Every finding on record at Meadowbrook Care Center

Based on observations, interviews and record review during survey, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drug and biologicals) that meet the needs of each resident. This was identified for 12 (Resident #31, Resident #33, Resident #43, Resident #48, Resident #53, Resident #97, Resident #175, Resident #229, Resident #259, Resident #271, Resident #276, Resident #283) of 40 residents on Unit 3A during the Medication Storage task. Specifically, during the medication storage task observation on 05/20/2026 12 of 40 resdient's on unit 3A did not receive their medications on time, one hour before or after medication order time, as per the physician's orders. This is a repeat deficiency. The findings inlcude but were not limited to: The facility's Medication Administration policy last reviewed on 04/20/2026 documented nurses will read the medication order as stated on the Medication Administration record and will note the name, dosage, route, and time of administration to make certain the frequency and schedules correspond. Medications are to be administered in a two-hour time frame (i.e. one hour before or after medication order time). The facility's Medication-Time Schedule for Dispensing Medication policy last reviewed 06/22/2022 documented that the medication schedule for unit 3A low side (room [ROOM NUMBER]-214) are as follow: Q.D. (once a day) 8:30AMB.I.D. (twice a day) 8:30AM ; and 4:30PMT.I.D. (three times a day) 8:30AM ; 12:30PM and 4:30PMQ.I.D. (four times a day) 8:30AM ; 12:30PM, 4:30PM and 8:30PM Any times other than those specified above is at the discretion of the resident's attending physician and must be written for specific times. During the medication storage observation on unit 3A on 05/20/2026 at 11:01AM, Licensed Practical Nurse # 5 was observed administering medications to residents in the dining room. Licensed Practical Nurse # 5 stated they (Licensed Practical Nurse # 5) still have to give out morning medications to a few more residents on the unit.1) Resident #175 was admitted with diagnoses of hypertension (high blood pressure), cerebral infarction (blockage or reduced blood supply to the brain) and gastrostomy status (presence of a surgical opening in the stomach). The Quarterly Minimum Data Set assessment dated [DATE] documented that the Brief Interview for Mental Status (BIMS) score was not assessed due to resident was unable to understand. Resident #175's physician orders as of 05/20/2026 included the following medications due for 08:30 AM administration:-amlodipine 5 milligrams, give one (1) tablet by percutaneous endoscopic gastrostomy tube route (a medical device inserted directly into the stomach) once daily for hypertension.-metoprolol tartrate 25 milligrams, give half (0.5) tablet by percutaneous endoscopic gastrostomy tube route every 12 hours for hypertension.-clopidogrel 75 milligrams, give one (1) tablet by percutaneous endoscopic gastrostomy tube route once daily for cerebral infarction A review of the Medication Administration Audit Report (a report indicating medication administration time) for 05/20/2026 for Resident #175 revealed that Licensed Practical Nurse #5 documented the 8:30 AM medications were administered at 11:55 AM.2)Resident #31 was admitted with diagnoses of hypertension (high blood pressure), peripheral vascular disease (reduced circulation of blood in a body part that is not the brain or the heart) and myocardial infarction (blockage or reduced blood supply to the heart muscle). The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score was not assessed due to resident was unable to understand. Resident #31's physician orders as of 5/20/2026 included but are not limited to the following medications due for 8:30 AM administration:-metoprolol tartrate 100 milligrams, give one (1) tablet by gastrostomy tube (G-tube) route (a medical device inserted directly into the stomach) two (2) times per day for hypertension.-clopidogrel 75 milligrams, give one (1) tablet by gastrostomy tube (G-tube) route (a medical device inserted directly into the stomach) once daily for peripheral vascular disease.A review of the Medication Administration Audit Report (a report indicating medication administration time) for 05/20/2026 for Resident #31 revealed that Licensed Practical Nurse #5 documented the 8:30 AM medications were administered at 11:47 AM.3) Resident #271 was admitted with diagnoses of type 1 diabetes metllitus (non insulin dependent) with hypoglycemia, hypertension (high blood pressure), and polyneuropathy (malfunction of peripheral nerves throughout the body). The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of six (6) which indicated severely impaired cognition. Resident #271 received hypoglycemic medication but no insulin injections was ordered or administered in the look-back period. Resident #271's physician orders as of 5/20/2026 included but are not limited to the following medications due for 8:30 AM administration:-janumet 50 milligrams -1000 milligrams (combination of two hypoglycemic medications), give one (1) tablet by oral route two (2) times per day for diabetes mellitus.-jardiance 25 milligrams, give one (1) tablet by oral route once daily for type 1 diabetes mellitus with hypoglycemia. A review of the Medication Administration Audit Report (a report indicating medication administration time) for 05/20/2026 for Resident #271 revealed that Licensed Practical Nurse #5 documented the 8:30 AM medications were administered at 11:37 AM.During an interview on 05/20/2026 at 11:51AM, the Director of Nursing Services stated that all medications should be administered within a two-hour timeframe of the medication order time. The Director of Nursing Services stated that 08:30 AM medication should be administered between 07:30 AM to 09:30AM. The Director of Nursing Services stated that medication nurses should notify the unit manager if they have difficulty completing the task on their own. The Director of Nursing Services stated they expected the unit manager to assist in administering medications to the residents and that theresident should not received their medications late. During an interview on 05/20/2026 at 01:06 PM, Licensed Practical Nurse #5, the medication nurse on Unit 3A, stated that they were not regularly assigned to unit 3A and were late in medication administration this morning because they were not familiar with the residents and were adjusting to the new workload. Licensed Practical Nurse # 5 stated they notified the unit manager, Registered Nurse # 7, that they required assistance; however, Registered Nurse # 7 was unable to assist them until residents' treatments were completed. Licensed Practical Nurse # 5 stated they were administering all the medications on their own until around 11:00AM. During an interview on 05/20/2026 at 01:17 PM, Registered Nurse #7, the unit manager, stated Licensed Practical Nurse #5 asked for assistance with medication pass shortly before 11:00 AM. Registered Nurse #7 stated they did not know that at that time there were 12 residents who still needed to receive their morning medications. Registered Nurse #7 stated that they did not assist Licensed Practical Nurse #5 in medication pass because they were administering scheduled morning treatments to the residents. Registered Nurse #7 stated medication nurse is typically responsible for giving out medications and completing treatments and they were assisting Licensed Practical Nurse #5 by doing the treatments. During an interview on 05/20/2026 at 01:43 PM, Physician #1, who is also the Associate Medical Director, stated the residents should receive the physician ordered medications within one (1) hour before or one (1) hour after the timeframe specified in the physician's orders. Physician #1 stated and the facility worked closely with pharmacy to reduce unnecessary medication. Associate Medical Director stated extra help should also be considered to ensure medications are administered to residents in a timely manner. During an interview on 05/20/2026 at 02:19 PM, the Medical Director stated stated if the nurses are late in administering medications, they should ask for help. Generally, the nurses should administer medication within one (1) hour before or one (1) hour after the physician-ordered administration time. 10 New York Code Rules and Regulations 415.18(a)

Based on observation, record review, and interviews during the survey, the facility failed to ensure it provided an infection control program designed to help prevent the development and transmission of communicable diseases for two (Resident #140 and #125) of five residents observed during medication administration and for one (1) (Resident #193) of ten (10) residents reviewed for infection control task. Specifically, during the medication administration observation on 05/14/2026, 1) Licensed Practical Nurse #3 wore gloves to fill an irrigation kit bottle with tap water from the bathroom sink and then went to the bedside of Resident #140 to flush the gastrostomy tube without changing gloves or sanitizing hands; 2) Licensed Practical Nurse #4 used bare hands to break a potassium chloride table in half at the request of Resident #125 because the table was too large to swallow; and 3) Resident #193 had a physician's order to maintain contact precautions for colonization of multi drug resistant organisms in the urine and chronic wounds on the lower extremities. On 05/13/2026, Certified Nursing Assistant #3 was observed entering Resident #193's room without applying appropriate personal protective equipment. The findings include: The facility policy titled Medication Administration, revised 05/30/2025, does not address hand washing/hand sanitizing or changing gloves during the medication administration process. The policy does not state that medication tablets should not be handled with bare hands. A facility policy titled Infection Control-Transmission Based Precautions last revised 05/01/2025 documented the facility utilizes transmission-based precautions in with standard precautions for residents who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. The use of transmission-based precautions, special instructions and any restrictions on activities which may be imposed are to be explained to all staff involved and the residents or their representatives. Appropriate signage will be posted on the resident's door. Appropriate personal protective equipment will be donned (put on) upon entry into the environment of a resident on transmission-based precautions since the nature of the interaction with the resident cannot be predicted with certainty and contaminated environmental surfaces ae important source for transmission of pathogens. 1) Resident #140 was admitted with diagnoses including cerebrovascular accident, gastrostomy (a small opening in the abdominal wall directly into the stomach to place a feeding tube (gastrostomy tube), and respiratory failure. The 02/14/2026 quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 5, indicating the resident had severe cognitive impairment. The Minimum Data Set indicated the resident had a feeding tube. A physician's order dated 03/02/2026 and renewed on 05/01/2026 documented gastrostomy tube, size 22 French, balloon size 20 cubic centimeters. A physician's order dated 04/17/2026 and renewed on 05/01/2026 documented tube feeding, Jevity 1.5 to run at 80 milliliters per hour for 15 hours for a total of 1,200 milliliters. Flush gastrostomy tube with 30 milliliters of water before and after each full medication administration. Each individualized medication is to be diluted in 10-15 milliliters of water. Flush gastrostomy tube with 10 milliliters of water after each individual medication is administered. During an observation on 05/14/2026 at 8:32 AM, Licensed Practical Nurse #3 prepared Resident # 140's physician ordered medications for administration. Licensed Practical Nurse #3 put on personal protective equipment (gown and gloves) as the resident was on enhanced barrier precautions and proceeded to the resident's bedside with the medications. While wearing the gloves, Licensed Practical Nurse #3 took the irrigation bottle that was hanging in a plastic bag at the resident's bedside and brought it into the resident bathroom to fill with tap water; using the same gloves the nurse handled the sink faucets and rinsed out the bottle and filled the bottle with water. Licensed Practical Nurse #3 did not change gloves or sanitize their hands and went back to the resident's bedside. Using the same gloves, Licensed Practical Nurse #3 picked up the syringe and was about to flush the gastrostomy tube when the surveyor pointed out that the nurse had not changed gloves or sanitized hands after handling the bathroom sink faucets. Licensed Practical Nurse #3 stated they should have removed their gloves and sanitized hands and proceeded to wash their hands. During an interview on 05/18/2026 at 9:45 AM, the Registered Nurse Infection Preventionist stated this not washing hands created a potential infection control breach because the sink faucets are dirty. Licensed Practical Nurse #3 should have removed gloves and sanitized hands before handling any resident equipment or attempting to flush the gastrostomy tube. During an interview on 05/19/2026 at 1:00 PM, the Director of Nursing Services stated the nurses must follow the infection control protocols such as washing hands, changing gloves, and preparing the medications before entering the residents' room. 2) Resident #125 was admitted with diagnoses including hip fracture, congestive heart failure, and hypertension. The 04/09/2026 5-day Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. During the medication pass administration observation on 05/14/2026 at 9:03 AM, Licensed Practical Nurse #4 prepared the following physician-ordered medications at the medication cart outside the resident's room by placing each medication in a souffle cup: Amiodarone 200 milligram tablet (for prevention of dangerous irregular heart rhythms). Amlodipine 5 milligram-atorvastatin 10 milligram tablet (treats high blood pressure and high cholesterol). Gabapentin 300 milligram capsule (treats nerve pain). Hydroxychloroquine 200 milligram tablet (treats rheumatoid arthritis). Multiple Vitamin-Minerals tablet (supplement). Potassium chloride 20 milliequivalent (supplement for low potassium levels); and Torsemide 20 milligram tablet (treats excessive fluid in body). Physician's orders documented that Resident #125 received regular food consistency and thin liquids, indicating there were no swallowing concerns. Licensed Practical Nurse #4 brought the prepared medications to the bedside. During the process of administering the medications, the resident handled the potassium chloride tablet and stated they wanted the tablet cut in half to ease swallowing. The resident handed the tablet back to the nurse. Licensed Practical Nurse #4 brought the tablet back to the medication cart and discarded the tablet; the nurse sanitized their hands and then popped another potassium chloride tablet from the blister pack using bare hands and then broke that tablet in half and placed the two-halved tablets in a souffle cup to administer the medications to the resident. Upon questioning, Licensed Practical Nurse #4 stated it was not appropriate to touch the tablets with bare hands and that they should have used gloves. Licensed Practical Nurse #4 then discarded the potassium chloride tablet that they just broke in half, put on a pair of gloves, and popped a new tablet to administer to the resident. During an interview on 05/18/2026 at 9:45 AM, the Registered Nurse Infection Preventionist stated the nurse should have worn gloves to handle the medication and not bare hands. During an interview on 05/19/2026 at 10:15 AM, the Assistant Director of Nursing Services, responsible for nursing education, stated the nurse should have used gloves, or had the potassium chloride tablet order changed to the liquid form; the nurse did not meet the infection control protocol by handling a medication with bare hands. During an interview on 05/19/2026 at 1:00 PM, the Director of Nursing Services stated the nurses must follow the infection control protocols, washing hands, and changing gloves. follow the protocol, follow the training. The nurses are not supposed to handle medications with bare hands. 3) Resident #193 was admitted with diagnoses including methicillin susceptible staphylococcus aureus infection, resistance to carbapenem, chronic venous hypertension with ulcer of the right and left lower extremity. A Significant Change in Status assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The Minimum Data Set assessment documented that the resident had two (2) venous and arterial ulcers present, and the resident had frequent urinary incontinence. A comprehensive care plan titled Contact Precautions initiated 02/09/2026 and last revised on 02/11/2026 documented interventions to educate the resident, family, and staff on contact precautions; alert the physician of any signs and symptoms of inability to contain infection and report any changes in the resident's condition to the Physician. A physician's order initiated 03/03/2026 and renewed on 05/06/2026 documented to maintain contact precautions secondary to colonization of carbapenem resistant Enterobacterales (bacteria) in the urine and methicillin resistant staphylococcus (bacteria) in the wounds (lower extremities). During an observation on 05/13/2026 at 12:54 PM, a sign was observed posted outside the resident's door that documented Contact Precautions: everyone must clean their hands, including before entering the and when leaving the room. Providers and staff must also put on gloves and gown before room entry and before room exit. Certified Nursing Assistant #3 was observed entering Resident #193's room with a meal tray. Certified Nursing Assistant #3 did not have any personal protective equipment as per the signage. Certified Nursing Assistant #3 placed the meal tray on the resident's bedside table and adjusted the resident's water pitcher and other items on the bedside table. Certified Nursing Assistant #3 then stepped outside the resident's room, performed hand hygiene and applied a gown and gloves from a bin that was placed outside the resident's room and went back into the resident's room. During an interview on 05/13/2026 at 1:03 PM, Certified Nursing Assistant #3 stated they did not have to apply personal protective equipment to bring a meal tray for the resident. Certified Nursing Assistant #3 stated the resident then wanted assistance with repositioning in bed and that is when they (Certified Nursing Assistant #3) on the personal protective equipment because at this time they were going to provide direct care to the resident. During an interview on 05/13/2026 at 1:27 PM, Registered Nurse #6, the unit manager, stated Resident #193 had a physician's order for contact precautions and Certified Nursing Assistant #3 should have put on appropriate personal protective equipment prior to entering the resident's room and must remove them prior to exiting the resident's room no matter the circumstance. During an interview on 05/15/2026 at 2:31 PM, the Infection Preventionist stated Resident #193 was on contact precautions because of multidrug resistant organism infection in the urine and the wounds. Prior to entering the resident's room Certified Nursing Assistant #3 should have applied a gown and gloves, as per the signage posted outside the resident's room. During an interview on 05/19/2026 at 2:31 PM, the Director of Nursing Services stated Certified Nursing Assistant #3 should have applied gown and gloves prior to entering Resident #193's room for every instance they enter the resident's room because the resident was on contact precautions. 10 New York Code Rules and Regulations 415.19(b)(1)

