Every finding on record at Nathan Littauer Hospital Nursing Home

Based on observations, record review, and interviews during a recertification survey, the facility did not ensure that each resident was treated with respect and dignity and cared for in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, residents were observed to be fed by staff wearing gloves in the west dining room and by the east nurses station. This is evidenced by: Policy titled Quality of Life- Dignity effective 05/2020 last reviewed 05/2024 documented each resident should be cared for in a manner that promoted and enhanced quality of life, dignity, respect, and individuality. Interpretation and implementation of this policy included residents should be treated with dignity and respect at all times. Treated with dignity meant the residents would be assisted in maintaining and enhancing their self-esteem and self-worth. During an observation on 02/10/2025 at 12:10 PM in the [NAME] dining room, staff wore gloves while feeding residents. During an observation on 02/12/2025 at 12:33 PM in the [NAME] dining room, staff wore gloves while feeding residents. During an observation on 02/13/2025 at 12:05 PM in the [NAME] dining room, staff wore gloves while feeding residents. During an observation on 02/14/2025 at 12:28 PM in the [NAME] dining room, staff wore gloves while feeding residents. During an observation on 02/18/2025 at 12:25 PM in the hall by the East Nurses station, a staff member wore gloves while feeding a resident. During an observation and interview on 02/14/2025, Certified Nurse Aide #1 was feeding a resident in their room and they were not wearing gloves. Certified Nursing Aide #1 stated they do not wear gloves when feeding residents because it was a dignity issue. During an interview on 02/14/2025 at 12:33 PM, Certified Nurse Aide # 2 stated they wore gloves when feeding residents to prevent the spread of germs. They stated they did not think it was a dignity concern, but they did not know how the residents felt about it. During an interview on 02/14/2025 at 12:28 PM, Licensed Practical Nurse #1 stated when they feed residents, they wear gloves to prevent their germs from spreading to the resident. It is a part of facility procedure to wear gloves when feeding residents. Licensed Practical Nurse # 3 stated they did not feel there was a dignity concern to feed residents while wearing gloves. During an interview on 02/14/2025 at 12:50 PM, Director of Nursing #1 stated if a resident needed total assist with feeding, staff should wear gloves. Director of Nursing #1 could not find in a facility policy where it stated staff should wear gloves when feeding a resident and stated it should be written in a policy. Director of Nursing #1 stated staff wearing gloves when feeding a resident was not a dignity concern because they want to keep the residents safe. If the residents had issues relating to dignity while being fed by staff members wearing gloves, they could put it in the resident's care plan so the staff would not wear gloves when feeding the resident. During an interview on 02/18/2025 at 11:37 AM, Nurse Manager #1 stated when a staff member fed a resident, they were to wash their hands and wear gloves. They stated it could be a dignity concern as it could make the residents feel like the staff thought they were dirty, and the residents may not realize they were wearing the gloves to protect the residents. 10 New York Code, Rules and Regulations 415.11 (c)(2)(ii)

Based on observation and staff interviews during a recertification survey, the facility did not ensure a safe, comfortable home-like environment and effective housekeeping and maintenance services were maintained for 2 (East and West) of 2 resident units. Specifically, (a.) the floors were soiled with dirt next to walls, in corners, along door thresholds, and where door frames meet the floor in the corridors on the East and [NAME] Units; (b.) door frames and doors were in disrepair for multiple resident rooms; walls in the East and [NAME] units were in disrepair with scrapes, smudge, chips, and marks; (c.) resident room NH. 44 wall was in disrepair and unfinished; (d.) ceiling tiles in the television rooms had water stains; (e.) shower rooms were soiled with dirt next to walls, and in corners, and (f.) handrails through unit were scuffed and scrapped exposing the underlying wood of the rails. This is evidenced by: The undated Policy &Procedure, titled Maintenance/Housekeeping Work Order Policy, documented that it was the facility's policy to ensure all areas maintained a clean, comfortable, and well-functioning environment. When problems were identified, employees were required to complete a Maintenance/Housekeeping Work Order. During observations on 02/13/2025 at 12:43 PM, the following items were observed; -Floors were soiled with dirt next to walls, in corners, along door thresholds, and where door frames meet the floor in the corridors on the East and [NAME] Units for room #s 2, 5, 18, 21, 25, 31, 36, 44, and 48. -Door frames and doors were in disrepair