licensed Practical Nurse #1 (the medication nurse) entered Resident #77's room and observed the intravenous medication being administered. Licensed Practical Nurse #1 stated the medication was set up and started by Registered Nurse Infection Preventionist #1.During an interview on 02/01/2026 at 12:30 PM, Registered Nurse Supervisor #1 stated Registered Nurse Infection Preventionist #1 initiated Resident #77's vancomycin administration. Registered Nurse Supervisor #1 stated there should be a label on the intravenous medication vial, the normal saline bag, and the tubing as required to ensure the right resident is getting the right medication and that the medication is being administered according to the physician's order.Review of the February 2026 medication administration record revealed that the 9:00 AM dose of intravenous vancomycin was administered to Resident #77 by Registered Nurse Infection Preventionist #1.During an interview on 02/02/2026 at 2:10 PM, Registered Nurse Infection Preventionist #1 stated they administered the morning dose of vancomycin antibiotic to Resident #77 on 02/01/2026. Registered Nurse Infection Preventionist #1 stated the medication vial, the normal saline bag, and tubing should have been labeled to ensure resident safety and prevent medication errors.During an interview on 02/04/2026 at 11:30 AM, the Director of Nursing Services stated to ensure the right resident is getting the right medication and that the medication is being administered according to the physician's order, the intravenous medication should be labeled with the resident name, time and date of the administration, and initials of the staff member who started the administration.10 NYCRR 415.18(d)

Based on record review and interviews, the facility did not ensure that completed Minimum Data Set assessments were encoded and transmitted within fourteen (14) days after completion. This was identified for two (2) (Resident #21 and Resident #118) of two (2) residents reviewed for Resident Assessment. Specifically, Resident #21's and Resident #118's Minimum Data Set Assessments were transmitted 41 and 40 days late respectively. The finding is: A facility policy titled Minimum Data Set Submission and Transmission dated 08/13/2025 documented to submit and transmit all required Minimum Data Set assessments to the Internet Quality Improvement and Evaluation System (iQIES) Assessment Submission and Processing database in accordance with current Omnibus Budget Reconciliation Act (OBRA) and Skilled Nursing Facility Prospective Payment System (SNF PPS) regulations. The Minimum Data Set Coordinator or designee shall be responsible for ensuring that Minimum Data Set assessments are submitted to the Internet Quality Improvement and Evaluation System Assessment Submission and Processing database in accordance with the Federal and State guidelines. A review of the Minimum Data Set (MDS) 3.0 Nursing Home Validation Report revealed the following: Resident #21's Discharge - Return Not Anticipated Minimum Data Set assessment, with an assessment reference date of 12/03/2025, was completed on 12/09/2025 and was not transmitted to the Center for Medicare and Medicaid Services until 02/02/2026. This assessment was submitted 41 days late. Resident #118's Discharge - Return Not Anticipated Minimum Data Set assessment, with an assessment reference date of 12/04/2025, was completed on 12/10/2025 and was not transmitted to the Center for Medicare and Medicaid Services until 02/02/2026. This assessment was submitted 40 days late. During an interview on 02/05/2026 at 2:22 PM, the Minimum Data Set Coordinator stated that the completed Discharge Minimum Data Set assessments for Resident #21 and Resident #118 were not transmitted within fourteen (14) days after their completion. The Minimum Data Set Coordinator stated that they did not know that the assessments were not transmitted and there was a transmittal error until they pulled the Nursing Home Validation Report today. The Minimum Data Set Coordinator stated that they are responsible for reviewing for errors on transmittals. During an interview on 02/05/2026 at 2:25 PM, the Administrator stated that they were not aware that the completed Minimum Data Set assessments for Residents #21 and Resident #118 were not transmitted within the required timeframe. 10 NYCRR 415.11

Based on record review, and interviews, the facility did not ensure medical records were in accordance with accepted professional standards and practices. This was identified for four (4) (Resident #12, Resident #34, Resident #27, and Resident #77) of five (5) residents reviewed for Immunizations. Specifically, information pertaining to each residents' immunization records was either unavailable or incomplete.The finding is:The facility's policy titled Covid-19 Vaccination for Residents and Staff, revised 11/04/2025, documented if an eligible resident is due for and wishes to receive a Covid 19 vaccination, such a dose should be offered and administered or accommodated with 14 days of admission. All resident, representative will be educated regarding the benefits and risks and potential side effects of the vaccine. Declinations will be obtained for residents after being educated regarding risks and benefits and potential side effects. The Consent or the decline will be documented in the medical record. The medical record includes documentation that the resident or representative was provided education regarding benefits, potential risks and potential side effects.During an interview on 02/02/2026 at 10:45 AM, the Director of Nursing Services stated that the resident immunization records were stored on paper in each resident's paper chart at the nursing station.-Resident #12 was last admitted to the facility on [DATE]. The resident's name was not on the Covid-19 Vaccination Consent Form. The Covid-19 form indicated the vaccine was refused due to personal reasons; however, the refusal forms did not document the date of refusal. The form was not signed by the resident or the resident's representative.-Resident #34 was admitted on [DATE]. The Covid-19 vaccination was declined; however, there was no date or whether the declination was received from the resident or representative as there was no signature.The paper medical records for Resident #12 and Resident #34 were reviewed with Registered Nurse #2 (the unit manager) and Registered Nurse Infection Preventionist #1 on 02/02/2026 at 11:00 AM. Registered Nurse #2 and Registered Nurse Infection Preventionist #1 stated the immunizations forms would have to be reviewed and updated for accuracy and completeness.-Resident #27 was admitted on [DATE] and Resident #77 was admitted on [DATE]. The Covid-19 Vaccination Consent Form for both the residents were not completed, and the medical record did not indicate the residents' Covid-19 vaccine status.The paper medical records for Resident #27 and Resident #77 were reviewed with Registered Nurse #3 (unit manager) on 02/02/2026 at 11:20 AM. Registered Nurse #3 stated the Registered Nurse Infection Preventionist #1 may have the vaccine status information for these residents.During an interview on 02/06/2026 at 8:45 AM, Registered Nurse Infection Preventionist #1 stated the immunization forms were supposed to be thoroughly completed. The staff should have documented each resident's full vaccination status on the immunization forms. Any nurse on the unit could fill in the immunization forms. The vaccine information for each resident was on their (Registered Nurse Infection Preventionist #1) vaccination tracker that they kept for their personal records; however, the information was not on the immunization sheets in the residents' medical records.During an interview on 02/06/2026 at 11:32 AM, the Director of Nursing Services stated the admission packet for immunizations is stapled together; the packet has the resident's name label on the first page. If the individual sheets in the packet get separated, there will be pages that would not have the resident's name, which was the case with Resident #12. All sheets in the immunization packet should have the resident's name. The signatures section should indicate who accepted or rejected the vaccine, the resident or the resident's representative. The admission nurse was responsible for initiating the immunization sheets and if the vaccine information was not complete during the admission process, then Registered Nurse Infection Preventionist #1 and the unit managers should have completed the sheets and followed up within 14-21 days. All the immunization sheets in the paper charts for Resident #12, Resident # 34, Resident #27, and Resident #77 should have been complete and up to date.10NYCRR415.22(a)(1-4)