Based on observations, record review and staff interviews, the facility failed to ensure that all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles. This was identified for two (2) (Resident #5 and Resident #13) of four (4) residents reviewed for accidents. Specifically, 1) Resident #5 was observed with an unlabeled bottle of Tums (antacid medication to relieve heartburn and acid indigestion) on their overbed table. Resident #5 did not have a physician's order for the use of Tums or a self-administration assessment. There was no Nursing staff within the vicinity of Resident #5's room. 2) Resident #13 was observed with a labeled clotrimazole cream (an antifungal cream) one (1) percent on their overbed table. There were no nursing staff within the vicinity of Resident #13. Resident #13 did not have a self-administration assessment or a physician's order to self-administer the medications including the antifungal cream.The findings include:The facility's policy titled Medication Storage and Handling, last revised on 09/19/2025, documented that the Unit Nurse will assure that all resident medications are to be properly labeled, stored, and locked securely in the medication room or medication cart. All drugs and biologicals are stored in locked compartments under proper temperature controls and only authorized personnel have access to the keys.1)Resident #5 was admitted with diagnoses including atrial fibrillation (irregular heart rhythm), gastroesophageal reflux disease (stomach acid repeatedly flows back into the esophagus) and diabetes mellitus (high blood sugar). The annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated that Resident #5 had moderate cognitive impairment. The annual Minimum Data Set assessment documented an active diagnosis of gastroesophageal reflux disease. A Comprehensive Care Plan (CCP) titled, Abdominal Discomfort, dated 05/18/2026 documented interventions including medications as ordered by the Physician, observation for decreased appetite, nausea, vomiting, complaints of gastric pain and evaluation of effectiveness of medication. A review of Resident #5's electronic medical record revealed that Resident #5 did not have a physician's order for Tums.A review of Resident #5's electronic medical record revealed that Resident #5 did not have a self-administration assessment or a physician's order to self-administer medications. During an observation on 05/14/2026 at 9:28 AM, Resident #5 was lying in bed. A bottle of unlabeled Tums was observed on the overbed table. There was no nurse within the vicinity of Resident #5's room.2) Resident #13 was admitted with diagnoses including chronic obstructive pulmonary disease (progressive lung disease that makes breathing hard), diabetes (high blood sugar) and rash (an area of inflamed, swollen or irritated skin). The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated that Resident #13 had moderate cognitive impairment. The Minimum Data Set documented that Resident #13 did not have an open lesion (localized area of abnormal tissue damage) other than ulcers (open sore), rashes, and cuts. A physician's order dated 05/11/2026 documented Lotrimin (antifungal) one percent cream, apply topically to the right posterior (back) upper arm twice a day for fourteen (14) days. A Comprehensive Care Plan (CCP) titled, Skin Integrity: Rash dated 05/11/2026 documented interventions including medication and treatment as ordered by the Physician and observation of effectiveness of prescribed treatment and medication. A review of Resident #13's electronic medical record revealed that Resident #5 did not have a documented assessment or a physician's order to self-administer the medication.During an observation on 05/14/2026 at 9:26 AM, Resident #13 was observed lying in bed. A labeled Lotrimin cream one percent was on the overbed table. There was no nurse within the vicinity of Resident #13's room.During an interview on 05/14/2026 at 9:30 AM, Licensed Practical Nurse #1, the medication nurse, stated that they did not notice the bottle of Tums on Resident #5's overbed table. Licensed Practical Nurse #1 stated that the bottle of Tums was unlabeled and did not come from the facility. Licensed Practical Nurse #1 stated that the Lotrimin cream for Resident #13 must have been left by the nurse from the previous shift. Licensed Practical Nurse #1stated they did not give the antifungal cream tube to Resident #13. Licensed Practical Nurse #1 stated that Resident #5 and Resident #13's medications are administered by the nurses at the facility. Licensed Practical Nurse #1 stated that all medications should be locked in the medication cart after administration. During an interview on 05/14/2026 at 9:33 AM, Registered Nurse #1, the unit manager, stated that all medications should be locked in the medication cart after administration. Registered Nurse #1 stated that Resident #5 and Resident #13 did not have any assessment to self-administer their medication because they (Resident #5 and Resident #13) needed assistance from a nurse to administer their medication. During an interview on 05/15/2026 at 8:52 AM, Licensed Practical Nurse #2, Medication Nurse for 3:00-11:00 PM shift, stated they applied the antifungal cream on Resident #13's upper arm on their shift (3:00-11:00 PM) and was called by another resident. Licensed Practical Nurse #2 stated they forgot to take the antifungal cream from Resident #13's room and the medication was left on the resident's overbed table. Licensed Practical Nurse #2 stated they forgot to lock the antifungal cream in their medication cart. During an interview on 05/18/2026 at 2:39 PM, the Director of Nursing Services stated that nurses should follow the medication administration and storage policy which include locking the medication in the medication cart after administration. The Director of Nursing Services stated that all nursing staff should be checking and reporting any medications left in resident's room.10 New York Code Rules and Regulations 415.18(e) (1-4)

Based on record review and interviews during survey, the facility failed to ensure that for each resident, radiological diagnostic tests were obtained in a timely fashion. This was identified for one (1) (Resident #293) of three (3) residents reviewed for hospitalization. Specifically, on 03/09/2026 Resident #293 had a physician order for a chest x-ray due to fever. There was no documented evidence that the chest x-ray was ever completed. On 03/11/2026 the resident was transferred to the hospital and was admitted with a diagnosis of pneumonia.(Complaint #2967962) The findings include:The facility's policy titled Radiologic Testing Services, dated 03/31/2021 last revised on 03/11/2026, documented the facility will provide the appropriate radiology testing required to maintain the overall health of its residents in accordance with state and federal guidelines. Radiology orders will be entered into the resident's electronic medical record and transmitted to the contracted vendor. Qualified nursing personnel will receive and review test reports and communicate results to the physician within 24 hours of receipt of results unless the report indicates results fall outside of clinical reference ranges and require immediate attention at which time the physician will be notified upon receipt of results. Documentation of the tests, the results, and date and time of physician notification will be maintained in the electronic medical record; The policy revision dated 03/11/2026 included that an audit will be conducted to ensure all orders were completed and results were obtained within 24 hours, unless the order is STAT (immediate); in that case the audit will ensure the results were obtained within eight (8) hours. The physician will be notified of any orders that do not fall within these timeframes.Resident #293 was admitted with diagnoses including cancer, hip fracture, and anxiety disorder. The 12/20/2025 admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 11, indicating the resident had moderate cognitive impairment.A nursing progress note dated 03/09/2026 at 09:58 PM, written by Registered Nurse Supervisor #2, documented Resident #293 was observed in bed flushed (sweaty, reddened, warm skin), shivering, temperature 101.9 degrees Fahrenheit (normal 97 degrees Fahrenheit -99 degrees Fahrenheit), blood pressure 177/90 millimeters of mercury (normal about 120/80 millimeters of mercury), pulse 94 beats per minute (normal 60-100 beats per minute), respiratory rate 18 breaths per minute (normal 16-20 breaths per minute), and an oxygen saturation on room air 92% (normal 95%-100%). The Physician was notified and ordered blood work, urinalysis (a test to screen urine for infection and abnormalities), urine culture and sensitivity (identifies the kind of bacteria in urine and which antibiotic will be effective), and a chest x-ray.A physician's order dated 03/09/2026 at 09:55 PM documented to obtain chest x-ray (STAT0044), one time on 03/09/2026 during the 11:00 PM-07:00 AM shift for unspecified fever.A nursing progress note dated 03/10/2026 at 08:15 AM, documented the resident was receiving intravenous fluids and remained without fever throughout the night. The laboratory results were pending for chest x-ray, urinalysis, urine culture and sensitivity, and blood work.A nursing progress note dated 03/10/2026 at 08:10 PM, written by Registered Nurse Supervisor #5, documented abnormal diagnostic urinalysis results were reviewed with the Physician. The next step would be to follow up on the pending urine culture.A nursing progress note dated 03/10/2026 at 08:44 PM, written by Registered Nurse Supervisor #5, documented abnormal diagnostic blood test results were reviewed with the Physician.A physician assistant note dated 03/11/2026 at 02:31 PM documented the resident was seen and examined at the bedside. Upon assessment, the resident was awake, alert, and oriented to person and place with periods of forgetfulness. The resident denied shortness of breath, chest pain, nausea, vomiting, feeling warm, chills, and dysuria (painful urination). Respiratory status was stable. The physician assistant documented that they would follow up with chest x-ray and urine culture and sensitivity results for further intervention.A review of the medical record revealed no evidence that the x-rays were obtained as per the 03/09/2026 physician's order.A nursing progress note dated 03/11/2026 at 06:57 PM, written by Registered Nurse Supervisor #3, documented that the resident was alert with confusion. The writer (Registered Nurse Supervisor #3) was called to unit by the unit nurse regarding the resident's intravenous line being dislodged. Upon arrival in the room the resident was noted shaking uncontrollably. The resident's family member was at the bedside and requested the resident to be transferred to the hospital. While the writer was assessing the resident and attempting intravenous line insertion, the resident's family called 911 (emergency service). The Physician made aware and approved the resident's transfer to the hospital for altered mental status evaluation.A nursing progress note dated 03/11/2026 at 11:58 PM documented the hospital confirmed that the resident was admitted to the hospital with a diagnosis of pneumonia.During an interview on 05/18/2026 at 11:20 AM, Registered Nurse Supervisor #2 stated they received the x-ray order for Resident #293 on 03/09/2026. They entered the order in the electronic medical record and sent the requisition to the x-ray vendor, documented the orders in the supervisor communication book in the nursing office, and called the resident's family. Registered Nurse Supervisor #2 stated that if x-ray vendor did not arrive in four (4) hours, the nurse, on the next shift, should have called the x-ray vendor again.During an interview on 05/19/2026 at 9:37 AM, the x-ray vendor representative stated they were unable to find the x-ray requisition and any evidence that the x-rays were obtained for Resident #293.During an interview on 05/19/2026 at 10:45 AM, the Director of Nursing Services stated the x-ray order on 03/09/2026 was not an actual STAT (immediate) order. The STAT0044 in the physician's order was just a communication code indicating the vendor's name (STAT). If the x-ray order was an actual STAT (immediate) order, it would be specified in the physician's order. The 03/09/2026 x-ray order was a routine x-ray order, and the x-rays should have been taken within 24 hours (on 03/10/2026) after the physician's orders. The Director of Nursing Services stated the x-ray was not done and they called the vendor on 03/10/2026 to follow up on the status. The x-ray vendor company was unable to locate the order and therefore the chest x-ray for Resident #293 was not done. The Director of Nursing Services stated they then notified Physician #1 on the evening of 03/10/2026. Physician #1 told them that a physician assistant will see the resident on 03/11/2026 to re-assess the resident and determine if the x-rays needed to be re-ordered. The Director of Nursing Services stated there were no progress notes written on 03/10/2026 regarding the communication with Physician #1 or the follow-up with the x-ray vendor company for the missed x-rays for Resident #293. The Director of Nursing Services stated Resident #293's x-rays were done timely because of a communication error between the facility and the x-ray vendor company.During an interview on 05/19/2026 at 11:30 AM, Physician #1 stated they would expect a routine x-ray to be done by the next day at least (03/10/2026) and they did not know why the ordered chest x-ray for Resident #293 was not done.During an interview on 05/19/2026 at 12:10 PM, Registered Nurse Supervisor #3 stated they worked on the 3:00 PM-11:00 PM shift on 03/11/2026. At the beginning of the shift the resident was shaking uncontrollably and had periods of confusion. Registered Nurse Supervisor #3 stated they reviewed the physician's orders and saw the chest x-rays were not done. They sent the requisition on 03/11/2026 and the x-ray technician finally came when the resident was on the stretcher heading out the door. Registered Nurse Supervisor #3 stated they did not know why the x-rays were not done prior to 03/11/2026 because when a requisition is sent the x-ray company usually responds in about 10 minutes. Registered Nurse Supervisor #3 stated that the facility staff should have documented any communication and follow up with the x-ray company in the resident's medical record including the reason why the x-rays were not completed within 24 hours (on 03/10/2026).Review of the medical record revealed there was no documentation follow-up with the x-ray vendor regarding the status of the x-ray ordered on 03/09/2026.10 New York Code Rules and Regulations 415.21