with scrapes, chips, and gouges for resident rooms 2, 5, 18, 21, 25, 31, 36, 44, and 48. -Walls in the East and [NAME] Units in all corridors were in disrepair with scrapes, chips, and unpainted. -Resident room NH. 44 wall was in disrepair and unfinished. -Several ceiling tiles in the East and [NAME] Unit television rooms had water stains -The floors and walls behind fire doors on the East and [NAME] Units were soiled with dirt and grime. -Shower rooms in the East and [NAME] Units were soiled with dirt next to walls, and in corners and appeared to have a dark black substance on walls. -Handrails through the East and [NAME] Units were scuffed and scrapped exposing the underlying wood of the rails. During an interview on 02/14/2025 at 11:45 AM, Environmental Services Director #1 stated that their staff was responsible for the overall cleaning of the facility. They stated that the cleanliness of the areas that had been lacking. They stated that they were in the process of developing a duty list of responsibilities the environmental service individuals were to complete daily. In showing the areas of concern the Environmental Service Director #1 stated that the areas should have been cleaned and that was the reason they wanted to develop the lists. During an interview on 02/18/2025 at 10:22 AM, Engineering Supervisor #1 stated that they oversee the overall appearance of the facility. They stated that they do have staff that worked with them daily and took care of the daily general workload of the facility. They stated their staff were responsible for fixing minor issues on a day-to-day basis such as lighting issues, Call bell issues, and general maintenance. Engineering Supervisor #1 stated that they received approximately 6- 8 work orders per day from staff on issues in the facility. They stated that they did a walk-through each morning to identify issues for repair or maintenance. They stated that approximately a year ago they had staff do a full facility touch-up on walls and door frames. They stated that they had a 3-month plan for renovations on the unit which included but was not limited to fixing the resident room doors, installing kick plates on the doors to protect them from damage, floors in the resident rooms, and general overall appearance. Engineer Supervisor #1 stated that resident room [ROOM NUMBER] had a water pipe break in the wall of the room. They stated that before they could finish fixing the entire wall a resident was moved into the room. They stated they had a work order to finish the wall in the room. 10 New York Codes of Rules and Regulations 415.5(h)(2)

Based on observation, record review, and interviews conducted during a recertification survey, the facility did not develop and implemented a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframe's to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 3 (Residents #s 3, 9, and 19) of 25 residents reviewed for Care Plans. Specifically, (a.) Resident #3 did not have a care plan for falls that documented interventions that were in place including the use of multiple mattresses in their room; (b.) Resident #9's intervention for treatment of edema (swelling caused by fluid buildup in the body's tissues) was not care planned, and Resident #19 did not have a care plan that addressed their vision problems. This is evidenced by: A facility policy titled Interdisciplinary Care Plan Committee effective 09/1992 last revised 04/2024 documented the plan of care is a working tool that provided a profile of the needs of each resident, identified the roles of each service in meeting these needs, and the supportive measures each service, along with the resident, will use to accomplish the overall goals of care. Each discipline was responsible for identifying a problem/concern if any existed for their discipline and identify an intervention for any problem/concern that was relevant to their discipline. Resident #3 Resident #3 was admitted to the facility with diagnoses of diffuse Lewy body disease (a neurodegenerative disorder characterized by dementia, fluctuations in mental status, hallucinations, and parkinsonism), Parkinson's Disease Dementia (dementia that is associated with Parkinson's disease), and coronary atherosclerotic heart disease (buildup of plaque which causes coronary arteries to narrow, limiting blood flow to the heart). The Minimum Data Set (an assessment tool) dated 12/05/2024, documented the resident had severe cognitive impairment, and rarely or never could be understood or understand others. During an observation on 2/11/2025 at 10:21 AM, resident was sitting in a lounge chair in their room. The resident's bed was at its lowest position and has multiple mattresses propped up against the walls in the room. A record review documented Resident #3 has a Care Plan for fall risks developed upon initial entrance to the facility on [DATE]. Resident #3 was discharged to the hospital on 11/30/2024 and returned several days later on 12/05/2024. The resident care plan for falls did not include the use of mattresses in their room. A