Based on record review, and interviews, the facility did not ensure the resident's medical records for influenza and pneumococcal vaccine did not included documentation that each resident received the influenza and pneumococcal immunizations and the residents or the resident representatives were provided education regarding the benefits or potential side effects of the vaccinations. This was identified for four (4) (Resident #12, Resident # 34, Resident #27, and Resident #77) of five (5) residents reviewed for Immunizations. Specifically, a review of Resident #12, Resident # 34, Resident #27, and Resident #77's medical record indicated that the influenza and pneumococcal immunization records were either unavailable or incomplete.The finding is: The facility's policy titled Pneumococcal Vaccine, dated 04/2025, documented assessments of pneumococcal vaccination status will be conducted within 5 working days of resident's admission. Resident/representatives have the right to refuse vaccination. If refused, licensed nurse will document the resident/representative's refusal in the resident's medical record as appropriate. For the resident who received the vaccine, administering nurse will document in the resident's medical record as appropriate. The resident/representative shall receive information and education regarding the benefits and potential side effects of the vaccine. Provision of such education shall be documented in the resident's medical record. The facility's policy, titled Influenza Vaccination Program, effective 5/2025 documented prior to any administration of medication, residents' current and past medical record is to be reviewed to determine if the vaccine has been administered prior to the admission. This information should be documented on the residents' immunization record. The administration of the vaccine is to be recorded on the resident's immunization record. During an interview on 02/02/2026 at 10:45 AM, the Director of Nursing Services stated that the resident immunization records were stored on paper in each resident's paper chart at the nursing station. -Resident #12 was last admitted to the facility on [DATE]. The resident's name was not on the Flu/Pneumococcal Immunization Screens Consent/Education Records. The influenza and pneumococcal vaccines were rejected; however, the refusal forms did not document the dates of the refusal, and the forms were not signed by the resident or the resident's representative. -Resident #34 was admitted on [DATE]. The status of the pneumococcal vaccine (accepted/rejected) was not completed. The influenza vaccine was rejected, and a verbal consent was obtained; however, the consent form did not indicate if the consent was provided by the resident or their representative. The paper medical records for Resident #12 and Resident #34 were reviewed with Registered Nurse #2 (the unit manager) and Registered Nurse Infection Preventionist #1 on 02/02/2026 at 11:00 AM. Registered Nurse #2 and Registered Nurse Infection Preventionist #1 stated the immunizations forms would have to be reviewed and updated for accuracy and completeness. -Resident #27 was admitted on [DATE] and Resident #77 was admitted on [DATE]. The Flu/Pneumococcal Immunization Screens Consent/Education Records for Residents #27 and Resident #77 did not indicate the residents' Flu/Pneumococcal vaccine status. The paper medical records for Resident #27 and Resident #77 were reviewed with Registered Nurse #3 (unit manager) on 02/02/2026 at 11:20 AM. Registered Nurse #3 stated the Registered Nurse Infection Preventionist #1 may have the vaccine status information for these residents. During an interview on 02/06/2026 at 8:45 AM, Registered Nurse Infection Preventionist #1 stated the immunization forms were supposed to be thoroughly completed. The staff should have documented each resident's full vaccination status on the immunization forms. Any nurse on the unit could fill in the immunization forms. The vaccine information for each resident was on their (Registered Nurse Infection Preventionist #1) vaccination tracker that they kept for their personal records; however, the information was not on the immunization sheets in the residents' medical records. During an interview on 02/06/2026 at 11:32 AM, the Director of Nursing Services stated the admission packet for immunizations is stapled together; the packet has the resident's name label on the first page. If the individual sheets in the packet get separated, there will be pages that would not have the resident's name, which was the case with Resident #12. All sheets in the immunization packet should have the resident's name. The signatures section should indicate who accepted or rejected the vaccine, the resident or the resident's representative. The admission nurse was responsible for initiating the immunization sheets and if the vaccine information was not complete during the admission process, then Registered Nurse Infection Preventionist #1 and the unit managers should have completed the sheets and followed up within 14-21 days. All the immunization sheets in the paper charts for Resident #12, Resident # 34, Resident #27, and Resident #77 should have been complete and up to date. 10 NYCRR 415.19

Based on observation, record review, and interviews during the Recertification Survey initiated on 10/7/2024 and completed on 10/11/2024, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #58) of three residents reviewed for Transmission Based Precautions. Specifically, Resident #58 was placed on Contact Isolation for Extended-Spectrum-Beta-Lactamases (ESBL-an enzymes that are resistant to most antibiotics) bacteria in the urine as per the physician's order. Certified Nursing Assistant #1 was observed entering Resident #58's room without wearing appropriate Personal Protective Equipment including a gown and gloves. The finding is: The facility's policy and procedure titled Transmission Based Precautions, last revised on 9/11/2024 documented the facility will use Transmission-Based Precautions to manage specific, highly transmissible, or epidemiologically important pathogens based on the mode of transmission: contact, droplet, and airborne. The Infection Preventionist/Designee will explain and inform staff members about the need for Transmission-Based Precautions and will perform periodic observations to ensure accurate implementation. Nurses will obtain appropriate Transmission Based Precautions category orders, develop a Comprehensive Care Plan, and post appropriate isolation signage outside the resident's room. Personal Protective Equipment (PPE) includes gloves, surgical mask, gown, and goggles/eye shield if splashing is expected. Contact Precautions will be used when there is evidence of multi-drug-resistant organisms (MDRO) or other epidemiologically significant organisms causing clinical symptoms. Hands should be washed with soap and water before and after each resident contact and after contact with resident's belongings, environmental surfaces, and resident care equipment. Resident #58 was admitted with diagnoses of Type 2 Diabetes, Sepsis, and Extended-Spectrum-Beta-Lactamases (ESBL) Resistance in the urine. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #58 had intact cognition. The Admission Minimum Data Set (MDS) assessment documented that Resident #58 had incontinence of both bowel and bladder. Resident #58 was dependent on staff for all activities of daily living including toileting, personal hygiene, and showering. The Comprehensive Care Plan (CCP) titled Contact Isolation, dated 9/25/2024 documented interventions which included maintaining precautions as per the physician's order; maintaining single room isolation; wearing Personal Protective Equipment (PPE); and monitoring signs and symptoms of infection. A physician's order dated 9/25/2024 documented Contact Precautions/Isolation secondary to Extended-Spectrum-Beta-Lactamases (ESBL) in urine. A physician's order dated 9/25/2024 documented Meropenem (antibiotics) one gram per 50 milliliters in 0.9 percent sodium chloride. Give 1 milliliter (0.02 grams) by intravenous route every 8 hours for 5 days. A physician's order dated 10/8/2024 documented Vancomycin (antibiotics) 1,000 milligrams intravenous, infuse 1250 milligrams daily for 3 days. During an observation in Unit 1 on 10/7/2024 at 12:36 PM, a precautions sign outside Resident #58's room indicated Contact Isolation Precautions: everyone must perform hand hygiene before and after entering Resident #58's room. The sign also instructed to use Personal Protective Equipment (PPE) including wearing a gown and gloves before entering Resident #58's room and discarding the gown and gloves before exiting the room. Certified Nursing Assistant #1 was observed entering Resident #58's room with a lunch tray without using a gown and gloves. Certified Nursing Assistant #1 did not perform hand hygiene before entering Resident #58's room and when exiting the room. During an interview on 10/7/2024 at 12:40 PM, Certified Nursing Assistant #1 stated they did not wear a gown and gloves before entering Resident #58's room because they did not know that Resident #58 was on contact precautions and they were only bringing the meal tray for Resident #58. Certified Nursing Assistant #1 stated they did not read the precautions sign outside Resident #58's room. Certified Nursing Assistant #1 stated when a resident is on contact isolation, Personal Protective Equipment (PPE) should be only used for high-contact care. During an interview on 10/7/2024 at 12:45 PM, Registered Nurse #1, the Unit Supervisor stated Certified Nursing Assistant #1 should have read and followed the instructions on the signage outside Resident #58's room. Registered Nurse #1 stated that Resident #58 was on contact isolation and that everyone who entered Resident #58's room should have performed hand hygiene and put on a gown and gloves before entering the resident's room. During an interview on 10/9/2024 at 11:05 AM, the Infection Preventionist stated Certified Nursing Assistant #1 should have followed the instructions for the contact isolation precautions posted outside the resident's room. The Infection Preventionist stated all staff and visitors must perform hand hygiene, and wear a gown and gloves when entering Resident #58's room. During an interview on 10/10/2024 at 1:46 PM, the Director of Nursing Services stated that Certified Nursing Assistant #1 had breached the infection control precautions as soon as they entered the room without performing hand hygiene and without wearing the appropriate Personal Protective Equipment (PPE), as indicated on the signage outside Resident #58's room. The Director of Nursing Services stated they expect all staff to follow all infection protocols in the facility to prevent the spread of infection. 10 NYCRR 415.19(a) (1-3)

Based on observation, interviews, and record review during the Recertification Survey initiated on 10/7/2024 and completed on 10/11/2024, the facility did not ensure that drug records were in order and accounted for all controlled drugs. This was identified for one (Unit 2) of two nursing units during the Medication Storage Task. Specifically, the Controlled Substance Administration Record form for Resident #29 for Lacosamide (Vimpat-a controlled medication) indicated there were 56 tablets available; however, the blister pack for Lacosamide only had 55 tablets remaining. The finding is: The facility policy titled Controlled Substance Handling, effective 1/2011 and last revised 12/2022, documented that after a [controlled medication] dose is administered, the licensed nurse administering the drug signs the electronic medication administration record and the controlled substance administration record sheet. Resident #29 was admitted with diagnoses including Seizures and Type 2 Diabetes Mellitus. The Annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for a Mental Status score of 11, which indicated the resident had moderate cognitive impairment. A Comprehensive Care Plan titled Diagnosis-Neurological Status effective 2/2/2024 and reviewed on 10/1/2024 documented the resident had a Seizure disorder with interventions including administering medication as ordered, monitoring for signs and symptoms of impaired swallowing, encouraging rest periods, and assisting with activities of daily living as needed. A physician's order effective 3/6/2024 and last renewed on 10/8/2024 documented to administer Vimpat (an anti-seizure medication) 150 milligrams tablet, 1 tablet by oral route every 12 hours for Seizures. During an observation of Unit 2's medication cart on 10/10/2024 at 12:22 PM with Licensed Practical Nurse #1, Resident #29's Controlled Substance Administration Record form for Lacosamide (Vimpat) documented that 56 tablets were remaining; however, the blister pack for Lacosamide (Vimpat) only had 55 tablets remaining. During an interview conducted immediately after the observation on 10/10/2024, Licensed Practical Nurse #1 stated they had administered one tablet of Lacosamide (Vimpat) to Resident #29 at 8:40 AM; however, they forgot to document on the Controlled Substance Administration Record form. Licensed Practical Nurse #1 stated they should have signed the Controlled Substance Administration Record form immediately after administering the medication. During an interview on 10/10/2024 at 2:26 PM, Registered Nurse #2, the nurse supervisor for Unit 2, stated they expected the Controlled Substance Administration Record form to be updated at this time the controlled substance medication is administered. Licensed Practical Nurse #1 should have updated the Controlled Substance Administration Record form at the time the controlled medication was administered. During an interview on 10/10/2024 at 3:25 PM, the Director of Nursing Services stated the nurse should have signed the Controlled Substance Administration Record form for Resident #29 immediately after administering the medication. 10 NYCRR 415.18(b)(1)(2)(3)