Based on observation, record review, and interviews during the Recertification Survey initiated on 7/23/2024 and completed on 7/29/2024, the facility did not ensure that an account of all controlled drugs was accurately maintained. This was identified on one (Unit 1B) of eight units. Specifically, during the medication storage task observation on Unit 1B, the Oxycodone (a narcotic pain medication) count documented in the controlled substance record did not match the amount of Oxycodone tablets present in the blister pack for Resident #407. The finding is: The facility's policy titled Management of Controlled Medications, revised 5/24/2024, documented all controlled drugs will be subject to special receipt, handling, storage, disposal, and record keeping. Controlled drug records will be maintained in such a manner as to ensure accountability, security, and ease of tracking. The medication nurse is responsible for adhering to the procedures for ordering, receiving, storing, administering, and recording the administration of controlled drugs. The medication nurse is responsible for recording any administered medications on the front of the appropriate controlled drug sheet, including the date, time, amount used, signature, and amount remaining. Resident #407 was admitted with diagnoses including Unspecified Fracture of the Left Tibia (leg bone), Hypertension, and Deep Vein Thrombosis. The 5/17/2024 Admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. A physician's order dated 7/23/2024 documented to administer Oxycodone 5 milligrams tablet, give one tablet by oral route every 6 hours. The diagnosis was an unspecified fracture of the upper end of the left tibia (bone in the lower leg). On 7/25/2024 at 1:12 PM during the medication storage task, on Unit 1B with Licensed Practical Nurse #1, the controlled drug record sheet for Resident #407's Oxycodone, 5 milligrams, indicated 29 tablets were remaining; however, the corresponding Oxycodone blister pack only had 28 tablets. Licensed Practical Nurse #1 was interviewed immediately after the observation on 7/25/2024 and stated they had administered a 5-milligram Oxycodone tablet to Resident #407 at 8:48 AM on 7/25/2024 and did not record the administration of the Oxycodone on the controlled drug record sheet and it was an oversight. The resident's medication administration record was signed indicating the medication (Oxycodone) was administered as ordered by the Physician. Registered Nurse #4, the Nurse Educator, was interviewed on 7/25/2024 at 1:58 PM and stated to ensure that the narcotic count matches, as soon as the medication nurse removes the controlled medication out of the blister pack, the nurse should document in the controlled drug record sheet that the medication was removed. The Director of Nursing Services was interviewed on 7/25/2024 at 2:05 PM and stated the nurses are supposed to sign the controlled drug record sheet immediately when administering a controlled substance. 10 NYCRR 415.18(b)(1)(2)(3)

Based on record review and interviews during the Recertification Survey initiated on 7/23/2024 and completed on 7/29/2024, the facility did not ensure that the facility assessment accurately included what resources were necessary to care for its residents competently during day-to-day operations. Specifically, the Facility Assessment incorrectly assessed the need for an excessive number of Certified Nurse Aides during the day shift (7:00 AM-3:00 PM). The finding is: The Facility assessment dated [DATE] documented the facility was assessed to have 57 Certified Nurse Aides (39 facility staff and 18 agency staff) for the day shift (7:00 AM - 3:00 PM). The Administrator was interviewed on 7/29/2024 at 1:57 PM and stated they reviewed and approved the Facility Assessment on 5/1/2024. The Administrator stated that they did not agree that the facility required 57 Certified Nurse Aides on the day shift and believed that it was a typographical error. The Administrator was re-interviewed on 7/29/2024 at 2:15 PM and stated that the number of Certified Nursing Assistants (57) in the Facility Assessment did not reflect the actual total amount of Certified Nursing Assistants required on each unit for a specific shift based on assessment of resident's need and acuity level. The Administrator stated that they should ensure the information in the Assessment was accurate and up to date when they conducted the review in May 2024. A revised Facility Assessment was provided and reviewed on 7/29/2024. The date of Assessment was unchanged. The revised Assessment documented that 39 Certified Nurse Assistants were required on the day shift (7:00 AM-3:00 PM). 10 NYCRR 415.26

Based on observation, record review, and interviews during the Recertification Survey initiated on 7/23/2024 and completed on 7/29/2024 the facility did not ensure that each resident's medical record was maintained in accordance with accepted professional standards and practices. The facility did not maintain medical records for each resident that were complete and accurately documented. This was identified for one (Resident #452) of seven residents reviewed for Respiratory Care. Specifically, Resident #452 was observed receiving oxygen on 7/23/2024, 7/24/2024, and 7/25/2024 without a physician's order. The finding is: The facility policy titled, Oxygen Therapy and Monitoring dated 9/17/2019 and revised on 9/11/2023 documented that residents requiring oxygen will have oxygen ordered either as needed or continuously by the physician and/or physician extender. Resident #452 was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Heart Failure, and Acute Kidney Failure. The Admission Minimum Data Set assessment dated , 5/22/2024 documented a Brief Interview for Mental Status score of 13, indicating the resident had an intact cognition. The Admission Minimum Data Set assessment documented Resident #452 was receiving continuous oxygen therapy upon admission. Resident #542's Comprehensive Care Plan for Respiratory Disorders/Chronic Obstructive Pulmonary Disease/Asthma, effective 5/16/2024 documented interventions to administer oxygen as ordered by the medical doctor. During an observation on 7/23/2024 at 10:30 AM Resident #452 was observed in their bed and was receiving 2 liters of oxygen per minute via a nasal cannula (a device that delivers oxygen through a tube and into your nose). Resident #452 was interviewed on 7/23/2024 at 10:30 AM and stated they were not sure how long they had been receiving oxygen. During a second observation on 7/24/2024 at 11:50 AM Resident #452 was observed in their bed. The resident was receiving 2 liters of oxygen per minute via a nasal cannula. During a subsequent observation on 7/25/2024 at 9:49 AM Resident #452 was observed in their bed. The resident was receiving 2 liters of oxygen per minute via a nasal cannula. There was no documented evidence of a current physician's order for supplemental oxygen. Licensed Practical Nurse #2, the medication nurse, was interviewed on 7/25/2024 at 11:38 AM and stated they provided Resident #452 with their morning medications and observed Resident #452 receiving supplemental oxygen. Licensed Practical Nurse #2 stated they did not check Resident #452's physician's orders for supplemental oxygen and did not realize there was no order in place. Licensed Practical Nurse #2 stated they would not provide medications or treatments that did not have a physician's order and they should have checked for an order. Registered Nurse #1, the Unit Manager was interviewed on 7/25/2024 at 11:50 AM and stated if supplemental oxygen was in use there should have been a current physician's order in place. The Director of Nursing Services was interviewed on 7/25/2024 at 4:44 PM and stated a physician's order should be in place if the resident was receiving oxygen therapy. 10 NYCRR 415.22(a)(1-4)

Based on record review and interviews during the Recertification survey initiated on 7/23/2024 and completed on 7/29/2024, the facility did not ensure that all completed Minimum Data Set (MDS) assessments were electronically transmitted to the Center for Medicare and Medicaid Services (CMS) within 14 days of the resident assessment completion. This was identified for three (Residents #201, #205, and #63) of three residents reviewed for the Resident Assessment Facility Task. Specifically, Resident #201's Discharge Minimum Data Set (MDS) assessment was not electronically submitted to the Centers for Medicare and Medicaid Services (CMS) until 132 days after completion of the assessment; Resident #205's Quarterly Minimum Data Set (MDS) assessment was not electronically submitted to the Centers for Medicare and Medicaid Services (CMS) until 16 days after completion of the assessment; Resident #63's Discharge Minimum Data Set (MDS) assessment was not electronically submitted to the Centers for Medicare and Medicaid Services (CMS) until 90 days after completion of the assessment. The findings are: The facility policy titled Minimum Data Set Assessment, last revised on 10/1/2019, documented that the facility will conduct and submit a Minimum Data Set (MDS) required assessments in accordance with the Federal and State guidelines. The policy did not document the timeframe of when the assessments should be transmitted. A review of the Minimum Data Set (MDS) 3.0 Nursing Home Validation Report provided by the facility revealed the following: -Resident #201's Discharge Minimum Data Set assessment with the reference date of 3/19/2024 was submitted to the Centers for Medicare and Medicaid Services on 7/29/2024. Resident #201's Discharge Minimum Data Set transmittal was 132 days late. -Resident #205's Quarterly Minimum Data Set assessment with the reference date of 6/22/2024 was submitted to the Centers for Medicare and Medicaid Services on 7/6/2024 and was rejected. Resident #205's Quarterly Minimum Data Set was re-submitted to the Center for Medicare and Medicaid Services on 7/22/2024, Resident #205's Quarterly Minimum Data Set transmittal was 16 days late. -Resident #63's Discharge Minimum Data Set assessment with the reference date of 4/30/2024 was submitted to the Centers for Medicare and Medicaid Services on 7/29/2024. Resident #63's Discharge Minimum Data Set transmittal was 90 days late. The Director of Nursing Services was interviewed on 7/29/2024 at 1:00 PM and stated they were not aware of how the Minimum Data Set (MDS) assessments were completed and transmitted to the Center for Medicare and Medicaid Services. The Minimum Data Set Coordinators are responsible for tracking and transmitting the Minimum Data Set assessments to the Centers for Medicare and Medicaid Services. The Minimum Data Set Coordinator #1 was interviewed on 7/29/2024 at 2:00 PM and stated that Resident #201 and Resident #63's Discharge Minimum Data Set assessments were never submitted. The Minimum Data Set Coordinator #1 stated they should have checked to ensure that the Discharge and Quarterly Assessments were transmitted to the Centers for Medicare and Medicaid Services promptly. 10 NYCRR 415.11

Based on observations, record review, and interviews during the Recertification Survey and Abbreviated survey (Complaint # NY 435 and NY 476) initiated on 11/7/22 and completed on 11/14/2022 the facility did not ensure that residents who have an indwelling catheter, receives the appropriate care and services to prevent urinary tract infections to the extent possible. This was identified for one (Resident # 295) of two residents reviewed for Urinary Catheter. Specifically, Resident #295 was admitted to the facility with a chronic long-term use of a Foley catheter and treatments to flush the catheter. The Foley catheter (F/C) care was not documented as completed every shift as ordered by the Physician. The finding is: Resident #295 was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #295 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. The MDS documented the resident required extensive assistance of two persons for transfers and toilet use. The resident was non-ambulatory and had an indwelling catheter. The Urinary Incontinence and Indwelling Catheter Comprehensive Care Plan (CCP) dated 3/12/2021 documented the resident had an Indwelling Catheter in place for Urinary Retention, [CONDITION(S)] Bladder, Obstruction and or Stage III /IV Pressure Ulcer of the sacral area. Interventions included to continue infection control teaching for compliance, assess color, amount, odor of urine and report changes to the Physician. Catheter Care as per facility policy. Change drainage bag weekly and as needed (PRN). Change Foley Catheter (F/C) as ordered The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Use of a Foley Catheter #24 French (Fr) with 15 cubic centimeter (cc) balloon to Bed Side Drainage (BSD) for Malignant Neoplasm of bladder. Change Foley Catheter every 4 weeks; Flush Foley catheter every shift with 50 cc Normal Saline 5 times for a total of 250 cc. Flush with 50 cc, pull back the 50 cc and discard. Repeat 5 times. The Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Treatment Administration Record (TAR) from March 2021 to January 2022 revealed no documented evidence the Foley Catheter was flushed, or the Foley Catheter care was provided as ordered as listed below: -During the 7 AM-3 PM nursing shift there were 19 occasions where there was no documented evidence that the Foley catheter care was provided to Resident #295. -During the 3 PM-11 PM nursing shift there were 21 occasions where there was no documented evidence that the Foley catheter care was provided to Resident #295. -During the 11 PM-7 AM nursing shift there were 4 occasions where there was no documented evidence that the Foley catheter care was provided to Resident #295. Licensed Practical Nurse (LPN) # 3, who provided care on dates including April 3rd, April 17 and April 22, was interviewed on 11/14/22 at 12:13 PM and stated that they recall providing care to the resident and stated Resident #295 made sure the Foley catheter was flushed. The LPN stated at times when they were the only LPN on the unit, they could not flush the catheter and would notify the Registered Nurse (RN) Manager to flush the catheter. If there were missing initials on the TAR, it meant either they did not flush the catheter with expectations the RN would do it or they forgot to initial the TAR. The Registered Nurse (RN) Manager # 7 was interviewed on 11/14/22 at 11:17 AM and stated that they cared for the resident on their unit. RN #7 stated that sometimes they (RN #7) flushed the catheter. When they (RN #7) provided catheter care or flushed the catheter, they (RN #7) would document this on the TAR. RN #7 could not explain why there were no initials by the nurse on the TARs to show that catheter care was provided. RN #7 stated that the TAR should have been initialed to reflect that care was provided as ordered by the physician. RN # 9 was interviewed on 11/14/22 at 12:17 PM and stated when RN # 7 was not available, they (RN #9) would provide the catheter care to Resident # 295. RN #9 stated the TAR should be initialed to show the Foley catheter care was provided. If the LPN could not flush the catheter, then the RN Manager would be responsible to flush the catheter. LPN # 6, who provided care on April 11, 2021 (when the TAR was not signed), was interviewed on 11/14/22 at 1:55 PM. LPN #6 stated they never irrigated the resident's foley catheter and only cared for the resident three times. The resident wouldn't allow me to irrigate the Foley and I would tell the charge nurse to irrigate the catheter. LPN #6 stated they did not sign the TAR because they did not provide the catheter care. The Director of Nursing Services (DNS) was interviewed on 11/14/22 at 2:10 PM and stated the missing initials on the TAR are not acceptable. It would be difficult to determine whether the treatment or care was provided if the TAR is not signed. The Medical Director was interviewed on 11/14/22 at 3:11 PM and stated they were not aware the TAR was not being signed for Catheter care and that not flushing this resident's catheter can cause complications such as obstruction and other urinary complications. The Medical Director stated that it was important to provide catheter care and flush the catheter as ordered. 415.12(d)(2)