record review of the Certified Nurse Aide's daily assessment documented the daily safety precautions were to have the bed in the lowest locked position with mattresses next to the bed. During an interview on 2/13/2025 at 10:45 AM, Certified Nurse Aide #2 stated that Resident #3 had the mattresses in their room due to having multiple falls. They stated that the mattresses were there to protect the resident from falls. They stated that their daily plan was to have the bed in the lowest locked position with mattresses next to the bed. Certified Nurse Aide #2 stated that the daily assessment was populated from the resident's care plan. They stated they did not know where in the care plan it was located as they do not deal with care plans. During an interview on 2/18/2025 at 2:33 PM, Nurse Manager #1 stated that the resident had a care plan for falls and that the mattresses on the residence floor were to be care planned. Nurse Manager #1 stated that they could not locate in the care plan where the mattress for the resident was documented. During that time Assistant Director of Nursing #1 was in the office with the Nurse Manager #1 and stated that the care plan was not implemented when the resident returned from the hospital. Resident # 9 Resident #9 was admitted to the facility with the diagnoses of hypertension (high blood pressure, a condition in which the force of the blood against the artery walls is too high), chronic kidney disease stage IV (longstanding disease of the kidneys leading to renal failure) and bilateral lower extremity edema (swelling in both legs below the knees). The Minimum Data Set, dated dated dated [DATE] documented Resident #9 had intact cognition and made decisions regarding tasks of daily life. The Comprehensive Care Plan for Edema initiated 04/11/2024 documented Resident #9 has chronic bilateral lower extremity edema. The outcome with a start date of 04/11/2024 and a target date of 04/08/2025 was Resident #9 would not have an alteration in skin integrity related to edema through the next review in 90 days. Intervention for Edema included: elevate legs as much as possible, avoid tight fitting shoes/socks, monitor skin integrity, medication as ordered, monitor weight, monitor for complaint of pain, and make provider aware of any changes/increases in amount. There was no intervention that included wrapping Resident #9 bilateral lower extremities with ACE bandages daily. Physician order with start date 01/14/2025 documented wrap bilateral lower extremities with ACE wraps daily and remove at hour of sleep. The diagnosis code/problem on this order was listed as edema, unspecified. Nurses progress note dated 01/14/2025 documented Resident #9 was seen by provider regarding bilateral lower extremity edema. New order was received to wrap bilateral lower extremities with ACE wraps during the day and off at hour of sleep. Resident #9 was agreeable to this plan. During an interview on 02/10/2025 at 11:27 AM, Resident #9 stated they have a severe case of edema, and their legs need to be wrapped with ACE bandages. They stated the nurses wrapped their legs when they get situated in the morning, and they come off in the evening. During an interview on 02/14/2025 at 11:29 AM, Licensed Practical Nurse #4 stated ACE bandages were applied to Resident #9's bilateral lower extremities after they were cleaned up in the morning and they were removed at night. Licensed Practical Nurse #4 stated they did not know if it was care planned for Resident #9's legs to be wrapped. During an interview on 02/14/2025 at 11:30 AM, Registered Nurse #2 Charge Nurse stated ACE bandages were applied to Resident #9's bilateral lower extremities in the morning and they were removed at night due to edema. The Licensed Practical Nurse was responsible for wrapping the legs in the morning and removing the wraps in the evening. Registered Nurse #2 Charge Nurse stated the use of these wraps should be care planned because Resident #9 has edema. They checked Resident #9's care plan for edema and skin breakdown and said the intervention for wrapping Resident #9's legs should be on one of those two care plans, but it was not on either of those care plans. During an interview on 02/14/2025 at 12:50 PM, Director of Nursing #1 stated if a resident had their legs wrapped due to edema, this intervention should be indicated on their care plan. They would expect to see it on their edema care plan for Resident #9 and Director of Nursing #1 acknowledged this intervention was not on Resident #9's edema care plan. Resident #19 Resident # 19 was admitted to the facility with diagnoses of diabetes type 2 (a disease of inadequate control of blood levels of glucose), diabetic retinopathy (having too much sugar in your blood can damage your retina - the part of your eye that detects light and sends signals to your brain), and Significant Right Eye Cataract (a clouding of the lens in your eye). The Minimum Data Set, dated dated dated ,d+[DATE], documented resident was cognitively intact, could be understood, and understand others. The Comprehensive