Based on observation, record review, and interviews during the Recertification Survey initiated on 10/7/2024 and completed on 10/11/2024, the facility did not ensure that drugs and biologicals were labeled in accordance with currently accepted professional principles. This was identified for one (Unit 2 medication cart) of two units observed during the Medication Pass. Specifically, on 10/9/2024, the medications cart for Unit 2 was observed with an opened bottle of Lipopolysaccharide-Sugar Free (LPS-SF) supplement without a date indicating when the bottle was first opened for use. The finding is: The facility policy and procedure titled Supplement, last revised on 5/29/2024, documented that all oral supplements including Lipopolysaccharide-Sugar Free (LPS-SF) shall be maintained by nursing or in the nursing medication cart. Once opened, the supplement will be dated and discarded per the manufacturer's guidelines. The storage instructions on the bottle for Lipopolysaccharide-Sugar Free (LPS-SF) documented that Lipopolysaccharide-Sugar Free (LPS-SF) should be stored at room temperature in a clean hygienic manner. Reseal tightly after opening and discard after 60 days. Resident #331 was admitted to the facility with diagnoses that included Cellulitis, Multiple Rib Fractures, and Congestive Heart Failure. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderately impaired cognition. The Minimum Data Set (MDS) documented that Resident #331 was at risk for developing pressure ulcers and needed pressure-reducing devices, nutrition, and hydration. A Comprehensive Care Plan (CCP) dated 9/20/2024 titled Dietary Nutrition, documented Resident #331 had potential weight fluctuations related to fluid shifts secondary to Congestive Heart Failure, with interventions including adequate nutrition and hydration, dietary supplements, snacks, and nourishment. A physician's order dated 9/23/2024 documented Supplement: Give Lipopolysaccharide-Sugar Free (LPS-SF) 30 milliliters orally daily. During a Medication Pass observation on 10/9/2024 at 8:26 AM with Licensed Practical Nurse #1, the medication cart on Unit 2 was observed with a bottle of Lipopolysaccharide-Sugar Free that was opened and had no date to indicate when the bottle was first opened. During an interview on 10/9/2024 at 9:00 AM, Licensed Practical Nurse #1 stated the Lipopolysaccharide-Sugar Free bottle was already opened and they did not know when the bottle was first opened. Licensed Practical Nurse #1 stated they should have discarded the undated bottle. During an interview on 10/9/2024 at 1:40 PM, Pharmacist #1 stated the undated Lipopolysaccharide-Sugar Free bottle should have been discarded. As per the manufacturer's guidelines, after opening the Lipopolysaccharide-Sugar Free bottle should be discarded after 60 days. Pharmacist #1 stated to determine the 60th day, the nurses should have dated the bottle when it was first opened. During an interview on 10/9/2024 at 2:13 PM, Registered Nurse #2 stated the medication nurses are responsible for checking the medication carts for expired medications, undated opened supplements, and other medications. Registered Nurse #2 stated that Licensed Practical Nurse #1 should have discarded the undated opened bottle of Lipopolysaccharide-Sugar Free and opened a new one. During an interview on 10/10/2024 at 12:14 PM, the Director of Nursing Services stated the Lipopolysaccharide-Sugar Free supplement bottles must be dated when opened. The Director of Nursing Services stated the nurse should discard the undated open bottle, should have opened a new one, and should have indicated the date on the new bottle when it was first opened. 10 NYCRR 415.18(e) (1-4)

Based on observation, record review, and interviews during the Recertification Survey completed on 6/2/2021 the facility did not maintain an Infection Prevention and Control Program designed to help prevent the development and transmission of communicable diseases and infections on 1 of 2 nursing units. Specifically, during a medication pass observation for Resident #289, who was on isolation precautions for [CONDITION(S)] (C-Diff) infection, the Licensed Practical Nurse (LPN #1) did not don (put on) appropriate Personal Protective Equipment (PPE) as indicated on the sign posted at the resident's doorway and did not perform hand hygiene. The finding is: The facility's policy titled Transmission-Based Precautions (TBP), revised on 10/28/2020, documented that nursing staff will don appropriate PPE when entering resident's room and remove all PPE before exiting the resident's room. Resident #289 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A laboratory report dated 5/27/2021 documented the resident was positive for C. Difficile toxin. A nursing progress note dated 5/27/2021 documented that the laboratory reported the resident was positive for C-Diff and GDH [MEDICATION(S)] (an [MEDICATION(S)] that is produced by C-Diff). During a medication pass observation on 6/2/2021 at 9:09 AM a sign was observed outside Resident #289's room that documented Contact/Droplet Precautions. The sign also indicated that providers and staff must put on gloves and a gown before entering and discard the gloves and gown before exiting the resident's room. LPN #1, medication nurse, was observed entering Resident #289's room with a plastic tray that contained a medication cup and the water cup to administer medications to the resident. LPN #1 was wearing a mask and a face shield but did not put on gloves or a gown. LPN #1 placed the plastic tray on the over-bed table; the resident consumed the medication with the water. LPN #1 then picked up the plastic tray and brought the tray outside of the room and placed the tray on top of the medication cart. LPN #1 put on gloves and sanitized the plastic tray with a germicidal wipe but did not wash their hands. LPN #1 medication nurse was interviewed on 6/2/2021 at 9:12 AM after the nurse exited the resident's room. LPN #1 stated that the resident had a C-Diff infection, and a gown and gloves should have been put on prior to entering the room. LPN #1 further stated that not having donned a gown and gloves and not washing hands was an oversight. The unit Registered Nurse (RN) Supervisors #2 and #3 were interviewed concurrently on 6/2/2021 at 1:24 PM. They stated the resident was being treated with [MEDICATION(S)] for C-Diff. They stated the diarrhea has subsided; however, the resident remains on isolation precautions until the [MEDICATION(S)] is completed. They stated LPN #1 should have worn gloves and a gown when conducting the medication pass. The RN Infection Preventionist (IP) was interviewed on 6/2/2021 at 1:37 PM. The IP stated full PPE is needed if coming in contact with the resident, but for giving medications to an alert resident who is on isolation precautions the gown and gloves may not be necessary if the nurse does not have direct contact. The IP stated gown and gloves would have to be put on if the resident required additional assistance that required contact. The IP stated hand washing is recommended rather than use of the hand sanitizer when working with a resident who has a C-Diff infection. The IP further stated that hand washing should have been done after LPN #1 exited the resident's room. 415.19(a)(1-3)

Based on record review and Interviews during the Recertification Survey and Abbreviated Survey (Complaint # NY 086) completed on 6/2/2021, the facility did not ensure that the Health Care Proxy (HCP) for 1 of 1 resident (Resident #139) reviewed for notification of change was promptly notified of a change in the resident's medical condition. Specifically, Resident #139 was administered Intravenous Fluids (IVF) as per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The finding is: The Facility's policy and procedure on notification of Physician of Resident change in condition dated July 2016 documented that the family of the resident will be notified of the change in condition as soon as possible. Resident #139 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. The resident required supervision and setup help for eating. A Nursing Progress Notes dated 1/28/2021 at 11:18 PM documented the Resident's Laboratory values indicated a Blood Urea [MEDICATION(S)] (BUN) level of 42 milligram/deciliter (mg/dl)(normal range 5-20 (mg/dl)) and a Sodium (NA) level of 149 milliequivalents per liter (mEq/L) (normal range between 135 and 145 mEq/L)). The Physician was notified and a new order to start 0.9% Normal Saline (NS) 75 Milliliter/Hour (ml/hr.) for 24 hrs. via IV route. The IV line was inserted to the resident's left forearm. The IV fluid was in progress. There was no documentation in the medical record that the resident's family was notified of the change in the resident's condition. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . for 24 hrs. A family member was interviewed on 6/2/2021 at 2:30 PM and stated that the family member was not notified that the resident was started on an Intravenous fluids (IV) on 1/29/2021. The family member stated that they found out about the resident being placed on IV fluids during a Facetime video conducted on 1/31/2021. The Registered Nurse (RN) #7 Supervisor was interviewed on 6/2/2021 at 4:00 PM and stated they (RN#7) did not notify the family member and that the family member should have been notified. If RN #7 did call the family member, there would have been documentation that the family was notified of the resident's change in condition. The Director of Nursing Services was interviewed on 6/2/2021 at 4:20 PM and stated the family should have been notified whenever there is a change in condition. 415.3(e)(2)(ii)(b)