Based on record review and staff interviews during the Recertification Survey initiated on 11/7/2022 and completed on 11/14/2022, the facility did not implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical and nursing needs that are identified in the comprehensive assessment. This was identified for one (Resident #61) of three residents reviewed for Accidents. Specifically, Resident #61, was occasionally incontinent of bladder and required assistance with toileting every 2-4 hours as indicated on the Comprehensive Care Plans (CCP). There was no documented evidence that the resident was toileted every 2-4 hours as indicated on the CCP. Resident #61 had an unwitnessed fall on 9/5/2022 and was found sitting on the floor in their (Resident #61) room near the bathroom and sustained a Left [CONDITION(S)]. The finding is: The facility's policy titled Comprehensive Assessment and Baseline Care Plan Development, revised 11/2021, documented the Comprehensive Care Plan (CCP) must be person-centered, updated and revised by all members of the interdisciplinary team as needed (to reflect the resident's current condition), and in accordance with the MDS schedule. The CCP must include measurable objectives, desirable outcomes, and outline services provided in order to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Resident #61 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/1/2022 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 4, indicating the resident had severe cognitive impairment. The MDS documented that the resident required extensive assistance of one staff member for toilet use and personal hygiene and required staff assistance for moving on and off the toilet. The resident required limited assistance for transfers and walking in their room; the resident was occasionally incontinent of urine and frequently incontinent of bowel; and the resident had one none-injury fall and one minor-injury fall prior to this MDS assessment. A CCP titled Self Care Deficit documented the resident requires Assistance with Activities of Daily Living (ADLs), effective 6/25/2022 included an intervention to provide extensive assistance of two staff members with toileting. The CCP documented that the resident transfers with extensive assistance of two staff members. A CCP titled Falls, effective 6/25/2022, documented the resident at risk for falls related to unsteady gait, and inability to recognize unsafe actions related to Dementia. Interventions included but were not limited to providing incontinence care every 2-4 hours. The CCP titled Elimination: Bowel and Bladder incontinence, effective 6/27/2022, documented the resident has alteration in elimination due to bowel and bladder incontinence and needs assistance with toileting. Interventions dated 7/19/2022 included but were not limited to: toilet every 2-4 hours and on request, and provide assistance with toileting. The Resident Nursing Instructions (care instructions provided to the Certified Nursing Assistants [CNA]) as of 9/1/2022 documented the resident was continent of bladder and incontinent of bowel. The resident required limited assistance of one person for toileting. The schedule section documented to toilet the resident every day at 7 AM-3 PM, 3 PM-11 PM and 11 PM-7 AM. There was no direction to toilet the resident every 2-4 hours as indicated on the falls and elimination CCPs. The Resident CNA Documentation History Detail Report documented the following on 9/4/2022: -7 AM - 3PM nursing shift the resident was provided extensive assistance of one person for toileting. - 3 PM-11 PM nursing shift the resident required limited assistance of one person and was incontinent of both bowel and bladder. - 11 PM- 7 AM nursing shift there was no documented evidence that the resident was provided toileting care. The fall risk assessments dated 8/27/2022 documented the resident had a fall risk score of 8; however, the assessment does not indicate if a score of 8 identified the resident at low, moderate, or high risk for falls. Additionally, the fall risk assessment dated [DATE] only assessed 6 of the 8 categories included on the form to determine falls risk. Both the level of consciousness/mental status and the Ambulation/Elimination status were left blank. A nursing note written by Registered Nurse (RN #2) on 9/5/2022 at 7:24 AM documented at 4:00 AM, the unit nurse notified RN #2 that the resident (Resident #61) was observed on the floor in their room. Upon arrival to the resident's room, the resident was observed on the floor in their bedroom, seated on their buttocks, in front of their bathroom door. Body assessment was done, and the resident was noted to have pain to left femur and pelvis. RN #2 contacted Resident # 61's Primary Care Physician and orders for STAT (immediate) x-ray of the left femur and pelvis were obtained. A medical progress note dated 9/5/2022 at 2:49 PM documented the resident was seen for left hip pain and poor range of motion. The physical examination revealed Exam with left leg shorter than right, externally rotated, associated with pain, cannot bear weight, likely fracture. Transfer [the resident] to the emergency department for further evaluation. A nursing progress note dated 9/5/2022 at 5:35 PM documented the resident was admitted to the hospital with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A CCP titled Non-Compliance dated 9/23/2022, (developed after the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident refuses care and can be aggressive during care due to [CONDITION(S)]. CNA #1 was interviewed on 11/10/2022 at 11:15 AM and stated they (CNA #1) worked on 9/4/2022-9/5/2022 on the 11 PM - 7 AM shift. CNA #1 stated that Resident #61 used the bathroom by themselves CNA #1 stated the resident gets up and goes to the bathroom by themselves and does not need help. CNA #1 stated sometimes Resident #61 urinates on the floor. CNA #1 stated they (CNA #1) did not know when the resident had last used the bathroom prior to the fall on 9/5/2022. CNA #2, the regularly scheduled 7 AM-3PM CNA for Resident #61, was interviewed on 11/10/2022 at 1:26 PM. CNA #2 stated Resident #61 cannot go to the bathroom by themselves. CNA #2 stated after the resident fell on [DATE], they (Resident #61) needed much more assistance, but before the fall, the resident also needed help for toileting because of confusion. The CNA stated because of safety reasons we did not want the resident to be alone. RN #2, who was the night supervisor on 9/4/2022-9/5/2022, was interviewed on 11/10/2022 at 1:55 PM and stated Resident #61 needed assistance for toileting on 9/5/2022 as per the Resident Nursing Instructions. RN #2 stated the CNAs are supposed to review the nursing care instructions at the start of their shift. RN #2 stated the medication nurse on the unit knows the floor and the residents and should ensure that the CNAs are following the Resident Nursing Instructions to care for each assigned resident. CNA #3, who was the regularly assigned 3 PM-11 PM CNA, was interviewed on 11/10/2022 at 3:14 PM and stated before the fall on 9/5/2022, the resident needed help with toileting activities because the resident would sometimes wet themselves. CNA #3 stated they (CNA #3) would not let the resident go to the bathroom by themselves, the resident was very impulsive, prone to falls, and was very confused. The Licensed Practical Nurse (LPN) #1, who was the assigned 11 PM-7 PM LPN on 9/4/2022-9/5/2022, was interviewed on 11/14/2022 at 8:22 AM. LPN #1 stated CNA #1 is regularly assigned to the resident and that CNA #1 knows Resident #61. LPN #1 stated they (LPN #1) constantly repeat with the CNAs that no resident is considered independent, and all residents must be helped.LPN #1 stated CNA #1 would be expected to know what assistance the resident needs. RN #3 and RN #4 (MDS coordinators) were interviewed on 11/14/2022 at 8:30 AM concurrently regarding why the 9/1/2022 MDS assessment requiring extensive assist for toileting did not match the nursing care instructions of limited assist that were effective 9/1/2022. RN #3 and RN #4 stated the MDS assessment was based on a 7 day look back period and on 3 occasions the resident required extensive assistance. RN #5, who was the unit manager, was interviewed on 11/14/2022 at 9:24 AM and stated they are responsible to update the care plan and care instructions. RN #5 stated that Resident #61's toileting care instructions should have been documented as extensive assistance prior to the fall. RN #5 stated the Resident Nursing Instructions were not changed to extensive assistance until after the resident came back from the hospital following the fall on 9/5/2022. The Director of Nursing Services (DNS) was interviewed on 11/14/2022 at 10:44 AM The DNS stated if the CCP documents to toilet the resident every 2-4 hours, that intervention should have been transposed to the CNA nursing instructions (Resident Nursing Instructions) or else there is no way for the CNA to know. The DNS stated the MDS assessment of extensive assistance for toileting should have been communicated to the unit supervisor to put on the Resident Nursing Instructions; that is the process. 415.11(c)(1)

Based on record review and staff interviews during the Recertification Survey initiated on 11/7/2022 and completed on 11/14/2022, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were 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. This was identified for one (Resident #61) of three residents reviewed for Accidents. Specifically, Resident #61 had an unwitnessed fall on 9/5/2022 and was found sitting on the floor at 4 AM in their (Resident #61) room near the bathroom. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility did not report the Accident, which resulted in serious injury, to the New York State Department of Health (NYSDOH) within the required timeframe. The finding is: Resident #61 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/1/2022 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 4, indicating the resident had severe cognitive impairment. The MDS documented that the resident required extensive assistance of one staff member for toilet use and personal hygiene and needed staff assistance for moving on and off the toilet; the resident was occasionally incontinent of urine and frequently incontinent of bowel; and the resident had one none-injury fall and one minor-injury fall prior to this MDS assessment. A Comprehensive Care Plan (CCP) titled Self Care Deficit - Requires Assistance with Activities of Daily Living (ADLs), effective 6/25/2022, included an intervention to provide extensive assistance of two staff members with toileting and transfers. A CCP titled Falls, effective 6/25/2022, documented an intervention to provide incontinence care every 2-4 hours. The CCP documented the resident had falls on 6/29/2022, 7/5/2022, 8/27/2022, and 8/30/2022 prior to the 9/5/2022 fall. A nursing note written by Registered Nurse (RN) #2 on 9/5/2022 at 7:24 AM documented at 4:00 AM, the unit nurse notified RN #2 that the resident (Resident #61) was observed on the floor in their room. Upon arrival to the resident's room, the resident was observed on the floor in their bedroom, seated on their buttocks, in front of their bathroom door. Body assessment was done, and the resident was noted to have pain to left femur and pelvis. RN #2 contacted the Primary Care Physician and orders were obtained for STAT (immediate) x-ray of the left femur and pelvis. A medical progress note dated 9/5/2022 at 2:49 PM documented the resident was seen for left hip pain and poor range of motion. The physical examination revealed Exam with left leg shorter than right, externally rotated, associated with pain, cannot bear weight, likely fracture. Transfer [the resident] to the emergency department for further evaluation. A nursing progress note dated 9/5/2022 at 5:35 PM documented the resident was admitted to the hospital with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Accident and Incident (A/I) report dated 9/5/2022 documented that the resident was found at 4 AM sitting on their buttocks in their (Resident #61) room in front of the bathroom. The floor was wet with urine, the resident did not use the call bell, and the resident was unable to provide details of the incident. Review of the assigned Certified Nursing Assistant (CNA) statement (CNA #1) revealed that the fall was unwitnessed, and the CNA last saw the resident at 3:30 AM. The conclusion in the A/I report documented there was no CCP violation observed and criteria was not met for reporting. CNA #1 was interviewed on 11/10/2022 at 11:15 AM and stated they (CNA #1) worked on 9/4/2022-9/5/2022 on the 11 PM - 7 AM shift. CNA #1 stated that Resident #61 used the bathroom by themselves. CNA #1 stated the resident gets up and goes to the bathroom by themselves and does not need help. CNA #1 stated sometimes Resident #61 urinates on the floor. CNA #1 further stated they (CNA #1) did not know when the resident had last used the bathroom prior to the fall on 9/5/2022. RN #2, who was the night supervisor on 9/5/2022, was interviewed on 11/10/2022 at 1:55 PM and stated Resident #61 needed assistance for toileting on 9/5/2022 as per the CNA accountability (Resident Nursing Instructions). RN #2 stated the CNAs are supposed to review the Resident Nursing Instructions at the beginning of the shift. RN #2 stated the medication nurse on the unit knows the floor and the residents and will ensure that the CNAs are following the care instructions. RN #6, the Risk Manager who wrote the conclusion on the 9/5/2022 A/I report, was interviewed on 11/14/2022 at 10:24 AM. RN #6 stated being that the CNA did not document anything about toileting, that would indicate that the CNA did not provide toileting assistance. RN #6 stated they (RN #6) did not recall speaking to the CNA who worked that night. RN #6 stated the resident is very impulsive and required assistance but will not wait and therefore it was not necessary to determine when the resident was last toileted. RN #6 stated there was no care plan violation and we did everything for the resident to make sure the resident was safe. RN #6 stated the Director of Nursing Services (DNS) is responsible for reporting incidents to the NYSDOH. The DNS was interviewed on 11/14/2022 at 10:44 AM. The DNS stated it was the responsibility of the Risk Manager (RN #6) to follow up if there is something in the A/I report that is left unanswered. The DNS stated if the CCP documents to toilet the resident every 2-4 hours on the elimination care plan, that intervention should have been transposed to the CNA nursing instructions or else there is no way for the CNA to know. The DNS stated they (DNS) are responsible for reporting incidents to the NYSDOH, and they did not deem this reportable because there was no care plan violation and there was no abuse or neglect. 415.4(b)(2)