Care Plan dated 12/2024, for Resident #19 did not include a plan for vision and or glasses. During an interview on 2/11/2025 at 11:24 AM, Resident #19 stated they had difficulty with vision. They did not wear their glasses anymore because the glasses really do not help. The glasses were really old, and they had been asking to see the eye doctor, but no appointment had been made. Ophthalmology consult dated 7/27/2020 documented diagnosis of diabetic retinopathy, significant right eye cataracts and corneal dystrophy (eye diseases that involve changes in the cornea). Recommended follow up in three months. During an interview on 02/14/2025 at 10:57 AM, Director of Nursing #1 stated resident was seen by ophthalmology in 2020, which was prior to their admission to the facility . They stated Resident #19 had not been seen by ophthalmology since admission. Residents were seen by specialist as needed, but generally once per year. They stated it was the responsibility of the unit manager to coordinate follow up specialist visits. During an interview on 02/14/2025 at 12:47 PM, Registered Nurse #1 stated Resident #19's Comprehensive Care Plan did not include vision and/or glasses. They were not aware resident wore glasses and would update the care plan. 10 New York Code of Rules and Regulations 415.11(c)(1) 48615 51317

Based on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed 5% for 2 (Resident #s 4 and 38) of 16 residents observed during a medication pass for a total of 25 observations. This resulted in a medication error rate of 8%. This is evidenced by: The facility's policy and procedure titled Medication Administration last revised ,d+[DATE] documented, all Registered Nurses and Licensed Practical Nurses must have successfully passed the written medication exam and the medication administration competency to administer medications as outlined below. Registered Nurses and Licensed Practical Nurses have the responsibility to administer medications in accordance with this policy and any other relevant education and/or certification. Right Documentation - Administration is recorded in the electronic Medication Administration Record. If medication is held or refused or not given on time, a reason for such is recorded in the electronic Medication Administration Record. If there are any signs of adverse reaction or change in resident's medical condition, there is documentation in the electronic Medication Administration Record. Check expiration date prior to administration. Verify that the medication selected is stable based on visual inspection for particulates or discoloration and that the medication has not expired. Do not administer single dose vial if seal has been broken. Check expiration date prior to administration. The Registered Nurses or Licensed Practical Nurses would make an evaluation, prior to administering any medication, of the resident's physical condition, lab values, and vital signs as indicated. Any contraindication to administering the medication would be discussed with the physician. Refused/Omitted/ Missed Dose: a. When medication is refused or omitted, select reason in electronic Medication Administration Record, selecting from drop downs. b. State reason for refusal/omission, any communication to physician and action taken in a Clinical Note. A Registered Nurse Supervisor and provider must be notified when a medication was not available. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, had determined that they have the decision-making capacity to do so safely. Resident #4: Resident # 4 was admitted to the facility with diagnoses of diabetes mellitus (a disease of inadequate control of blood levels of glucose), hip Fracture and depression (a mental health condition that involves a low mood and loss of interest in activities). The Minimum Data Set (an assessment tool) dated [DATE], documented resident had moderate cognitive impairment, could be understood, and understand others. Resident #4's current physician orders dated [DATE] and the Medication Administration Record dated ,d+[DATE] documented, before meals give Insulin Lispro Injection 300 unit/3 milliliter three times a day at 08:00, 12:00, and 17:30 per sliding insulin scale. At 11:17 AM, Resident #4 had a documented blood glucose fingerstick of 347 Milligrams per deciliter. At 12:40 PM, Licensed Practical Nurse #2 administered 10 units of Lispro insulin based on the sliding insulin scale. Resident #4 had already consumed their lunch at approximately 12:10 PM. During an interview at 12:40 PM, Licensed Practical Nurse #2 stated insulin was ordered to be given before meals and should be given immediately after finger stick had been recorded. They stated it was wound rounds that day and they did not get to give the insulin until 12:40 PM. Licensed Practical Nurse #2 stated they should have prioritized and given the insulin first before passing other resident medications. Licensed Practical Nurse #2 did not obtain another blood glucose fingerstick, and did not report the late medication administration to a Registered Nurse and