Based on observation, record review and interviews during the Recertification Survey completed on 6/2/2021, the facility did not ensure that each resident with pressure ulcers received necessary services consistent with standards of practices to promote healing and prevent infection for one (Resident #36) of two residents reviewed for pressure ulcers. Specifically, the weekly wound assessments performed from 3/20/2021 through 4/16/2021 did not document thorough assessments of each pressure ulcer including a complete description of the wounds. The finding is: The Policy/Procedure for Pressure Ulcer Prevention and Care dated 10/2017 documented that the measurements of the ulcer/wound must be done weekly until the area is healed. Measurements are to be done by the Wound Care Nurse and the Wound Care Physician. Resident #36 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented that a Brief Interview for Mental Status (BIMS) could not be completed. The resident required total dependence of two staff members for bed mobility, transfers, toilet use, and bathing. The resident was non-ambulatory and was always incontinent of bowel and bladder. The resident had two Stage 2 Pressure Ulcers (PU), one Stage 3 PU, and one Unstageable PU that were all present upon admission. A wound care observation of the left hip wound was conducted on 6/2/2021 at 11:00 AM with LPN #1 and no concerns were identified during the treatment. The Admission physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1- Clean the Left hip with Normal Saline Solution (NSS), apply [MEDICATION(S)] (enzymatic [MEDICATION(S)] agent) and [MEDICATION(S)] Foam (a cover dressing) daily (QD). 2- Clean Right elbow with NSS and apply [MEDICATION(S)] and [MEDICATION(S)] Foam QD. 3- Clean Right hip with NSS apply [MEDICATION(S)] and [MEDICATION(S)] Foam QD 4- Clean Intergluteal cleft (groove between the buttocks that runs from just below the sacrum) with NSS apply [MEDICATION(S)] and [MEDICATION(S)] Foam QD 5- Clean Right Lower buttock with NSS, apply [MEDICATION(S)] and [MEDICATION(S)] Foam bandage QD. The initial wound care consult dated 3/26/2021 documented the resident had a right hip Stage 2 pressure ulcer; a left hip necrotic unstageable wound; a right heel, and a right lateral foot ulcer (no staging). The Physician's assessment did not include wound length, width, depth, drainage, undermining (when the tissue under the wound edges becomes eroded, resulting in a a pocket beneath the skin at the wound's edge), and color. Furthermore, the consult documented a request for the Wound Care Physician to evaluate the right elbow pressure ulcer. The Wound Care Physician's documentation did not include an assessment of the right elbow. The weekly pressure ulcer/wound flow sheets were reviewed from 3/20/2021 through 4/16/2021. The assessments did not include the depth of the wounds, undermining, drainage, color, odor and pain management. The Comprehensive Care Plan (CCP) dated 4/10/2021 for the left hip, right elbow, and right hip pressure ulcers documented to administer medication/treatments as per the Physician; Weekly wound care charting/rounds; Monitor for signs and symptoms of infection (redness, increase temperature, warmth, increase drainage, inflammation); Monitor healing process; assess weekly; and to Monitor/report changes in ulcer's size, drainage and odor. The Wound Care Registered Nurse (RN #2) was interviewed on 6/1/2021 at 1:00 PM and stated they (RN #2) was off from work when the resident was admitted , and that RN # 3 completed the wound assessment. RN #2 further stated that all the wounds should have the measurements including depth, color, presence of eschar, presence of undermining, odor, and drainage. The wound care physician assessment should include a complete assessment of each of the resident's pressure ulcers. RN #3 was interviewed on 6/1/2021 at 1:30 PM and stated Resident #36's wound assessments were not thorough. RN #3 could not explain why they were not thorough and stated wounds that are Stage 3 and Stage 4 had depth that were not documented. RN #3 further stated they (RN #3) could not recall the depth of the pressure ulcers. The Wound Care Physician was interviewed on 6/2/2021 at 11:23 AM and stated that the Wound Care Physician did not have access to the Electronic Medical Record (EMR) and all of the wound assessments were documented on paper. The Wound Care Physician stated the documentation is poor and a better system will be implemented to ensure thorough assessments are documented. The Wound Care Physician stated they (the Wound Care Physician) was relying on the nursing staff to document the wound measurements, odor, drainage, undermining and color. The Wound Care Physician further stated that they did not assess the right elbow wound because this was not brought to their attention. The Director of Nursing Services (DNS) was interviewed on 6/2/2021 at 4:13 PM and stated a thorough assessment should be documented every time the resident's wounds were assessed by the Wound Care Team. 415.12(c)(2)