Based on record review and staff interviews during the Recertification Survey initiated on 11/7/2022 and completed on 11/14/2022 the facility did not ensure that accident were thoroughly investigated for one (Resident #61) of three residents reviewed for Accidents. Specifically, Resident #61 who required assistance with toileting, had an unwitnessed fall on 9/5/2022 and was found sitting on the floor at 4 AM in their (Resident #61) room near the bathroom. The Accident and Incident (A/I) report did not identify that the assigned Certified Nursing Assistant (CNA) #1 did not provide toileting assistance to Resident #61 as indicated in the resident's plan of care. Additionally, the A/I report sections were left blank regarding when the resident was last toileted; if the resident was wearing appropriate footwear; and the report did not identify the resident's ambulation and transfer status. The finding is: The facility's policy titled Risk Management: Resident/Patient Incidents and Accidents, effective 3/2022, documented to assess all residents on admission, readmission, and whenever a change of condition occurs; in order to identify risk factors, and implement appropriate interventions to decrease or to prevent incidents/accidents. An individualized plan of care will be formulated quarterly in conjunction with the care planning team that identifies risk factors and interventions for the prevention of incidents/accidents. Quality improvement processes will continually identify factors to decrease the risk of falls and injuries, and implement them via plan of care, accountability records, and specific fall prevention endeavors. Resident #61 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/1/2022 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 4, indicating the resident had severe cognitive impairment. The MDS documented that the resident required extensive assistance of one staff member for toilet use and personal hygiene and required staff assistance for moving on and off the toilet; the resident required limited assistance for transfers and walking in their room; the resident was occasionally incontinent of urine and frequently incontinent of bowel; and the resident had one none-injury fall and one minor-injury fall prior to this MDS assessment. A nursing note written by Registered Nurse (RN #2) on 9/5/2022 at 7:24 AM documented at 4:00 AM, the unit nurse notified RN #2 that the resident (Resident #61) was observed on the floor in their room. Upon arrival to resident's room, observed resident on the floor in their bedroom, seated on their buttocks, in front of their bathroom door. Body assessment was done, and the resident noted to have pain to the left femur and pelvis. Writer contacted physician with orders for STAT (immediate) x-ray of the left femur and pelvis. A medical progress note dated 9/5/2022 at 2:49 PM documented the resident was seen for left hip pain and poor range of motion. The physical examination revealed Exam with left leg shorter than right, externally rotated, associated with pain, cannot bear weight, likely fracture. Transfer [the resident] to the emergency department for further evaluation. A nursing progress note dated 9/5/2022 at 5:35 PM documented the resident was admitted to the hospital with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the A/I report dated 9/5/2022 revealed that that the resident was found at 4 AM sitting on their buttocks in their (Resident #61) room in front of the bathroom. The floor was wet with urine, the resident did not use the call bell, and the resident was unable to provide details of the incident. Review of the assigned CNA statement (CNA #1) revealed that the fall was unwitnessed, and the CNA last saw the resident sleeping at 3:30 AM. The Accident and Incident (A/I) report did not identify that the assigned CNA did not provide toileting assistance to Resident #61 as indicated in the resident's plan of care. Additionally, the A/I report sections were left blank regarding when the resident was last toileted; if the resident was wearing appropriate footwear; and the report did not identify the resident's ambulation and transfer status. The conclusion in the A/I documented the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . CNA #1 was interviewed on 11/10/2022 at 11:15 AM and stated they (CNA #1) worked on 9/4/2022-9/5/2022 on the 11 PM - 7 AM shift. CNA #1 stated that Resident #61 used the bathroom by themselves. CNA #1 stated the resident gets up and goes to the bathroom by themselves and does not need help. CNA #1 stated sometimes Resident #61 urinates on the floor. CNA #1 stated they (CNA #1) did not know when the resident had last used the bathroom prior to the fall on 9/5/2022. RN #6, the Risk Manager who wrote the conclusion on the 9/5/2022 A/I report, was interviewed on 11/14/2022 at 10:24 AM. RN #6 stated being that the CNA did not document anything about toileting, that would indicate that the CNA did not provide toileting assistance. RN #6 stated they (RN #6) did not recall speaking to the CNA who worked that night. RN #6 stated the resident is very impulsive and required assistance but will not wait and therefore it was not necessary to determine when the resident was toileted. The Director of Nursing Services (DNS) was interviewed on 11/14/2022 at 10:44 AM. The DNS stated it was the responsibility of the risk manager (RN #6) to follow up if there is something in the A/I report that is left unanswered. The DNS stated and they did not deem this incident to be reportable because there was no care plan violation and there was no abuse or neglect. 415.4(b)(3)

Based on staff interviews and record reviews during an abbreviated survey (NY 157) the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice for a resident with a history of constipation for (Resident #1) of 9 residents reviewed. Specifically, Resident #1 with a risk for constipation due to significant change in condition; the facility did not accurately document and monitor the bowel record. Resident #1 complained of abdominal pain and was transferred to the hospital on 10/23/21 and readmitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence that Resident #1's bowel regimen was reevaluated and consistently implemented. Additionally, the plan of care was not reviewed and revised to address fecal impaction to prevent reoccurrence. Consequently, resident #1 was sent to the hospital and admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings were: The facility's policy titled Prevention of Fecal Impaction dated 8/31/2021 documented all residents are assessed daily for any signs and symptoms of fecal impaction. If a resident does not have a bowel movement (BM) in three days, the physician will be notified to determine if any intervention is needed at this time. Resident #1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change in Status Minimum Data Set (MDS an assessment tool) dated 9/30/2021 documented the resident with Brief Interview for Mental Status (BIMS) score of 9 indicating moderately impaired cognition. The resident required extensive assistance with 2 staff members for toilet use. The resident was frequently incontinent of bowel and had no constipation. The Comprehensive Care Plan (CCP) dated 3/25/2014 documented resident with alteration in elimination related to constipation as manifested by medication. Interventions included administer laxatives/bowel medications as ordered, dietitian consult for evaluation of fiber intake, encourage fluid intake as medically appropriate, encourage mobility as tolerated, evaluation of pain medication regimen, notify MD of medical changes and report if no bowel movement in 3 days. An update to the CCP dated 5/21/2021 documented prune juice was provided for breakfast. Resident was receiving [MEDICATION(S)] and Senna and no signs and symptoms of fecal retention until 7/12/2021. The Certified Nurse's Aide Accountability Record (CNAAR) Instructions dated 2/1/2016 documented report to nurse if no BM for 2 days. The Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nurse's Progress notes (NPN) dated 9/15/2021 documented the resident was on 650 milligrams of acetaminophen and 2.5 milligrams of [MEDICATION(S)] was initiated ([MEDICATION(S)] can increase risk of constipation). The PO dated 9/23/21 documented Senna daily at bedtime for constipation. The PO also documented Tylenol 650 mg every 6 hours as needed for pain. All above medications were reordered on readmission. New medications included [MEDICATION(S)] 2.5 mg every 4 hours as needed, changed to 4 hours as needed on 9/29/21. Tylenol was changed to 500 mg every 6 hours as needed on 9/29/21. The CNAAR and bowel tracking form documented small BM on 10/4/21, 10/6/21, 10/7/21, 10/8/21, 10/10/21, 10/11/21 during dayshift. The CCP for constipation dated 10/6/2021 documented care plan was reviewed due to significant change in status. Daily BMs monitored and no signs and symptoms of fecal retention. The PO dated 10/8/2021 documented to administer [MEDICATION(S)] 30 ml daily at bedtime as needed for Constipation. Review of the Nurse's Progress notes (NPN), and PO dated 10/12/2021 to 10/14/21 documented a soap suds enema was administered on 10/12/21 due to constipation. The Medical doctor (MD) also ordered Polyethylene powder daily for constipation on 10/12/21.There was no documented BM after fleets enema was administered. On 10/13/21 the MD ordered [MEDICATION(S)] 10 mg rectal suppository and Polyethylene [MEDICATION(S)] and administered as a onetime dose. The resident had a small BM on 10/13/21 during day and night shift. On 10/14/21 the Resident was moving small minimal amounts of stool and no BM the past 4 days. A Fleet's enema was administered, and the resident had large BM. The MD discontinued the [MEDICATION(S)] due to constipation. The resident continues to complain of abdominal pain. The MD was notified and ordered Kidney Ureter and Bladder (KUB) x-ray. Tylenol was changed to 1000 mg every 8 hours standing due to chronic pain. The PO dated 10/14/21 documented Tylenol 1,000 mg every 8 hours, Fleet Enema rectal route once daily as needed If [MEDICATION(S)] suppository ineffective and x-ray of KUB stat. The KUB result dated 10/14/21 documented increased stool was present throughout the colon and rectum. The CCP dated 3/25/14 for constipation lacked documented evidence the CCP was reviewed and revised. The CNAAR and bowel tracking form dated 10/18/21 to 10/22/21 documented inactive for dayshift, evening and night shift documented no BM. The NPN dated 10/18/21 documented on 10/21/21 [MEDICATION(S)] 50mg PO Q8H was ordered due to pain. The NPN dated 10/23/2021 at 12:00 AM documented the resident complained of right lower quadrant pain during auscultation and unable to have BM. PRN fleet enema was administered with no results. The MD was notified the fleets were ineffective. The resident was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital History and Physical dated 10/23/21 documented patient presented with abdominal pain for three days. Resident found with stool impaction in ER and a [CONDITION(S)], status post [MEDICAL RECORD OR PHYSICIAN ORDER] . History of diverticulitis with colon resection. Impression is stercoral [CONDITION(S)]. Stool impaction with rectal and sigmoid measuring up to 8.7 cm in mild rectal wall thickening and presacral [CONDITION(S)] with stool throughout the colon compatible with constipation. The MD history and physical dated 10/27/2021 documented the resident was readmitted from hospital and was seen on 10/28/2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical record and CCP for Constipation dated 3/25/14 lacked documented evidence that the resident was reassess and plan or care for constipation was reviewed to address fecal impaction and evaluate effectiveness of bowel regimen in place. Review of the medical records documented the resident had no BM from 10/30/21 to 11/1/21. A fleets enema was given on 11/2/21 with positive result on all shifts. The resident had no documented BM on 11/8/21 to 11/9/21. The NPN dated 11/9/21 documented the resident was transferred to the hospital to rule out Urinary Tract Infection. The hospital discharge summary dated 11/13/21 documented resident presented toER on [DATE] for evaluation of lower abdominal pain and admitted with abdominal pain secondary to fecal impaction. CT of abdomen and pelvis dated 11/9/21 documented large volume of stool throughout the colon but most pronounced in the rectal vault which is markedly distended. There is subtle bowel wall thickening of the rectum suggesting proctitis related to fecal impaction. The discharge diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with dayshift Certified Nursing Assistant (CNA)#1 on 11/18/2021 at 10:58 AM they stated they were assigned to the resident on 10/7, 10/14, 10/28, 10/29 to 10/31/21. CNA #1 was assigned to the resident on 10/7/21 and stated they could not recall if they reported to the nurse when the resident had no BM between 10/4/21 to 10/6/21 and probably they did not check the book. On 10/29/21 and 10/31/21 CNA #1 was assigned to the resident and documented resident had no BM during shift. CNA #1 could not recall if it was reported to the nurse. During a telephone interview with night shift CNA #2 on 11/18/2021 at 11:46 AM, they stated resident was incontinent of bowel. CNA #2 stated she was not aware of the facility's protocol regarding BM. CNA #2 stated they reported to the nurse if the resident did not have BM during their shift but do not check or review the previous shift. CNA #2 stated they were not aware of symptoms of fecal impaction. During an interview with the dayshift LPN #1 on 11/18/2021 at 12:30 PM they stated they were assigned to the resident from 10/18/21 to 10/22/21. LPN #1 stated they check the CNAAR on a regular basis but does not recall checking the resident's bowel record between on 10/18-10/22/21. LPN #1 stated they were aware of the resident diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview with dayshift Registered Nurse Manager (RNM) #2 on 11/18/2021 at 2:06 PM they stated they review the bowel record couple times a week. And if no BM documented after three days, notify the MD. RNM #2 stated the staff did not report the resident had no BM when they were covering the unit. RNM #2 stated they were aware that resident#1 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . RNM #2 could not recall what interventions were in place. During an interview with evening shift CNA #4 on 11/18/21 at 2:59 PM they stated they were not knowledgeable of the symptoms of fecal impaction. CNA #4 documented that resident#1 did not have a BM between 10/18/21 to 10/21/21 in the CNAAR and logbook and reported to the nurse. CNA #4 stated they reported to the nurse when the resident did not move the bowel on their shift after three days. During an interview with 6 AM to 2 PM CNA #5 on 11/19/2021 at 9:06 AM they stated they were assigned to the resident#1 on 10/18/21, 10/19/21, 10/21/21, 10/22/21, 11/8/21 and 11/921. CNA #5 was shown the CNAAR and stated they were not aware that their electronic CNAAR was inactive. CNA #5 had no knowledge that the resident had fecal impaction when readmitted . During a telephone interview with RN Manager #1 via phone on 11/19/2021 at 10:10 AM. RNM #1 stated they check the bowel record 2-3 times a week. RNM #1 stated they were not aware the resident had no BM from 10/5/21 to 10/7/21 and 10/18/21 to 10/22/21. The staff did not report to RNM #1 that they were having issue with documenting in the CNAAR. RNM #1 stated they did not consistently check the bowel record. RNM #1 reviewed PRI and nurses notes and did not see the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During the interview with the Primary Physician (PMD) #2 on 11/19/2021 at 10:49 AM PMD #2 stated they were assigned to the resident's care on 11/8/21. PMD#2 Stercoral [CONDITION(S)] is a fecal impaction that leads to inflammation of the area of colon. PMD#2 stated that adequate documentation of bowel movements was also important to prevent fecal impaction. PMD #2 expected the staff to notify PMD if no BM within 24-48 hours. The staff did not report resident had no BM and there were no changes in bowel regimen. During a phone interview with PMD #1 on 11/19/2021 at 11:49 AM stated PMD #1 took care of the resident since admission. On 10/23/21 resident was transferred to the hospital for complained of abdominal pain. PMD #1 stated they were not informed that the resident did not have BM between 10/18/21 to 10/22/21 for (5 days). The staff is expected to call MD if resident did not move BM after 2 days. If PMD was made aware of no BM for 5 days PMD #1 would order to administer enema right away, [MEDICATION(S)] and MOM so resident could move the BM and the resident would not need to go to the hospital. PMD #1 stated they evaluated the resident on 10/27/21 and did physical exam on readmission. Staff is expected to monitor the BM and inform MD if no BM. During a telephone interview with the DON on 12/13/21 at 3:49 PM they stated the facility policy was to report to nurse and MD if the resident had no BM on the third day and the MD would order for bowel preparation. The facility has no specific standard bowel protocol, the MD determines the mode of treatment. DON stated they were not aware why the staff was documenting the bowel record on two separate forms. DON was not aware that there was a glitch in the system when the CNAAR documented inactive. A subsequent telephone interview with the DON on 12/15/2021 at 2:12 PM DON stated that 5 days of no documented BM was unacceptable. The discharge summary on 10/27/21 documented fecal impaction and manual dis-impaction was done. The DON stated the facility focused on the [CONDITION(S)] diagnosis. DON stated they expected the PMD and RNM to review the hospital record to know what the resident was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] A subsequent telephone interview with the DON on 1/13/2022 at 3:58 PM DON stated that the CNA reports to the nurse if the resident had no BM for three days and the nurse would document a change in condition. The nurse manager ensures they checked the resident for any change in condition including checking the CNAAR at the end of the shift for tracking the bowel movement. [10 NYCRR 415.12]