or physician. During an interview on [DATE] at 02:52 PM, Assistant Director of Nursing #1 stated insulin coverage should be given before meals per physician order. They stated insulin should be given as soon as possible after the blood glucose fingerstick. One hour and 20 minutes was considered an extended time between taking fingerstick and giving insulin coverage. In this case, a repeat fingerstick should have been taken and the physician should have been notified. Resident #38: Resident #38 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (a condition caused by damage to the airways or other parts of the lung); diabetes mellitus (a disease of inadequate control of blood levels of glucose), and depression (a mental health condition that involves a low mood and loss of interest in activities). The Minimum Data Set (an assessment tool) dated ,d+[DATE], documented resident had moderate cognitive impairment, could be understood, and understand others. Resident #38's Medication Administration Record dated [DATE] documented, Ipratropium/Albuterol (0XXX,d+[DATE] milligrams/3 milliliters). Nebulized two times daily at 07:30 and 16:30. Administered [DATE] at 07:17 signed by Licensed Practical Nurse #1. During an observation on [DATE] at 11:43 AM, Resident #38 was noted receiving a nebulizer treatment. During an interview on [DATE] at 11:45 AM, Resident #38 stated the medication in nebulizer was left at their bedside that morning [DATE] by Licensed Practical Nurse #1. They stated staff always left the medication at the bedside, and they took it when they were ready. Licensed Practical Nurse#2 stated, resident had the nebulizer applied and turned off nebulizer themselves when done. If the medication was not completed, the resident would restart the nebulizer when ready. Licensed Practical Nurse #2 stated, although the nebulizer was placed that morning by Licensed Practical Nurse #1, they would have done the same thing. During an interview on [DATE] at 11:50 AM, Licensed Practical Nurse #1 stated they signed for Resident #38's nebulizer treatment at 07:30 AM indicating it was administered. They stated they did not go back into resident's room to ensure medication was consumed and or to have resident rinse mouth following nebulizer treatment. During an interview on [DATE] at 12:57 PM, Director of Nursing #1 stated they had no residents at the facility who self-administered medications. They stated if resident wished to self-administer medications, they would have to be assessed for competency along with obtaining an order to self-administer medication by the physician, and a care plan would be put in place. Director of Nursing #1 stated nurses who administer medications should not leave medications at the bedside. Staff were to ensure the medication was consumed. 10 New York Codes, Rules, and Regulations 415.12 (m)(1)]

Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for 1 (West Unit Team 1) of 2 medication carts reviewed. Specifically, (a.) opened medications had no open and or expiration dates (b.) open bottles of eye drops had no label identifying patient and had no open and or expiration dates. This is evidenced by: The facility's policy and procedure last revised ,d+[DATE] documented, Multiple-Dose Vials a. Multiple-dose vials would not be used beyond the manufacturer's expiration date. Any multi-dose vial that has been opened or punctured would have an expiration date of 28 days-label the container when opened with the date of expiration (28 days from date of opening, or manufacturer's date of expiration if that is sooner) and initials. They must be stored under manufacturer's recommended conditions and discarded if potentially contaminated. Exceptions: Exceptions include when the manufacturer's stability is less than 28 days. For example, Mucomyst (Trademark) (acetylcysteine) vials should be dated upon initial entry. Acetylcysteine expires in 96 hours under refrigeration. Acetylcysteine would be issued with a fill-in-the-blank label for completion and application after the first use. Insulin vials would be dispensed as resident specific. Insulin removed from pyxis would be assigned to the resident for whom it was removed. Check expiration date prior to administration. Verify that the medication selected is stable based on visual inspection for particulates or discoloration and that the medication has not expired. Do not administer single dose vial if seal has been broken. Check expiration date prior to administration. During an observation on [DATE] at 11:34 AM, the [NAME] Unit Team 1 Medication Cart contained 1 open vial of Lispro insulin, and 1 open vial of glargine insulin both with no open and or expiration dates. The following open bottle of eye drops had no label identifying resident and had no open or expiration dates: 1 bottle each of Timolol; Brimonidine; Atropine; Ketorolac, GenTeal and Alaway. During an interview on [DATE] at 11:23 AM, Licensed Practical Nurse #1 stated medication was labeled when it came from the pharmacy. The label on the eye drops fell off, but they knew which patient