F880 J Based on observation, record review and interview during a COVID-19 Focused Infection Control Survey (Complaint # NY 772) the facility failed to maintain an Infection Control program to prevent the development and transmission of communicable disease and infection. The staff did not consistently follow the recommended Centers for Disease Control (CDC) Infection Control transmission-based procedure for residents on precautions leading to potential cross-contamination for 29 of 43 negative COVID-19 residents. Specifically, during an observation on 4/29/20 at 10:00 AM, Housekeeper #1 was observed mopping in room [ROOM NUMBER], that was identified as positive COVID-19, wearing a disposable jumpsuit, gloves and N95 mask with a surgical mask over the N95. The housekeeper then exited the positive COVID-19 room without removing his jumpsuit, gloves, and surgical mask and fully entered a negative COVID-19 resident's room [ROOM NUMBER]. This resulted in potential for serious harm for negative COVID-19 residents that is an Immediate Jeopardy. The Immediate Jeopardy was lifted on 4/30/20. Additionally, Housekeepers (#2 and #3) were not knowledgeable of the cleaning procedures as outlined by the facility policies and procedures. The findings are: The Daily Cleaning of Resident Rooms on Contact Precautions Policy and Procedure dated February 2020 documented staff must first put on appropriate PPE as indicated by Infection Control nurse. The policy did not address the procedure of removing PPE after completing a room cleaning. The Transmission-based Precautions including positive COVID-19 infection Policy and Procedure dated March 2020 documented the Housekeeping staff should put on appropriate PPE when entering the resident's room and remove all PPE before exiting the resident's room. Hand hygiene is the most important practice for preventing the transmission of potentially infectious microorganisms from one person to another. Hand hygiene reduces the incidence of healthcare-associated infections. Hands should be washed with soap and water after contact with resident's belongings, environmental surfaces, and resident care equipment. The policy further documented that Airborne Precautions are initiated when pathogenic organisms can be suspended in the air and be widely dispersed by air currents within a room or over a long distance. Examples of infectious diseases that require Airborne Precautions include positive COVID-19. The door of a room with Airborne Precautions should be closed at all times. Resident #1 was admitted to the facility with the [DIAGNOSES REDACTED]. Resident #1 has a Brief Interview for Mental Status (BIMS) Score of 15 indicating intact cognition. The physician's orders [REDACTED]. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #2 had a BIMS Score of 14 indicating intact cognition. Resident #3 was admitted to the facility with the [DIAGNOSES REDACTED]. Resident #3 had a BIMS Score of 13 indicating intact cognition. The current physician's orders [REDACTED].#3 did not indicate isolation precaution. On 4/29/20 at 10:00 AM, Housekeeper #1 was observed in Resident #1's room mopping the floor. Resident #1 was in the room. A red droplet precaution sign for the [DIAGNOSES REDACTED].#1's room. Housekeeper #1 was observed wearing an N95 mask with a blue surgical mask on top of the N95 mask, gloves, and a disposable jumpsuit. The door was completely open while the housekeeper was mopping. On 4/29/20 at 10:10 AM, Housekeeper #1 was observed exiting positive COVID-19 room [ROOM NUMBER] wearing the same jumpsuit, gloves, mask and crossed the hallway, entered the negative COVID-19 Room#110 (where resident #2 and resident #3 resides) to retrieve a wet floor sign. Housekeeper #1 then brought the wet floor sign to the positive COVID-19 room [ROOM NUMBER] Housekeeper #1 was interviewed on 4/29/20 at 10:10 AM in the hallway between room [ROOM NUMBER] and 113 after he exited room [ROOM NUMBER]. Housekeeper #1 stated that he was going to remove his gloves and blue surgical mask now. On 4/29/20 at 10:15 AM, Housekeeper #1 was observed sweeping the hallway. The housekeeper was wearing the same jumpsuit he wore while mopping the floor in room [ROOM NUMBER]. On 4/29/20 at 10:50 AM the Director of Environmental Services was interviewed. He stated the housekeepers are supposed to clean the negative COVID-19 rooms first and should not be going from positive COVID-19 to negative COVID-19 rooms. He stated housekeepers are supposed to wear yellow disposable gowns over the jumpsuit when cleaning a positive COVID-19 room because the same jumpsuit is supposed to be worn all day. He stated the housekeepers are supposed to remove their gloves and outer surgical mask before leaving a positive COVID-19 room. If housekeepers move from positive COVID-19 to positive COVID-19, they can keep the outer yellow gown on, but the gloves and surgical mask must be removed before exiting the positive COVID-19 room. On 4/29/20 at 11:15 AM Housekeeper #1 was re-interviewed. He stated he was supposed to wear a yellow gown over his jumpsuit while mopping room [ROOM NUMBER], and he should have removed the gloves and blue surgical mask when he exited room [ROOM NUMBER]. He said he made a mistake and it was bad planning on his part. He also said he should not have gone into room [ROOM NUMBER] (a negative COVID-19 room) while wearing the jumpsuit, gloves and surgical mask he was wearing in room [ROOM NUMBER] (a positive COVID-19 room). He stated the Director of Environmental Services discussed COVID-19 protocols with him. He said he knows that a red sign means that the room is positive COVID-19 and if there is no sign then the room is negative COVID-19. He stated that he should not go from a positive COVID-19 room to a negative COVID-19 room without first removing PPE. The Infection Control RN/In-service Coordinator was interviewed on 4/29/20 at 1:15 PM and at 3:38 PM. She stated the housekeepers are supposed to wear a yellow disposable gown over the jumpsuit, gloves, and a surgical face mask over the N95 mask when cleaning a positive COVID-19 room. She said the housekeepers are supposed to remove their gloves, surgical mask, and gown when exiting a positive COVID-19 room. The PPE should be placed in a bag, sealed and then placed it in a red bin. Housekeepers should then wash their hands before leaving a positive COVID-19 room. She stated the housekeepers should not go from a positive COVID-19 room to negative COVID19 room. She stated there is an infection control policy that documents this practice and she did an in-service for the housekeeping staff on 3/6/20 for COVID-19 preparation. She stated the in-service included terminal cleaning of resident rooms (not daily cleaning), properly putting on and removing PPE, and hand washing. She was unable to provide documented evidence that the housekeeping staff were in-serviced related to PPE use when entering and exiting positive COVID-19 rooms. She stated the Director of Environmental Services in-serviced his staff for daily room cleaning for positive COVID-19 rooms. The Director of Environmental Services was re-interviewed on 4/29/20 at 3:10 PM. He said he did the daily room cleaning in-service dated 3/24/20. He stated the hand-written lesson plan was meant as an addition to the Contact Precautions room cleaning policy. He said the hand-written lesson plan did not include anything about gown use over the jumpsuit when going in a room on precautions for COVID-19, which was an oversight, but he stated he told the housekeepers verbally. He stated he was not sure if there was a policy regarding cleaning positive COVID-19 rooms. The Daily Cleaning of Resident Rooms-Contact Precautions in-service dated 3/24/20 was delivered by the Director of Environmental Services to the housekeeping staff. The in-service documented that positive COVID-19 rooms must be cleaned last. Staff must remove gloves, wash hands, remove the surgical mask, put new gloves on, and a new surgical mask over the N95 mask before entering the next positive COVID-19 room. Staff must remove PPE after the last positive COVID19 room is done. The in-service did not include putting on or removing of the jumpsuit and or wearing a gown over the jumpsuit. In addition, the in-service did not describe the process for going from positive COVID-19 to a negative COVID-19 rooms. Housekeeper #1 signed and dated the in-service. 2) The Daily Cleaning of Resident Rooms on Contact Precautions Policy and Procedure dated February 2020 documented that Housekeeping staff should change the cleaning solution in mop bucket prior to and immediately after cleaning the room. The Transmission-based Precautions including COVID-19 infection Policy and Procedure dated March 2020 documented Housekeeping will perform appropriate daily and terminal cleaning in the isolation room because it is considered contaminated. The Infection Control RN will follow up with the housekeeping staff to ensure their readiness to work in isolation conditions, compliance with different requirements of Transmission Based Precautions, and disposal of cleaning products and/or supplies to reduce the risk of room to room transmission. The Director of Environmental Services was interviewed on 4/29/20 at 10:50 AM. He stated the housekeepers should be using the germicidal mop pads to clean the floors in the resident rooms and should be using the standard mop with water/bleach solution to clean the hallway floors. He stated every room should be cleaned every day. He stated the housekeeping staff has been in-serviced on this protocol. Housekeeper #2 was interviewed on 4/29/20 at 11:05 AM. He stated that all rooms are supposed to be cleaned every day, but this does not always happen. He said it all depends on how much work has to be done every day. He stated that he uses a standard mop with a germicidal solution to mop the resident room floors and will use the same mop for 3 to 4 rooms. He stated he does not use the germicidal mop pads to mop the resident room floors. He stated the standard mop is more effective. He also said that he changes the water in the mop basin every 3 to 4 rooms when mopping the positive COVID-19 rooms. Housekeeper #3 was interviewed on 4/29/20 at 12:00 PM. Housekeeper #3 stated that his responsibilities included cleaning the resident room floors, the hallway floor, and taking out the garbage. He stated that he should use the flat mop head when cleaning the resident rooms, but he feels that it does not do as good a job as the fluffy mop head. He uses the fluffy mop head for both the resident rooms and hallways. Housekeeper #3 stated that he will use one fluffy mop head to clean 2-3 rooms, with the same water containing the H2O Orange 2 cleaner with a little bleach if the rooms are not dirty. He would only clean rooms with the same precautions with the same mop head. He stated that there are always fluffy mop heads available for him to use. The Infection Control RN was interviewed on 4/29/20 at 1:15 PM. She stated there is a specific mop pad that is supposed to be used for resident rooms and the standard mop with a bucket for the hallways. She said when using the mop pads, the housekeepers should change the pads from room to room. She stated she was not sure if there was a policy for this. The Director of Nursing Services (DNS) was interviewed on 4/29/20 at 2:10 PM. She stated that the in-service for Daily Cleaning of positive COVID-19 rooms that was done by the Director of Environmental Services on 3/24/20 for the housekeeping staff was not appropriate because a hand-written lesson plan was utilized as an addendum to the Contact Precautions room cleaning policy. She stated it was not an appropriate teaching tool because COVID-19 requires droplet precautions. The DNS confirmed that Resident #1 was positive COVID-19 and on Contact and Airborne Precautions for COVID-19. The Director of Environmental Services was interviewed on 4/29/20 at 3:10 PM. He stated he never made a policy on what to use when cleaning the floors of positive COVID-19 rooms. He stated it was a verbal in-service and he had no sign-in sheets. The Infection Control RN was re-interviewed on 4/29/20 at 3:45 PM. She stated that any education that was directly related to COVID-19 cleaning procedures was provided to the housekeepers by the Director of Environmental Services. 415.19(a)(1-3) 415.19(b)(4)

Based on observation, record review, and staff interviews during the Recertification survey, the facility did not ensure that the comprehensive care plan (CCP) accurately reflected the residents current status. This was identified for 1 (Resident #19) of 1 resident reviewed for vision. Specifically, Resident #19's CCP developed for vision did not did not accurately reflect the use of corrective lenses. The finding is: Resident # 19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score as 5 indicating the resident had severely impaired cognition. The vision and corrective lenses section documented the resident had moderately impaired vision and utilized corrective lenses. The Optometry Consultations dated 4/4/18, 10/16/18 and 4/18/19 documented the resident had corrective lenses and that corrective lenses were dispensed on 4/4/18. The Certified Nursing Assistant Accountability Record (CNAAR) for (MONTH) 2019 and (MONTH) 2019 documented the resident had impaired vision and wore glasses. Resident #19 was observed on 7/10/19 at 8:20 AM in the unit dining room during breakfast with eye glasses resting on the tip of the resident's nose. The resident was observed to reposition the eye glasses twice but the glasses slid down as the resident lowered her head to eat. A CCP for vision initiated on 9/12/18 and updated on 9/14/18, 10/17/18, 1/15/19, and 4/15/19, documented that the resident had impaired vision, saw large print and did not have eye glasses. The Assistant Director of Nursing Services (ADNS) was interviewed on 7/10/19 at 11:46 AM and stated that CCPs are initiated and revised by the Nurses, including the unit Charge Nurse and MDS Nurses. The ADNS also stated that she personally conducted the CCP meetings held on 11/29/18, 2/21/19 and 5/23/19. She further stated the CCPs were reviewed for accuracy during the meetings and the inaccurate vision CCP was an oversight. 415.11(c)(3)(i)