Based on observations, record review and interviews during a COVID-19 Focused Infection Control Survey conducted on 2/22/2021 and 2/23/2021, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of COVID-19. Specifically, a Certified Nursing Assistant (CNA #1) was not wearing gloves or a gown and did not perform hand hygiene between setting up meal trays for two residents (Resident #1 and Resident #2) in a shared room that was designated to be on Contact and Droplet precautions. Additionally, CNA #1 did not perform hand hygiene before leaving the room. The finding is: The Centers for Disease Control and Prevention (CDC) guidance titled Transmission-Based Precautions (undated), provides: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning Personal Protective Equipment (PPE) upon room entry and properly discarding before exiting the patient room is done to contain pathogens. CDC guidance titled Using Personal Protective Equipment (PPE), updated 08/19/2020, documents the following first steps to doff PPE before exiting a patient's room: 1. Remove gloves. Ensure glove removal does not cause additional contamination of hands. 2. Remove gown. ; Upon exiting a patient's room, HCP should perform the following steps, per such guidance: 4. Perform hand hygiene. On March 26, 2020, the Department of Health provided guidance to nursing homes and adult care facilities in the form of a presentation titled COVID-19 Infection Control Guidance for Nursing Homes and Adult Care Facilities, which is publicly available on the Department of Health website (Infection Control Presentation). The presentation advised that standard precautions include hand hygiene for (e)very resident, every day. The Infection Control Presentation further directed facilities to review the U.S. Centers for Disease Control and Prevention (CDC) guidance for infection prevention and control in healthcare settings. The CDC guidance, titled Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings, recommended the following additional strategies to minimize chances for exposure: Hand Hygiene: HCP (healthcare personnel) should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. Department of Health Revised Health Advisory entitled COVID-19 Cases in Nursing Homes and Adult Care Facilities, dated 3/13/2020 and revised 7/10/2020, documented that if there are confirmed cases of COVID-19 in a Nursing Home, HCP and other direct care providers should wear gown, gloves, eye protection (goggles or a face shield), and N95 respirators (or equivalent) if the facility has a respiratory program with fit tested staff and N95s. Otherwise, HCP and other direct care providers should wear gown, gloves, eye protection, and facemasks. The facility's undated policy, titled Infection Control, documented that hand hygiene continues to be the primary means of preventing transmission of infection and that hand hygiene is required before and after assisting a resident with meals. In addition, the policy documented that contact transmission risk requires the use of contact precautions to prevent infections that are spread by person-to-person contact. The policy also documented that Personal Protective Equipment (PPE) will protect the staff member from contact with blood or other potentially infectious materials when used properly. For example, if the staff member is at risk for exposure to hands, wear gloves. The physician's orders [REDACTED].#1 was on contact isolation and droplet precautions. The physician's orders [REDACTED].#2 was on contact isolation and droplet precautions. On 2/22/2021 at 1:00 PM CNA #1 was observed in a room where Resident #1 (window bed) and Resident #2 (door bed) resided. At the room entrance signs were posted that indicated that the residents in the room were on Contact and Droplet precautions. CNA #1 was wearing an N95 mask with a surgical mask over it and eye goggles; CNA #1 was not wearing gloves or a gown. Both residents were out of bed in their wheelchairs. CNA #1 was observed adjusting and maneuvering Resident #1's overbed table that had the lunch tray on it. CNA #1 removed the insulated cover from the dish and prepared the resident's tray. After CNA #1 completed setting up Resident #1's meal tray, she proceeded to assist Resident #2 without washing her hands. CNA #1 removed the insulated cover from Resident #2's dish and prepared the resident's tray. CNA #1 then left the room holding the two insulated covers without performing hand hygiene and proceeded to the main cafeteria, where she deposited the insulated covers. CNA #1 was interviewed on 2/22/2021 at 1:10 PM and stated she should have worn gloves. CNA #1 further stated that she should have performed hand hygiene in between taking care of the two residents and she should have performed hand hygiene before leaving the room. The Registered Nurse (RN) unit manager was interviewed on 2/22/21 at 1:15 PM and stated CNA #1 should have performed hand hygiene in between taking care of Resident #1 and Resident #2 and should have worn gloves. She stated anything more than just dropping off a tray is considered resident care. The RN Infection Control Preventionist and Director of Nursing Services (DNS) were interviewed concurrently on 2/23/21 at 8:30 AM. They stated that CNA #1 should have performed hand hygiene after taking care of Resident #1 and before proceeding to Resident #2 and should have had gloves on. In addition, they stated CNA #1 should have washed her hands before exiting the room. 415.19(a)(1-2),(b)(4) 400.2

Based on observation, and staff interview during the Recertification Survey, the facility did not ensure that all drugs and biologicals were locked in compartments under proper temperature controls. The facility did not ensure that on one (unit 1A) of eight resident care units, medications including Insulin, were stored in the refrigerator at the proper temperature. The finding is: On 1/2/20 at 10:30 AM during the tour of Unit 1A, 1 vial of [MEDICATION NAME] purified protein, 1 vial of [MEDICATION NAME] 10,000 units, 1 bottle 2.5 milliliter (ml) Latanoprost, 3 [MEDICATION NAME] injection pens, 1 basaglar injection pen were observed stored in the Unit 1A medication refrigerator at a temperature of 30 degrees Fahrenheit (F). The Registered Nurse (RN) on the Unit 1 A was immediately interviewed at the time of the observation. The RN stated that she was not aware that the refrigerator temperature was at 30 degrees. She stated although the refrigerator temperatures was checked earlier that day, the medications should not be stored at this temperature. The manufacturer's package insert for [MEDICATION NAME] recommended to store in the refrigerator with a temperature no less than 36 degrees F and no greater than 46 degrees F. The Pharmacy Consultant was interviewed on 1/2/20 at 1:00 PM and stated medications should be stored at 36- 46 degrees F. The medications can crystallize and the drug manufacturers recommend to store the medications between 36- 46 degrees. The Director of Nursing Services (DNS) was interviewed on 1/6/20 at 12 PM and stated that nursing checks the refrigerator temperature every shift to ensure that medications are stored between 36-46 degrees F. She further stated that medications should not be stored below 36 degrees F. 415.18(e)(1-4)

Based on observation, record review and staff interview during the Recertification Survey the facility did not ensure that an infection prevention and control program (IPCP) designed to help prevent the development and transmission of infection was maintained. This was identified for one (Resident #20) of six residents reviewed for pressure ulcers and one out of sample resident (Resident #92) who was observed in the dining room during a lunch meal observation on 12/30/19. Specifically, 1) during a dressing change observation for Resident #20, the Registered Nurse (RN) was observed to not change gloves and wash her hands after cleansing the resident's right heel pressure ulcer; and 2) during a lunch meal observation, a Certified Nursing Assistant (CNA) was observed retrieving a paper napkin that fell on the floor and placing the napkin on the lunch tray of Resident #92. The findings are: 1) Resident #20 has [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) Score was 15 which indicated the resident had intact cognition. The MDS documented the resident had one Stage IV pressure ulcer. A physician's orders [REDACTED]. A Comprehensive Care Plan (CCP) for Skin Integrity dated 10/8/18 documented on 5/9/19 that the resident had a skin breakdown located on the Posterior Right Heel, Stage IV. Interventions included to apply local treatment as ordered by MD. A Wound care observation was conducted on 1/6/2020 at 8:55 AM with the Registered Nurse (RN) Manager. The resident was lying in bed. The RN was observed to wash her hands, don gloves, cleanse the wound with a saline gauze, then dry the wound with a dry gauze. Without changing gloves and washing her hands, the RN was observed to used the same gloves to apply skin prep to the peri-wound area. Using the same gloves, the RN applied the hydrogel gauze to the wound bed, covered the wound with non border foam, then secured the wound with a gauze wrap. The RN was interviewed immediately after the observation on 1/6/2020 at 9 :20 AM. The RN was asked if she should she have washed her hands after cleansing the resident's wound. The RN stated that she should have removed the gloves and washed her hands after cleansing the wound before proceeding to complete the dressing change. The Director of Staff Development, who was a RN, was interviewed on 1/6/2020 at 2:30 PM and stated that wound care competency is done on orientation with all nurses and that visual wound care competency is done on the unit as needed. The RN stated the nurse should have removed her gloves and washed her hands after cleansing the wound before proceeding to complete the treatment. The Infection Control Nurse was an interviewed on 1/6/2020 at 1:29 PM and stated that the nurse should have removed her gloves, washed her hands and donned clean gloves before proceeding with the dressing. 2) Resident #92 has [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) Score was 11 which indicated moderately impaired cognition. The resident required supervision with set up help for eating. During a lunch meal observation conducted on 12/30/19 at 12:25 PM, the Certified Nursing Assistant (CNA) was observed setting up the resident's tray. The napkin from the resident's tray fell to the floor. The CNA was observed to pick up the napkin and place the napkin on the resident's tray. The CNA was immediately interviewed on 12/30/19 at 12:27 PM. The CNA stated that she thought she had discarded the napkin. The CNA was then observed going over to the resident and removed the napkin from the tray. During a subsequent interview conducted on 1/6/ at 1:15 PM with the CNA, she stated that she made a mistake, and that she should have discarded the napkin that fell on the floor and should have given the resident a clean napkin. The CNA stated that she was assisting multiple residents at the same time and did not realize she had placed the dirty napkin back on the resident's tray. The Director of Nursing Services (DNS) was interviewed on 1/6/2020 at 1:29 PM and stated that the CNA should have discarded the napkin, washed her hands, and given the resident a clean napkin. 415.19(a)(1-3)

Based on observation, record review and staff interview during the Recertification Survey, the facility did not develop a person-centered, Comprehensive Care Plan (CCP) for each resident to address the resident's current needs and did not include measurable objectives and timeframe's to meet the residents' medical, mental and psychosocial needs that were identified in the comprehensive assessment. This was identified for one resident (#207) of one resident reviewed for Dementia Care and one (#97) of three residents reviewed for Respiratory care. Specifically, 1) Resident # 207 had a primary [DIAGNOSES REDACTED]. Additionally, goals were not updated to show new and updated interventions when the resident had a Significant Change in condition; and 2) For Resident # 97, the facility did not develop a CCP for the use of Oxygen. The findings are: 1) Resident # 207 was admitted with [DIAGNOSES REDACTED]. The MDS also documented that the resident had physical behavior symptoms directed to others and verbal behaviors directed to others for one to three days during the assessment period. A Significant Change MDS assessment dated [DATE] documented the resident had a BIMS score of 4, decline in Mood score to 15, with weight loss and development of a Pressure Ulcer. The MDS documented that the resident continued to have physical and verbal behavior symptoms one to three days during the assessment period. The resident's CCP for Dementia dated 10/8/19 documented that the resident had impaired decision making. The CCP documented the resident will demonstrate ability to make decisions in choice of activities. The interventions included to ask simple questions, evaluate medication regime, offer choices between two items and use simple words. There were no resident specific interventions and no measurable goals documented. An update to the CCP dated 12/3/19, for the Significant Change in condition, did not document a review or any revision of the interventions or establishment of new goals. A CCP titled Adjustment dated 10/8/19, and CCP for Behavior dated 10/9/19 also had interventions that were not resident specific and did not contain measurable goals. The CCPs did not address the resident's Dementia [DIAGNOSES REDACTED]. The CCPs were not revised to include resident specific goals and interventions and were not updated for the Significant Change in condition which included a decline in Mood. The resident was observed on 12/29/19 at 9:30 AM. The resident was in bed and asking to go home. A second observation was made on 12/29/19 at 11:00 AM. The resident was in his room, yelling help repeatedly. Staff entered the room and asked the resident what he needed. The Registered Nurse (RN)/Unit Manager was interviewed 1/02/20 at 12:14 PM. The RN stated that the Dementia and behavior related care plans are done by the unit's Social Worker. The RN stated that Interdisciplinary Team (IDT) meets and reviews the care plan. The RN stated that she does not usually attend the Care Plan Meetings but that the CCP information is reviewed and submitted to the team. The Assistant Activity Director was interviewed on 1/06/20 and 9:43 AM. The Assistant Activity Director stated that the she completes the CCP but does not attend the CCP meeting. The Assistant Activity Director stated that a care plan summary is completed and then it is taken by the department head to the CCP meeting. The Activity Director was interviewed on 1/6/20 at 9:56 AM. The Activity Director stated that she is updated about the resident before she attends the CCP meeting and information is communicated to the staff as Inservice education. Any updated or new information that was determined at the CCP meeting is also brought up at the morning meeting or reported to the unit manager, who updates the unit staff. The resident's Social Worker (SW) was interviewed on 1/06/20 at 10:49 AM. The SW stated that she completed the Dementia and Behavior CCPs for Resident # 207 but does not attend the CCP meetings. The SW Director attends with a summary and any updates are done on return from the meeting. The SW Director was interviewed on 1/6/10 at 11:02 AM. The director stated that the department directors go to the CCP meetings and the plan of care is reviewed. The director stated that usually if any behaviors are brought up at the CCP meetings or morning meetings, the behaviors are reported back to the resident's SW and that SW follows up with staff. 2) Resident #97 has [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental status Score of 6 indicating a severely impaired cognition and decision-making skills. The MDS also documented the resident was not receiving Oxygen or Respiratory Therapy. A physician's orders [REDACTED]. A review of the resident's Comprehensive Care Plan (CCP) from (MONTH) 2019 to (MONTH) 2019 revealed that no CCP had been developed for the use of O2. The unit Registered Nurse (RN) charge nurse was interviewed on 1/03/20 at 11:27 AM and stated that he is responsible to develop CCPs and the CCP for the use O2 was missed by him. The RN further stated that the CCP was reviewed during CCP meeting on 10/8/19 but the team did not identify that the CCP for O2 treatment was not developed. 415.11(c)(1)