Based on observation, record review, and interviews during the recertification survey the facility did not ensure that each resident received adequate supervision to prevent accidents for 1 (Resident # 33) of 2 residents reviewed for accidents. Specifically, during the first floor dining room lunch observation on 12/11/2017 Resident #33, who has a [DIAGNOSES REDACTED]. The finding is: The facility's policy, dated 9/2017, titled Feeding Family Participation, states that a responsibility of the Charge Nurse/Speech Therapist is to instruct family members in the correct way to feed the resident and to follow up as appropriate and provide intermittent assistance as necessary. Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 11/15/2017 30-day Minimum Data Set (MDS) Assessment documented the resident had a Brief Interview for Mental Status (BIMS) score of 4, indicating the resident had severe cognitive impairment. The MDS documented the resident required extensive assistance of one staff member for eating and received a mechanically altered diet. A physician's orders [REDACTED]. A physician's orders [REDACTED]. An Activities of Daily Living (ADL) CCP, dated 10/21/2017, documented that the resident required total assistance for feeding and was spoon fed. A Dysphagia Comprehensive Care Plan (CCP) dated 10/27/2017 documented the resident has a [DIAGNOSES REDACTED]. The CCP documented the nursing and speech language pathology disciplines were responsible to educate staff and family regarding precautions and limitations. A Swallowing Evaluation, dated 10/27/2017, documented recommendations for Dysphagia therapy with mechanical-soft diet with thin liquids, aspiration precautions with 1:1 assist/feed, patient/family education, and small bites/sips. On 11/6/2017 a Speech/Swallow Intervention Note documented a recommendation to downgrade the diet from mechanical-soft to puree with allowance for soft sandwich/soft dessert following the resident's request. On 12/8/2017 a Speech/Swallow Intervention Note recommended downgrading the liquids to nectar-thick because the resident was noted with coughing with thin liquids during the lunch meal that day. Resident #33 was observed on 12/11/2017 at 12:45 PM during the lunch meal in the first floor dining room. The resident was seated in a wheel chair at a table and was observed being fed by a family member. There were no staff member assisting the resident with feeding or supervising the feeding by the family member. The resident's neck was observed hyperextended (tipped backward) with her mouth pointed upwards toward the ceiling to receive the food. The resident's family member who was feeding the resident was interviewed on 12/11/17 at 1:47 PM and stated he did not receive any education regarding how to safely feed the resident. The resident's Certified Nursing Assistant (CNA) was interviewed on 12/13/17 at 10:52 AM and stated the resident does not feed herself and requires total care. She stated the resident eats pureed food with thickened liquids and has to be fed very slowly. The CNA stated she was in the dining room on 12/11/2017 during lunch and it was her responsibility to feed the resident. She stated that 12/11/2017, during the lunch meal, was first time that she had seen the resident's family members and they had asked to feed the resident. The CNA further stated that she did not question the family regarding their ability to feed the resident. On 12/13/2017 at 11:16 AM the Speech Therapist was interviewed. The Speech Therapist stated that on 12/11/2017 she was not in the first floor dining room during lunch because she was in a resident's room providing individualized therapy. She stated families can feed residents on aspiration precautions and she teaches families on a regular basis. The Speech Therapist stated that she had never met the family member that was feeding Resident # 33 and did not provide Resident #33's family any direct feeding instructions. She further stated if she is not available she would expect nursing to provide instruction regarding feeding the resident. The unit's Registered Nurse (RN) Charge Nurse was interviewed on 12/13/17 at 11:28 AM and stated Resident #33 has to be fed and that it would be preferable for the staff to feed the resident. She stated if family requests to feed the resident, a staff member could sit with them and assist to make sure there are no problems. The RN further stated that she did not instruct Resident #33's family on how to feed the resident, but a nurse is always observing and navigating in the dining room. The Licensed Practical Nurse (LPN) who was in the first floor dining room at the lunch meal on 12/11/2017 was interviewed on 12/13/17 at 1:36 PM and stated that she was in the lunch room on 12/11/17 from start to finish and she was the supervising nurse. She stated she circulates the room, but does not feed or sit down with anyone. The LPN stated that she had advised the family previously, not on 12/11/2017, that the resident needs small bites. The LPN stated that it was a casual discussion based on common sense, and she did not inform her supervisor or document any of the teaching that she did. The Director of Nursing Services (DNS) was interviewed on 12/14/17 at 1:40 PM and stated that the resident was in a supervised area. The DNS further stated that the family member who was feeding Resident #33 was never seen before and staff should have intervened and stopped him. 415.12(h)(1)

Based on record review and staff interview during the Recertification Survey the facility did not provide timely laboratory services for 1 of 3 residents reviewed for Pressure Ulcers out of a total Stage 2 sample of 28 residents. Specifically, Resident #106 was identified on 8/04/16 with a high [MEDICAL CONDITION] Stimulating Hormone (TSH) level, was prescribed a [MEDICAL CONDITION] medication, and had documented physician direction to repeat a TSH level in 4 weeks. The Primary Care Physician (PCP) ordered a TSH level to be drawn in September 2016; however, the TSH was not drawn. The finding is: Resident #106 has [DIAGNOSES REDACTED]. The 7/27/2016 Significant Change Minimum Data Set (MDS) assessment documented a Brief Interview of Mental Status (BIMS) score of 3, indicating the resident has severe cognitive impairment. On 8/2/2016 Resident #106 was seen by a Neurologist as requested by the resident's PCP. The consult was ordered because the resident had newly developed drooling, left sided weakness, and a change in mental status. One of the recommendations by the Neurologist was to obtain a TSH level. The PCP agreed and the order was placed. A nursing note dated 8/4/2016 documented that as a result of the 8/2/2016 Neurology visit, the TSH level was drawn and found to be high at 7.040, which was gradually increasing from the last TSH level in April 2016 of 4.510 (normal TSH range is 0.4-4.0). The PCP was notified and a telephone order dated 8/04/16 was received to start [MEDICATION NAME] (a medication to treat [MEDICAL CONDITION]) 25 micrograms (mcg) per day and repeat TSH in 4 weeks. A physician's orders [REDACTED]. On 10/6/2016 at 11:44 AM a representative of the laboratory was interviewed by phone. She stated that an order to draw blood for a TSH level for Resident #106 was not received for September 2016. On 10/6/2016 at 12:12 PM the Registered Nurse (RN) Unit Manager was interviewed. She was unable to find TSH level results for Resident #106 for September 2016. She stated that lab orders are normally entered into the computer by the night nurse. She stated, I think she did not specify exactly that the doctor wanted a blood draw in 4 weeks and the order was missed. On 10/6/2016 at 12:30 PM the RN Unit Manager was re-interviewed. She stated that the PCP was just contacted and that the TSH blood draw will be done on 10/7/2016. 415.20

Based on observation, interview and record review during an abbreviated survey, the facility did not maintain accurate clinical records on each resident in accordance with acceptable professional standard and practices. Specifically one (Resident #1) of three residents' medical records lacked documented evidence that the turning and positioning and intake output sheets were completed as per Resident #1's plan of care. Additionally, the toileting schedule dated 11/27/14 documented that Resident #1 was toileted at 11:30 AM and 1:20 PM. However, Resident #1 was out on pass during that time. Complaint ID: NY 799 The Finding is: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (an assessment tool) dated 11/29/14 documented the resident's cognition status as severely impaired and a turning/repositioning program. The facility policy dated 2/2013 titled, Turing and Positioning, documented each resident who is partially and totally dependent in positioning is positioned in good body alignment with frequent position changes. Unless otherwise determined all residents who are dependent in bed mobility or are at risk for skin breakdown will be placed on a positioning program. The positioning program is a side to right side positioning change every two hours. The facility policy dated 1/2011 titled, Intake and Output, documented when a record of resident's intake and output is necessary the 11-7 nurse will complete the 24 hours worksheet, recording the combine total on the permanent intake and output record in the resident's medical record. The Certified Nursing Aide Accountability Record (CNAAR) for Resident #1 documented strict intake output record and turning and positioning every two hours. The Comprehensive Care Plan (CCP) dated 11/17/14 documented resident has a potential for alteration in skin integrity. Intervention included pressure relieving devices, monitor skin for redness, lesion, opening, rashes and bruising. Encourage meal consumption and fluid intake, ensure plus 8 ounces and Calmoseptin cream as ordered. The Appointment Detail Combo (Ambulette Appointment Record) dated 11/27/14 documented Resident #1 was picked up from the facility at 11:00 AM and dropped off to the facility at 2:00 PM. The CCP dated 12/9/14 documented potential for complications related to peripheral line. Interventions included to administer normal saline 100 milliliter an hour. The medical record lacked documented evidence of turning and positioning on 11/18/14, 11/19/14, 11/21/14, 11/23/14, 11/24/14, 11/25/14 and 11/30/14. The medical record lacked documented evidence of intake output maintenance worksheet completed on 12/9/14, 12/10/14, 12/12/14, 12/15/14, 12/16/14, 12/20/14, 12/27/14, 12/30/14 and 1/4/15. The Turning and Positioning Chart for the month of November 2014 documented Resident #1 on turning and positioning every two hours. During an interview with the 3:00 PM-11:00 PM Licensed Practical Nurse (LPN #2) on 2/10/15 at 3:20 PM, LPN #2 stated that Resident #1's brief was changed every two hour and checked every thirty minutes upon request of the advocate. LPN #2 stated that the intake output records were being maintained for Resident #1 due to her poor oral intake and administration of intravenous fluids. LPN #2 stated that she forgot to document the intake and output for Resident #1 in the medical records. During an interview with the 3:00 PM-11:00 PM Registered Nurse Supervisor (RNS #1) on 2/10/15 at 3:47 PM, the RNS stated that the intake and output should be documented on residents receiving intravenous therapy for hydration to monitor effectiveness. The RNS stated that Resident #1 was receiving the fluids and was voiding, however it was not documented in the medical record. During an interview with the 7:00 AM-3:00 PM Certified Nursing Assistant (CNA #1) on 5/10/16 at 12:10 PM, CNA #1 stated that she had always turned and positioned Resident #1 due to her fragile skin and loose stools. CNA #1 stated that she forgot to document the turning and positioning on 11/25/14, 11/26/14, 11/29/14 and 11/30/14. CNA #1 stated that she should have documented the turning and positioning in the medical record. During an interview with the 11:00 PM-7:00 AM Certified Nursing Assistant (CNA # 3) on 5/10/16 at 1:10 PM, CNA #3 stated that she was turning and positioning Resident #1 every two hours however she forgot to sign for it in the medical record on 11/18/14 and 11/23/14. CNA #3 stated that she should have signed for the turning and positioning. During an interview with the 3:00 PM-11:00 PM Certified Nursing Assistant (CNA # 4) on 5/10/16 at 3:45 PM, CNA #4 stated that she was assigned to Resident #1 and was turning and positioning resident #1 as per her plan of care to prevent pressure ulcers. CNA #4 stated that she forgot to sign for the turning and positioning for Resident #1 on 11/18/14, 11/19/14, 11/21/14, 11/24/14, 11/25/14 and 11/30/14. During an interview with the 11:00 PM-7:00 AM Registered Nurse (RN #2) on 5/19/16 at 9:26 AM, RN #2 stated that when a resident is on intravenous therapy intake and output should be recorded to monitor effectiveness of therapy. RN #2 stated that she was working on 11/18/14, 11/19/14 and 11/20/14. RN #2 stated that Resident #1 was receiving intravenous therapy and was voiding. RN #2 stated that the findings were not documented on the medical records. RN #2 also stated that she did random rounds to ensure that the CNAs were turning and positioning Resident #1 every two hours as per her plan of care. During an interview with the Director of Nursing on 5/20/16 at 11:30 AM, the DON stated that the staff should have signed the turning and positioning sheets and intake output sheets. The DON stated that the Turning and Positioning Chart is part of the Accountability Record for the CNAs. Once the Turning and Positioning Chart is assigned to any resident, it is understood that turning and positioning needs to be completed for that resident, as it is considered part of their plan of care. 415.22(a)(1-4)

Based on observation, interview and record review during an abbreviated survey, the facility did not ensure a resident's physician was notified when the resident had an elevated temperature and there was a need to alter treatment. Specifically, one (Resident #1) of three residents reviewed for notification had an elevated temperature of 103.4 F. The abnormal temperature was not reported to the physician. Complaint ID: NY 799 The finding is: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS-an assessment tool) dated 11/29/14 documented the resident's cognition status as severely impaired. The Nursing Progress note dated 1/27/15 at 10:00 PM documented temperature of 99.7 pulse 80 and respiration of 20. At 3:00 AM, the notes documented a blood pressure of 152/92 and temperature of 103.4 (rectally). Sounds were congested, nonproductive cough. Tylenol suppository at 1:00 AM, urine for analysis and culture obtained. Resident #1's medical record lacked documented evidence that a physician was notified regarding Resident #1's elevated temperature. The facility 24 report dated 1/27/15 and 1/28/15 lacked documented evidence of physician notification related to Resident #1's elevated temperature on 1/28/15 at 3:00 AM. During an interview with the Director of Nursing (DON) on 5/20/16 at 11:30 AM, the DON stated that the medical record lacked documented evidence that a physician was notified of Resident #1's elevated temperature of 103.4. DON further stated that the physician should have been notified. During an interview with the 11:00 PM-7:00 AM Registered Nurse Supervisor (RNS #2) on 5/20/16, RNS #2 stated that she was most certain that she called the physician regarding Resident #1's elevated temperature and forgot to write the orders for the Tylenol suppository and also forgot to document in the medical records. RNS #2 stated that the unit nurse had documented about the elevated temperature in the nurse progress note but she did not include that the physician was notified. 415.3(e)(2)(ii)(b)

Based on record reviews and interviews conducted during the recertification survey, it was determined the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in regards to the maintenance of the controlled medications accountability records for 2 of 2 nursing units. Specifically, the facility's Administration, including the Administrator and DNS (Director of Nursing Services), did not: - revise medication- storage and handling of controlled substance policies for accuracy; - ensure that monitoring of controlled substances were accurately performed; - provide timely training to staff regarding how to accurately count controlled substances and - appropriately monitor staff for counting controlled medications after the facility identified that two blister packs of controlled medication [MEDICATION NAME] was missing on 8/25/15. - Refer to F 431-Scope and Severity - E- Storage of Medications - Complaint # NY 081 The findings are: The original policy and procedure for medications (Nur-126 and Nur-95) was dated 12/2004 and documented controlled substance are to be properly safeguard in accordance with security standards. Under double lock and key, a separate narcotic container is located in the drug room. The container is locked when not in use preventing error or misuse At the beginning and end of each shift, all narcotics and controlled substances will be accounted for by having two nurses one from the present and one from the oncoming shift count narcotics and sign the appropriate accountability records any discrepancy will be reported to the nursing supervisor immediately. On 8/25/15, two blisters of [MEDICATION NAME] 5 mg (60 tablets) were found missing. It was suspected that the narcotics were not properly counted for 3 shifts. This was reported to DOH on 8/25/15. On 9/22/15, the documentation for the control record of narcotics and sedatives was revised and changed to include the actual number of narcotics being handed over from nurse to nurse / shift to shift. The policy and procedure was revised on 9/25 to include A physical inventory of all controlled drugs is made at the change of each shift by two licensed nurses and is documented on and audit record. The DNS was interviewed on multiple occasions during the course of these investigations, including: - on 9/22/2015 at 3:15 PM, the DNS stated she met with the Administrator and they conducted an investigation and was not able to determine who took the medications on 8/25/15. The DNS was asked if there was any changes on how controlled substances medications were counted. There was inservicing after the 8/25/15 incident. She stated that a separate control substance accountability record was maintained for all unused blister packs of controlled medications and all nursing staff was re-educated on the maintenance, storage and narcotic count. The DNS was asked if the nurses were counting the total controlled medications on this sheet for each resident and the DNS replied that there was no documentation that included the total actual controlled medications prescribed per resident. - On 9/25/15 at 1:00 PM, the DNS was asked if there were any revisions to the policy and procedure on controlled substances storage and accountability. The DNS provided a new policy and procedure dated 9/25/15 for controlled substances handling. During an interview with the Administrator, on 8/25/2015 at 11:55 PM, he stated that his responsibilities included oversight of facility investigations which included determining completeness of the investigation. He stated that the 8/25/15 incident was reported to New York State Department of Health (NYS DOH), to the Attorney General and the local police Department. The Administrator further stated he was not aware of any concerns regarding the accountability of controlled substances and therefore, he has not taken any measures of correction in how medications are counted from shift to shift besides interviewing nurses on the policy/protocol for safe use, maintenance and storage of Narcotics. 415.26