Based on observation, record review and staff interview during the Recertification Survey the facility did not ensure an Accident/Incident (A/I) Report was thoroughly investigated. This was identified for one (Resident #81) of two residents reviewed for falls. Specifically, Resident #81 was found with an unwitnessed hematoma to the forehead and a small laceration to the hairline. The A/I report was not thoroughly investigated to determine the root cause of the injury to rule out abuse or mistreatment. The finding is: The facility policy and procedure for Accident/Incident protocol last reviewed 6/14/2019 included, 2) A systematic investigation of the A/I initiated by the Nursing supervisor. This investigation may include but is not limited to: written statements by individuals who observed or were present at the time of the Accident/Incident and written statements from the staff who cared for the resident before the Accident/Incident. Resident #81 was admitted to the facility with [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) Score was 15 which indicated the resident had intact cognition. The resident had no behavior symptoms, required extensive assist of one staff member for transfers and walking in the corridor, and limited assist of one staff member for walking in the room. A Comprehensive Care Plan (CCP) dated 10/7/19 for falls documented the resident was at risk for falls related to history of falls and unsteady gait. The CCP documented on 9/30/19 the resident sustained [REDACTED]. The CCP was updated on 12/23/19 and documented the Registered Nurse (RN) was called to see the resident lying crossway on the bed with her head dangling off the bed. The resident was observed with a small laceration to the forehead at the hairline and a small grape size hematoma to the forehead. An A/I Report dated 12/23/19 documented at 8:30 AM the resident was observed in her room with a Hematoma and laceration to her head. The resident's statement documented doesn't know. The Nursing Supervisor Investigation statement documented at 8:30 AM that she was called to see the resident. The resident was lying across the bed with her head hanging down next to the side rails with flailing arms and legs. The resident was able to make her needs known, was oriented, ambulated with assistance, and transferred with one person assist. The Employee Statement, completed by a Certified Nursing Assistant (CNA) documented the resident was last seen at 7:50 AM when the resident was toileted/brief changed. The A/I Report did not include the color of the hematoma, the size of the laceration, and there was no documentation of a description of the resident when the resident was last seen at 7:50 AM. A Progress note dated 12/23/19 documented the RN was called to see the resident lying crossway on bed with her head dangling off the bed and with a small grape size hematoma to the forehead. The Physician was called and an order was received to sent the resident to the hospital. The resident was interviewed on 1/2/2020 at 11:25 AM and stated that she had a fall several months ago while talking on the phone with her daughter, however, the resident stated that she did not recall the incident on 12/23/19 and how she had sustained the hematoma to her forehead. The RN Manager was interviewed on 1/3/2020 at 2:30 PM and stated when she entered the resident's room, she observed the resident lying across the bed. The RN stated the O2 tubing was off the resident's face, her head was hanging down off the bed near the bedside table, and her arms/legs were flailing. The RN stated that she could not verify when and what had actually happened to the resident, however, the resident had a history of [REDACTED]. The RN was not able to say if her assessment concluded the laceration was noted with fresh bleeding of if the hematoma was new. The Director of Nursing Services (DNS) was interviewed on 1/3/2020 at 3:46 PM and stated that the Assistant DNS was responsible for completing the A/I Reports. The DNS stated that there should have been a statement that described the resident's appearance when the staff last saw the resident at 7:50 AM. The DNS further stated that she would have expected the A/I Report to include staff interviews after any injury was identified. 415.4(b)(1)(ii)

Based on observation, record review, and interviews during the Recertification Survey, the facility did not ensure that residents were given the appropriate treatment and services to maintain or improve the resident's ability to carry out the ADLs, including ambulation. This was identified for one (Resident #81) of two residents reviewed for falls. Specifically, Resident # 81 had a physician's orders [REDACTED]. Additionally, there was no documented evidence that the Comprehensive Care Plan (CCP) was updated to reflect the current FAP. The finding is: Resident #81 was admitted with [DIAGNOSES REDACTED]. An Annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) Score as 15 which indicated the resident had intact cognition. The resident had no behavior symptoms and required extensive assist of one staff member for transfers, walking in the corridor, and limited assist of one staff member for walking in the room. A physician's orders [REDACTED]. A CCP dated 10/8/19 documented the resident has impaired walking skills. The interventions dated 10/8/19 included the resident was on floor ambulation program and to ambulate up to 50 feet or as tolerated with assistance of one staff using a rolling walker (R/W) for up to eight minutes twice daily (BID). There was no documented evidence of the current FAP of 200 feet reflected in the CCP. A Certified Nursing Assistant Documentation History Detail dated 12/10/19 to 1/3/2020 documented the resident ambulated a distance of 50 feet on the 7:00 AM-3:00 PM and the 3:00 PM - 11:00 PM shift. Resident # 81 was interviewed on 1/2/2020 at 11:25 AM. The resident stated that she did not walk enough. The resident stated that she sits in her wheel chair most of the time and that when the staff walks her it was only for a short distance and then back to her wheel chair. The resident further stated that she needed to walk more. The assigned Certified Nursing Assistant (CNA) was interviewed on 1/2/2020 at 1:11 PM and stated that she has cared for the resident since the resident was transferred to the unit. The CNA stated she walks the resident daily after lunch about 50 feet. The CNA further stated if the resident was unable to walk 50 feet she would report the decline to the supervisor. The resident was observed on 1/2/2020 at 1:30 PM during floor ambulation. The resident ambulated with a rolling walker and the CNA following with the resident's wheel chair with an oxygen tank in holder on the back of the wheel chair. The resident ambulated from her room to the end of her hallway approximately 100 feet as per the CN[NAME] The CNA then instructed the resident to sit and the resident was wheeled back to her room. The Registered Nurse ( RN) /Nurse Manager was interviewed on 1/3/2020 at 2:24 PM regarding the resident's FAP. The RN Nurse Manager she stated that the Rehabilitation Department was responsible for the FAP orders which is given to the RN Manager. The RN stated after receiving the new recommendations, she then enters the new FAP order in the electronic medical record. The RN stated that the CCP should have been updated, however, it was not revised to reflect the resident's current FAP order. The RN Nurse Manager also stated that the CNA Assignment was also to be updated at that time with the current FAP order. The RN further stated that she was not aware that the resident was ambulating only 50 feet. A subsequent interview was conducted on 1/3/2020 at 2:49 PM with the assigned CNA regarding the resident's current FAP order of 200 feet. The CNA stated she thought the resident was to walk 50 feet and she was not aware the resident was to ambulate 200 feet. She stated that she saw 50 feet documented in the Electronic CNA Assignment and was ambulating the resident 50 feet. During the interview the Electronic CNA Assignment was reviewed and revealed the directions on the screen titled Nursing Rehab walking documented FAP 50 feet. A second screen titled walk in corridor documented FAP 200 feet. The CNA stated that for the FAP she always reviews the screen that is titled Nursing Rehab walking. The CNA further stated when there is a change in an order for [REDACTED]. The Rehabilitation Registered Nurse (RN) was interviewed on 1/3/2020 at 3:00 PM. The RN stated the Physical Therapist recommends the resident for FAP and how many feet the resident should ambulate. The RN stated she was responsible for all the implementation of FAP recommendations. The RN stated that she initiated the CCP and updated the CNA Assignment when the resident was first recommended for the FAP of 50 feet. The RN stated that she was not aware that there was a new FAP order for 200 feet and that the nurse that received the new recommendation should have communicated the new order to her. The CCP and the CNA Assignment should have been updated by either herself or the Nurse Manager (NM) to reflect the new FAP order. The Director of Rehabilitation was interviewed 1/6/20 at 1:55 PM and stated that the Therapist initiates the orders for the floor ambulation program, which includes the distance and the adaptive devices used. The Director of Rehabilitation stated the first order for floor ambulation was initiated while the resident was still on Physical Therapy (PT) which was 50 feet. He stated after the resident was discharged from PT the distance for floor ambulation increased to 200 feet. 415.12(a)(2)

Based on interviews and record review during an abbreviated survey (Complaint #NY 951), the facility did not accurately assess and treat identified skin impairments on admission for one of five residents reviewed for Quality of Care. Specifically, Resident #1 was identified as having a venous ulcer to the left heel and excoriations to the buttock and groin area on admission. The medical records lacked documented evidence of treatment orders and or treatment administration to the left heel and the excoriations. Subsequently, four days later the resident was diagnosed as having an unstageable pressure ulcer with 100% soft dry black eschar to the left heel. The findings were: The facility's policy titled Pressure Ulcer Treatment and Prevention Protocol revised 7/3/2007 documented the condition of a resident's skin is assessed daily and whenever care is given. Formal assessment of the skin will be done on admission, once a week x4 weeks on all initial admissions, quarterly, and if a significant change occurs. Based on the resident assessment and evaluation process an individualize Comprehensive Care Plan (CCP) will be developed by all involved disciplines for prevention and treatment. The facility has protocols to facilitate pressure ulcer healing and to prevent infection. The facility policy lacked documented evidence for treatment protocol related to vascular/diabetic ulcers. The facility's policy titled Wound Care dated 4/23/18 documented the facility will perform wound care to prevent infection and promote healing. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 10/12/18 documented the resident's cognitive status as intact. He required extensive assistance in most areas of Activities of Living (ADLs) except for eating. He was at risk for pressure ulcers; no pressure ulcer, one venous/arterial ulcer, and one diabetic ulcer. The Braden Scale (a tool utilized to predict the risk for developing pressure ulcers) dated 10/5/18 documented the resident was at mild risk for developing pressure ulcers. The Admission Nursing Skin Exam Description dated 10/5/18 documented: Venous ulcer 9x5cm (site #21 on the body diagram - indicated left heel) Testicle excoriation (#24), excoriation to (#15, #17 and #29 - the sites were marked around the buttock area however, specific locations were not clear on the body diagram) The medical record dated 10/5/18 through 10/8/18 lacked documented evidence of description of the wounds, treatment orders, measurable goals and interventions for the left heel venous ulcer, and various excoriations as documented on the Admission Nursing Skin Exam. The Baseline Care Plan dated 10/5/18 completed on 10/7/18 titled Skin Concerns documented excoriations to bilateral buttocks. The interventions included to turn and position and to provide skin and wound treatment. The care plan lacked documented evidence of goals and interventions for the left heel venous ulcer. The Wound care note dated 10/9/18 documented Left heel posterior unstageable pressure ulcer, 100% soft dry black eschar (slough or piece of dead tissue), 5x6 cm with maceration (softening and breaking down of the skin resulting from prolonged exposure to moisture) and maroon bruising to peri-wound (an area around the wound bed). Fungal eruption to the sacral/buttock area and left groin. The physician's orders [REDACTED]. [MEDICATION NAME] swab for left heel posterior unstageable ulcer. [MEDICATION NAME] (antifungal) cream to the fungal rash to sacral buttock area and left groin twice a day. The weekly skin assessment dated [DATE] documented diabetic ulcer to left foot posterior (left heel) measuring 5x6.3 cm with necrotic black dry eschar. The wound care note dated 10/12/18 documented left heel posterior reevaluated as a diabetic ulcer with 100% dry black eschar measuring 5x6.3cm. The Registered Nurse Manager (RNM) #1 was interviewed on 11/29/18 at 12:36 PM and stated that the resident was admitted on [DATE] (Friday) and she came back to work on 10/9/18 (Tuesday). She reviewed the skin assessment against the physician's orders [REDACTED]. She stated the admission wound diagram was not clear and the specific sites could not be deciphered. The admission skin assessment also did not describe the wound bed and or wound characteristics. The wound nurse saw Resident #1 on 10/9/18 and ordered treatment for [REDACTED]. The RN Wound Care Nurse (RNWCN) was interviewed on 11/27/18 at 2:17 PM and stated she saw the resident on 10/9/18. The resident had excoriation to right buttock. The left heel had a wound that was unstageable. She reviewed the admission nursing assessment and hospital records. On admission assessment, the resident was assessed to have a venous ulcer to the left heel. The RNWCN reviewed the admission orders [REDACTED]. The RNWCN stated that there should be a treatment order for all identified skin impairments on admission. The RNWCN wrote the treatment orders for the left heel and the excoriations on 10/9/18 and notified the primary care physician (PMD). RN #1 (Admission/Treatment nurse) was interviewed on 11/27/18 at 4:24 PM and stated she could not recall Resident #1. Based on the documentation she completed the admission assessment for the resident. She would normally get treatment orders for the excoriations and vascular ulcers from the MD. RN #1 could not recall why she did not receive physician orders [REDACTED]. The sites were identified on the body diagram but were not clear and it was hard to recognize the specific sites. The Director of Nursing (DON) was interviewed on 3/18/19 at 3:59 PM and stated that the admission assessment was completed by the RN admission nurse. The admission nurse should follow the pressure ulcer protocol for treatment orders. The admission nurse should inform the physician and obtain the treatment orders. The RNWCN would assess the newly admitted residents on the next working day. The DON did not know why Resident #1 was not seen prior to 10/9/18 by the RNWCN. The DON acknowledged that the admission nurse did not obtain treatment orders for the resident's left heel. The admission nurse also did not document any description of the left heel wound except the size. The DON could not say if a treatment order was needed for the left heel or not because she did not know the description of the left heel wound. The DON also stated that the CCP was not initiated for the wound until 10/9/18. The Primary Medical Doctor (PMD) was interviewed on 3/26/19 at 2:59 PM and stated that he did not see Resident #1 until after 2 days of his admission. He was made aware of the resident's wounds on admission, however, could not recall the specific wounds. The admission nurse told him that she would call the wound care physician for orders. 415.12