br>Based on record reviews, observations and staff interviews during the recertification survey, the facility did not ensure that a system of records was established so that an account of all controlled drugs was maintained to identify loss or diversion. This was evident for 2 of 2 nursing units inspected for medication storage. Specifically, 2 blister packs of oxycodone were identified as missing on 8/25/15. Inspection of the facility's controlled medications accountability records did not include accurate counts all controlled medications. - Complaint # NY 081 The findings are: DOH case # NY 081 reported that 2 blister packs of Oxycodone 5 milligrams (mg) - 60 tablets were reported missing on 8/25/15. The facility initiated an investigation on 8/25/15. An observation of the medication rooms for both the first and second floor on 9/22/15 between 2:15 PM and 2:45 PM revealed the storage of controlled medications with the controlled substances medication records. An review of the controlled substances medication records on 9/22/15 revealed that the controlled drug administration record for 26 residents did not document the accurate amount of controlled substances. Findings included but not limited to: - Resident # 63 was prescribed Lorazepam 1 mg tablet twice daily. Two blister packets were delivered by the pharmacy on 9/19/15. The controlled drug administration record count was 23. The total tablets of Lorazepam stored in the narcotics cabinet was 53 as of 9/22/15. - Resident # 200 was prescribed Xanax 0.5 mg to be administered as needed every 6 hours. Two blister packets were delivered by the pharmacy on 8/7/15. The controlled drug administration record count was 17. The total tablets of Xanax stored in the narcotics cabinet was 47 as of 9/22/15. - Resident # 5 was prescribed Oxycodone HCL 10 mg every 8 hours as needed for pain. Two blister packets were delivered by the pharmacy on 9/18/15. The controlled drug administration record count was 3. The total tablets of Oxycodone stored in the narcotics cabinet was 33 as of 9/22/15. The Director of Nursing Services was interviewed on 9/22/15 at 3:15 PM and stated that a separate control substance accountability record was maintained for all unused blister packs of controlled medications. The DNS was asked if the nurses counted the controlled medications on this sheet and the DNS replied that no actual count was listed on these sheets. She stated that an actual count of all narcotic should be listed for each resident and a new system will be implemented immediately. On 9/24/15 at 4:15 PM, the dispensing pharmacist was interviewed and stated that the medications were dispensed as ordered. He further stated that controlled medications are dispensed for 30 days and it is possible to have more than one blister packet dispensed per resident. He further stated that the facility should be counting the total number of controlled substances if three blister packets of 90 tablets was dispensed. On 9/25/15 at 12:45 PM the pharmacy consultant was interviewed and stated we perform a check once monthly- we perform a check on 3 random controlled substance for the accuracy of the count at that moment in time. We do not observe change of shift counts of controlled substances. The nurses performing the narcotic counts should be counting the total amount of narcotics from one shift to another including the controlled substance that are in unused blister packets. 415.18(d)

Based on observation, record review, and staff interviews during the recertification survey, the facility did not ensure that the facility must immediately inform and consult with the resident's physician that has the potential for requiring physician intervention. This was evident in 1 of 5 residents reviewed for unnecessary medication in a total of 32 Stage 2 sampled residents. Specifically, Resident #211 had a physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. There was no documented evidence that the resident's Physician was made aware. The finding is: Resident #211 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The physician's orders [REDACTED]. On 9/21/15 at 9:25 AM, a License Practical Nurse (LPN) Medication Nurse was observed for medication pass conducted for Resident #211. The resident refused the Enoxparin Injection. In addition, there was also no [MEDICATION NAME] Injection supply available in the medication cart. On 9/21/15 at 9:35 AM, the LPN Medication Nurse was interviewed and stated that she ran out of the resident's [MEDICATION NAME] Injection supply. The LPN stated that she will inform the pharmacy provider that the resident has no [MEDICATION NAME] Injections available. The MAR for September 2015 documented [MEDICATION NAME] 40 milligram/0.4 milliliter (mg/ml) SQ syringe to inject 0.4 ml (40 mg) by SQ route once daily at 9:00 AM for [MEDICATION NAME] treatment. The MAR indicated [REDACTED]. On 9/24/15 at 10:15 AM, the LPN Medication Nurse was again interviewed. The LPN stated that the resident had been refusing [MEDICATION NAME] Injection for sometime and that she had reported the resident's refusal to the Unit Charge Nurse. The LPN also stated that she did not call the Physician to notify him that the resident had been refusing the [MEDICATION NAME] Injection. In addition, the LPN stated that she did not document the resident's refusal on [MEDICATION NAME] Injection from 9/15/15 through 9/21/15 in either the nurse's notes or on the 24-hour Report. On 9/24/15 at 10:30 AM, the Registered Nurse (RN) Unit Charge Nurse was interviewed. The RN stated that she was not made aware that the resident refused [MEDICATION NAME] Injection six times. An interview with the Attending Physician was conducted on 9/24/15 at 1:40 PM. The Physician stated that the nursing staff had not notified him that the resident had been refusing [MEDICATION NAME] Injection six times. The Physician also stated that if had he had been notified he could have ordered some other intervention. 415.3(e)(2)(ii)(a)

Based on observation, record review, and staff interviews during the recertification survey the facility did not ensure that a resident with pressure sores received necessary treatment and services to promote healing. This was evident in 1 of 3 residents reviewed for pressure ulcers (P/Us) in a total of 32 Stage 2 sampled residents. Specifically, 1a) Resident #9 was being treated for [REDACTED]. During the P/U treatment observation, the Licensed Practical Nurse (LPN) did not pack the P/U with Santyl and gauze as ordered by the Physician. The LPN covered the P/U with Santyl and gauze. This is a repeat deficiency from the 2014 Recertification Survey. The findings are: 1) Resident #9 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 8/1/2015 Admission Minimum Data Set (MDS) assessment documented that Resident #9 had short and long-term memory problems and severely impaired daily decision-making skills. The MDS documented that the resident required extensive assistance of two staff members for bed mobility, and total assistance of two staff members for transfers. The MDS documented that the resident was at risk for pressure ulcer development and had one Stage 2 and one Stage 3 pressure ulcer. The Stage 3 P/U measured 1.0 centimeter (cm) long x 2.0 cm wide x 0.1 cm deep. The documented skin and ulcer treatment interventions included pressure reducing device for chair and bed, turning and positioning program, and nutrition/hydration interventions. The Nursing Re-Admission Note dated 7/20/2015 documented that Resident #9 had the following wounds: Right heel--10 centimeters (cm) x 4 cm open dry blister. Left heel--open dry blister 5 cm x 4 cm pink and clean. Left Buttock 4 cm x 4 cm Stage 2. Left inner knee 2 cm x 1 cm Stage 2. Right inner knee dark pressure area. On 9/23/2015 at 2:40 PM the Registered Nurse (RN) wound care nurse was interviewed. She stated that the left heel and left inner knee wounds had healed and that the left buttock and right heel wounds were still being treated. A physician's orders [REDACTED]. A Comprehensive Care Plan (CCP) for the Right Medial Heel Pressure Ulcer, dated 6/1/2015, documented that the origin of this wound was in house. Interventions included bilateral heel pads. An update to the CCP on 7/21/2015 documented that the right heel wound was a Stage 3, 1.5 cm x 2.5 cm x 0.1 cm. The wound flow sheet is part of the CCP and an update made on 9/22/2015 documented that the right heel wound was a Stage 3, 0.5 cm x 2 cm x 0 cm, a 100% dry scab had formed, and treatment was ongoing with a dry protective dressing. On 9/21/2015 at 12:30 PM Resident #9 was observed in bed not wearing the bilateral heel boots. The heel boots were observed on the bedside table. On 9/23/2015 at 2:45 PM Resident #9's 7AM-3PM Certified Nursing Assistant (CNA) was interviewed. She stated that the resident does not turn and position herself and is on a turning and positioning schedule every 2 hours. The CNA further stated that there was a protective dressing on the heel, the resident wears heel boots while in bed and when out of bed she wears socks. On 9/23/2015 at 2:50 PM Resident #9 was observed in her geri-chair. The resident had socks on her feet and the heels were directly in contact with the geri-chair leg rests where they were being supported. On 9/23/2015 at 3:30 PM Resident #9's 3PM-11PM CNA was interviewed. She had just placed the resident back into bed. She stated that she puts the heel boots on when she put the resident to bed, but that the resident was only wearing socks when she was in the geri-chair. On 9/23/2015 at 3:40 PM the RN charge nurse was interviewed. He stated that Resident #9 may not need the heel boots anymore because the heel wounds are healed. However, an update to the CCP for the right heel wound on 9/22/2015 documented that the wound was Stage 3, 0.5 cm x 2 cm and the resident had a physician's orders [REDACTED]. The CNA Accountability Record (CNAAR) was reviewed. For Adaptive/Assistive Devices, bilateral heel lifts-remove for skin checks has been documented for all three shifts since Resident #9's return from the hospital. 1b) The physician's orders [REDACTED]. The Treatment Administration Record (TAR) for September 2015 documented to irrigate the Stage 3 sacral/left inner buttock with Normal saline (NS), pack lightly with Santyl and dry gauze, and cover with dry dressing once daily. The Wound Information Form dated 9/8/15 documented that the Left Inner Buttock wound measured 5 cm x 2.5 cm x 0.5 cm and was treated with Santyl. During the P/U dressing change with the Licensed Practical Nurse (LPN) Treatment Nurse conducted on 9/27/15 at 9:45 AM, the following was observed: -after the LPN irrigated the sacral P/U with NS, the LPN applied the Santyl Ointment with a dry gauze placed on top of the wound bed. The LPN then placed a dry dressing covering the gauze. Visually, the sacral pressure ulcer appeared to measure approximately 5 cm x 3 cm x 1.5 cm with tunneling at the 11 to 1 o'clock position. The LPN Treatment Nurse was not observed packing the the Santyl Ointment with the dry gauze as per the physician's orders [REDACTED].>An interview with the LPN Treatment Nurse was conducted on 9/27/15 at 10:10 AM. The LPN stated that she thought that she packed the wound bed with Santyl Ointment and gauze. An interview with the Registered Nurse (RN) Unit Charge Nurse was conducted on 9/27/15 at 10:30 AM. The RN stated that the LPN should have followed the physician's orders [REDACTED]. 415.12(c)(1)