Based on staff interviews and record review during an abbreviated survey the facility did not ensure that each resident who displays mental or psychosocial adjustment difficulty receives appropriate treatment and services to reach and maintain the highest level of mental and psychosocial functioning. Specifically, one (Resident #1) of six residents reviewed for mental and psychosocial functioning verbalized suicidal thoughts on three occasions from September 2014 to March 2015. This was not communicated to key staff and a plan of care for monitoring and supervision of the resident was not developed. On 3/30/15 at approximately 5:15 AM Resident #1 was found by staff in bed holding a large blood-covered knife, bleeding from her neck and saying she didn't want to live anymore. This resulted in actual harm that is not Immediate Jeopardy. Complaint Number: NY 415 The finding is: The Policy and Procedure on Verbalization of Self-Inflicted Harm dated 7/17/12 documented that a method of prevention will be implemented including but not limited to close observation/1:1 (one-to-one) as deemed necessary, Psychiatric/Psychological evaluation, referral to a Psychiatric facility, Family involvement and Social Work counseling. The resident status will be communicated on the 24 hour report until the resident is deemed safe. An interdisciplinary care plan will be initiated and updated as necessary. Ongoing monitoring and documentation of the resident by the Registered Nurse will continue until it is determined that the resident is not a threat to himself/herself. The Policy and Procedure for Referral of Psychological Services dated 6/13/13 documented that psychological consultations are reviewed with the Attending Physician. The Policy and Procedure on Abuse, Neglect or Mistreatment Prohibition and Investigation dated 8/26/14 documented that an investigation will include statements from staff who cared for and/or were responsible for the management of the resident's care before or after the incident. The relevant facility policies and procedures will be reviewed. The final determination of whether or not there is abuse, neglect or mistreatment and actions taken must be indicated. There is ongoing assessment, care planning and monitoring of residents with needs and behavior which might lead to conflict or neglect. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (an assessment tool) dated 1/29/15 documented that Resident #1's cognition was intact. The Care Plan Activity Report for Mood State effective 8/4/14 documented that Resident #1 was at risk for mood issues with interventions including but not limited to exploring with resident any possible emotional, physical or environmental causes for identified issues with disciplines responsible being activities, dietary, medical, nursing and social services. There was no documented evidence of an interdisciplinary care plan for verbalization of self-inflicted harm. The Nursing Progress Notes (NPN) dated 9/17/14 at 5:07 PM (written by the Registered Nurse) documented that the resident was noted making suicidal statements with no intent to harm herself or plan of action. Resident states she has no intent to harm herself but feels frustrated with her [MEDICAL CONDITION] medication regimen and chronic discomfort in bilateral eyes. Medication regimen reviewed with resident. Verbal support provided. Psychologist informed of suicidal statements. Primary doctor informed; psychiatric evaluation ordered. The Psychiatric Consultation Report (PCR) dated 9/29/14 documented Resident #1 has very needy personality; two weeks ago made suicidal statements, no intent. Patient is both frustrated and frustrating. The need for consistency, limited changes regarding medication, ongoing support and understanding that her cognitive capacity may be less intact than it appears on 1:1 exam should be noted. The NPN dated 12/12/14 documented that Resident #1 was transferred from Unit 1A to Unit 3B. The PCR dated 12/4/14 documented that Resident #1 denies [MEDICAL CONDITION]/homicidal ideations; no additional medications. The Neurology Consultation Report (NCR) dated 1/12/15 documented that Resident #1 had significant depression; severe suicidal thoughts-no intent. The NCR was signed by the attending physician. The NPN dated 1/12/15 at 10:49 PM documented that resident returned from doctor (neurologist) office at 8:30. 9:30 meds given. The 24 Hour Report dated 1/12/15 lacked documented evidence of Resident #1's suicidal thoughts. The NCR dated 3/26/15 documented that Resident #1 had suicidal thoughts. The NCR was signed by the attending physician. The NPN dated 3/26/15 at 3:24 PM documented that the resident returned from out on pass appointment with neurologist; recommendations called in to doctor's office; MD (medical doctor) to follow up. The 24 Hour Report dated 3/26/15 lacked documented evidence of Resident #1's suicidal thoughts. There was no documented evidence of a Psychiatric consultation or communication with the Psychiatrist in 2015. The Accident/Incident Report dated 3/30/15 at 5:15 AM documented that Resident #1 had a self-inflicted laceration to the neck and stated, "I did it because I can't live like this anymore." The resident was transferred to the hospital and admitted . The NPN dated 3/30/15 at 8:07 AM documented that STAT was called to resident's room. Upon entering room observed resident in a pool of blood with knife in her hand near her neck. Resident assessed immediately; alert and verbal stating, "I did it because I don't want to live anymore." Pressure applied to area; called out to staff to call 911. Police responded. 911 transferred to hospital for further medical treatment. Doctor notified. Message left for health care proxy. The NPN dated 3/30/15 at 2:58 PM documented that the resident was admitted to the hospital with [REDACTED]. The Nurse Supervisor Investigation (NSI) dated 3/30/15 documented that a STAT was called to the resident's room; observed resident with blood pooling behind her left neck, both hands bloody. Pressure immediately applied to left neck; oxygen applied via nasal cannula. 911 called immediately. Resident had no loss of consciousness however became [MEDICAL CONDITION]; placed in Trendelenburg position. Resident was transferred to the hospital. The NSI documented that there was adequate supervision of the resident; resident has a history of depression due to [DIAGNOSES REDACTED]. The NSI's sections 'Investigative Summary (to be completed by Director of Nursing or Designee)' and 'Evidence to suspect abuse, neglect or mistreatment' were left blank. An interview was conducted with the assigned 11:00 PM to 7:00 AM Certified Nursing Assistant (CNA #1) on 4/15/15 at 12:36 PM. CNA #1 stated that, on 3/30/15, she last saw Resident #1 sleeping in bed around 2:00 AM. At approximately 5:15 AM CNA #1 went in to the resident's room, turned on the overhead light and saw Resident #1 with a large knife at her neck and blood everywhere. She called out for the nurse. CNA #1 stated that she was in such shock and was never told to monitor the resident in any way. She further stated that she had never been told that Resident #1 ever voiced feelings of wanting to hurt herself. An interview was conducted with an 11:00 PM to 7:00 AM CNA #2 on 4/15/15 at 12:54 PM. CNA #2 stated that, on 3/30/15 around 5:15 AM, she heard CNA #1 yelling and ran into Resident #1's room. The resident had a knife at her neck and was saying that she didn't get the right spot. The nurse came in and a STAT was called. CNA #2 stated that she wasn't assigned to the resident but had never heard from any staff that Resident #1 had spoken or thought of wanting to hurt herself. An interview was conducted with the 11:00 PM to 7:00 AM Licensed Practical Nurse (LPN #1) on 4/15/15 at 1:28 PM. LPN #1 stated that she responded to CNA #1's yelling for help and observed Resident #1 holding a large knife close to her neck which was already cut; the resident was saying, "I hit the wrong spot." A STAT was immediately called and the supervisor came. LPN #1 stated that there was no specific monitoring in place for Resident #1 because LPN #1 had never been told of or seen on report about the resident ever having suicidal thoughts in the past. An interview was conducted with the 11:00 PM to 7:00 AM Registered Nurse Supervisor (RNS) on 4/15/15 at 1:34 PM. The RNS stated that, on 3/30/15 around 5:15 AM, she heard a STAT to the resident's room and, when she arrived, the RNS observed so much blood near and on Resident #1, who had a long knife in her left hand near her neck. The RNS stated that Resident #1 remained alert and was saying that she didn't want to live anymore like what she will become (speaking about the progression of her disease). The RNS stated that she applied continuous pressure to the resident's neck awaiting 911 which had already been called. The resident was ashen and started to lose color so the RNS placed Resident #1 in Trendelenburg position (on the back). The RNS stated that she was shocked by Resident #1's suicidal attempt; "I never saw any indication. She had no previous [MEDICAL CONDITION] or intent in the past to my knowledge." An interview was conducted with the assigned 7:00 AM to 3:00 PM CNA #3 on 4/15/15 at 2:10 PM. CNA #3 stated that Resident #1 was very independent and would spend a lot of her time in her room with headphones on. The resident received a lot of boxes in the mail but CNA #3 didn't see what was in the boxes. CNA #3 stated that she was never told to watch out for the resident in any way and "I definitely wasn't told about any suicidal thoughts." An interview was conducted with the 7:00 AM to 3:00 PM LPN #2 on 4/15/15 at 2:20 PM. LPN #2 stated, "After having breakfast each morning, she (Resident #1) would spend most of her time alone in her room withdrawn. She'd keep to herself." LPN #2 stated that Resident #1 was independent and did not have a monitoring in place. LPN #2 further stated, "I never heard of any history of [MEDICAL CONDITION] or attempts and I work five days a week." An interview was conducted with the 7:00 AM to 3:00 PM Registered Nurse (RN) on 4/15/15 at 3:01 PM. The RN stated that she is the charge nurse on Resident #1's previous unit; the resident moved off her unit in December 2014. The RN stated that she recalls Resident #1 saying something in September 2014 about wanting to hurt herself and she obtained a Psychiatric consult; the resident had no intention of hurting herself. The RN stated that she did not set up a specific plan of care regarding the resident's verbalization of wanting to hurt herself because it was a way of Resident #1 getting attention. The RN further stated that, when the resident was transferred off her unit in December 2014, she did not discuss any of this history with staff on the next unit. An interview was conducted with the Director of Social Work (DSW) on 4/16/15 at 11:40 AM. The DSW stated that Resident #1 was on one previous unit but that social worker no longer works at the facility. The DSW stated that, after the resident transferred to another unit in December 2014, the DSW has been the assigned social worker. The DSW stated that, after Resident #1's suicide attempt on 3/30/15, the DSW reviewed the resident's medical record and discovered a time in September 2014 that Resident #1 said she would kill herself. The DSW stated that she was never made aware of this verbalization and there was no care plan put into place. The DSW further stated that she was never made aware of Resident #1 having suicidal thoughts while at neurology appointments; "This is the first I'm hearing of this." An interview was conducted with the Psychologist on 4/16/15 at 12:01 PM. The Psychologist stated that he had been meeting with Resident #1 weekly and the resident had a past history of suicidal thoughts at the facility; the resident never offered any specific plan. The Psychologist stated that he does not know if staff were aware of the resident's suicidal thoughts but "if someone says I want to commit suicide it should be discussed and watched." The Psychologist stated that, on 3/26/15 while at the facility, the Director of Nursing asked him to see Resident #1 regarding a neurology consult saying the resident had suicidal thoughts. At the time, Resident #1 did not verbalize a plan to hurt herself. The Psychologist then stated, "The staff would have benefited from knowing about it." An interview was conducted with the Recreation Therapist (RT) on 4/16/15 at 12:26 PM. The RT stated that Resident #1 "was extremely independent, spent a lot of time doing her own thing at her speed. She would selectively come to things." The resident ordered many things through the mail and the RT would bring the boxes to Resident #1, leaving them for the resident to open in private. The RT further stated, "I was never told of any indicators that she thought of hurting herself." An interview was conducted with an Attending Physician (AP #1) on 4/16/15 at 3:02 PM. AP #1 stated that he had been Resident #1's attending physician since the beginning of March 2015. AP #1 stated that the resident was depressed due to [MEDICAL CONDITION]; he followed the neurologist's recommendations. AP #1 stated that he doesn't believe he ordered a Psychiatry consult after the resident's 3/26/15 neurology consult. AP #1 stated that Resident #1 "had big swings in mood." He further stated, "I don't think staff knew about her (Resident #1) suicidal thoughts but they (staff) should have known in order to monitor (the resident)." An interview was conducted with the 3:00 PM to 11:00 PM LPN #5 on 4/16/15 at 3:17 PM. LPN #5 stated that Resident #1 would have dinner daily and go back to her room, keeping to herself. LPN #5 stated that the resident was not monitored and LPN #5 was not aware of any time Resident #1 thought about hurting herself. LPN #5 stated that, on 1/12/15, she was on duty when the resident returned from the neurologist. She stated that "no one ever came up to me and tapped me on the shoulder to give me papers." LPN #5 reviewed the 1/12/15 NCR and stated, "I never saw this consult. I figured she (Resident #1) had no papers. Usually a driver or aide will tap me on the shoulder and give me papers." LPN #5 stated that she did not discuss the consult with the doctor and has never been aware of the resident having any suicidal thoughts. An interview was conducted with the Psychiatrist on 4/16/15 at 3:30 PM. The Psychiatrist stated that he last saw Resident #1 in December 2014 when the resident was mildly sad but not suicidal. He stated that he would have been due to see the resident for follow-up in March or April 2015. The Psychiatrist stated, "Staff should have zero tolerance for any patient who has suicidal thoughts and, as soon as a patient starts talking about a suicidal thought or if they (staff) become aware of it, a Psychiatric consult should immediately happen. "The Psychiatrist stated that he was not aware of the resident having neurology consults where she voiced suicidal thoughts. The Psychiatrist further stated, "I've never been called by the staff this year (2015) to see the patient (Resident #1) about this." An interview was conducted with an AP #2 on 4/17/15 at 11:05 AM. AP #2 stated that he was Resident #1's attending physician in January and February 2015. The resident "would often come across pleasant but also had mood swings and looked to increase narcotics." He stated that staff should always be aware of a patient with suicidal thoughts even if there is no intent. AP #2 further stated that he does not recall ever reading a 1/12/15 neurology consult saying the resident had severe suicidal thoughts. AP #2 further stated, "I don't know how I signed it (neurology consult). I don't ever recall any staff telling me about suicidal thoughts. I would have addressed that right away." An interview was conducted with the In-Service Coordinator (ISC) on 4/17/15 at 1:32 PM. The ISC stated that staff are in-serviced annually on interventions to handle a resident verbalization of self-inflicted harm; the last in-servicing was in February 2015. Staff must immediately report verbalizations to the nursing supervisor; a Psychiatric consult and social work involvement must occur. The ISC stated that any nurse would be expected to read an entire consult when a resident returns from a doctor. The ISC further stated that, since Resident #1's suicide attempt on 3/30/15, there has been no specific in-servicing of staff in response to the incident. An interview was conducted with the Neurologist on 4/17/15 at 1:53 PM. The Neurologist stated that Resident #1 has a debilitating neurological disease and Depression; the resident would verbalize suicidal thoughts even if there was no intent in the moment. The Neurologist stated that he wrote about the resident's suicidal thoughts on the consult sheet so that facility staff would be aware. He further stated that, if he writes a consult, he would expect the facility to follow-up. An interview was conducted with the Clinical Coordinator (CC) on 4/17/15 at 2:08 PM. The CC stated that she does the investigations for accidents and incidents but, in the case of Resident #1's suicidal attempt on 3/30/15, she gathered statements from the immediate staff on duty and deferred the remainder of the investigation to the Director of Nursing. The CC stated that she does not believe the resident's medical record was reviewed for the investigation, which focused solely on the incident itself. The CC stated that she did not make any conclusion with regard to abuse, neglect or mistreatment of [REDACTED]. An interview was conducted with the Director of Nursing (DON) on 4/17/15 at 2:56 PM. The DON stated that she reviewed the statements of and met with the staff who found Resident #1 on 3/30/15. She stated that she notified the NYSDOH but did not complete an investigation summary. The DON stated that there was no indication that the resident had [MEDICAL CONDITION]. The DON was not aware of the resident's suicidal verbalization in September 2014 and stated that there should have been a specific care plan developed. The DON stated that, with regard to the resident's neurology consults documenting suicidal thoughts, she thought the physician addressed it since the consults were signed by the attending physicians. The DON stated that there is a specific policy for verbalization of self-inflicted harm but this was not used in Resident #1's case. She further stated, "She (Resident #1) never voiced anything to staff here, just to the neurologist." 415.12 (f)(1)