the eye drop belonged to. Licensed Practical Nurse #1 stated they did not write the expiration date on the bottles, the pharmacy wrote the expiration date. During an interview on [DATE] at 02:52 PM, Assistant Director of Nursing #1 stated all medications came labeled from the pharmacy. They stated the fill date was different from the open date. The nurse opening the medication should write the open and expiration dates on the medication. When labels fall off, for example on eye drops, it was the nurse's responsibility to re-apply the label or request another medication from the pharmacy. During an interview on [DATE] at 10:45 AM, Director of Nursing #1 stated upon opening a medication the nurse should label the medication with open and expiration dates. Each nurse received medication administration training upon hire. Medication administration training included checking medication expiration dates prior to administration. 10 New York Codes, Rules, and Regulations 415.18(d)

Based on observation and interviews during the recertification survey, the facility did not ensure that food was stored, prepared, distributed, or served following professional standards for food service safety in 2 of 2 resident unit nutrition areas and the main kitchen. Specifically, the area of the main kitchen and resident kitchenettes were not clean. This is evidenced by: During the initial inspection in the main kitchen on 2/10/2025 at 11:05 AM, the following observations were made: The manual can open had a build-up of debris in the cutting area of the device The mixer had dirt and debris on and under the device. Dust and dirt were on top of two fire extinguishers in the main kitchen. During an inspection of the East nutrition area on 2/12/2025 at 12:48 PM, the following observations were made: Temperature logs for the refrigerator and freezer for February 6, 8, 9, 10, and 12/2025 were missing. There was dirt and grime on the top of the refrigerator/freezer unit. There was dirt, grime, and food particles on the freezer bottom and shelves. There was dirt, grime, and food particles on the refrigerator bottom and shelves. There was dirt and grime on the seals of the refrigerator and freezer. There was dirt, grime, and food particles within the microwave. There was dirt, grime, and food particles built up on the drawers under the microwave. During an inspection of the East nutrition area on 2/12/2025 at 12:58 PM, the following observations were made: Temperature logs for the refrigerator and freezer for February 9, 10, and 12 were missing. Dirt and grime on the top of the refrigerator/freezer unit. Dirt, grime, and food particles on the freezer bottom and shelves. Dirt, grime, and food particles on the refrigerator bottom and shelves. Dirt and grime on the seals of the refrigerator and freezer. Dirt, grime, and food particles within the microwave. Dirt, grime, and food particles built up on the drawers under the microwave. During the follow-up inspection in the main kitchen on 2/13/2025 at 11:45 PM the following observations were made: The walk-in refrigerator had a large pool of free-standing water on the floor. The storage area for clean pots, pans, and food containers had multiple containers stacked together that were not fully dried. Containers, pots, and trays were put away wet and contained moisture. The rolling toaster contained a large amount of debris under and behind the apparatus. Dirt and grime on the shelving unit above the grill cooking area. Final rinse pressure on the dishwasher was 13 pounds per square inch. The signage on the device had a recommendation of 20 pounds per square inch. During an interview on 2/13/2025 at 12:22 PM, Director of Food Services #1 stated that their staff were responsible for the cleaning of the equipment being used in the kitchen. They stated they would need to be more diligent in cleaning the equipment and kitchen areas. They stated that they were made aware of the water in the cooler this morning and engineering was working on a potential leak but unsure of what they found or the progress that had been made with it. They stated that the individual who was washing the pots, pans, and containers did not let them dry fully and put them away too soon as it took several hours to fully dry. They stated that they would have to educate the individuals washing the pans on the proper time for drying. Food Service Director #1 stated that the main dishwasher was out of service on Tuesday 2/11/2025 due to a malfunction. The Administrator was made aware, and the service company was called immediately to repair the machine. It was found that a sensor wire corroded away causing the malfunction. Food Service Director #1 stated that they had the service individuals look at the gauges for the dishwashing machine and it was found that the water pressure gauge was not working appropriately and had a faulty sensor. They stated that the service company ordered a new part and would be back to fix it as soon as the part came in. The service individual stated that the recommended pressure on the system was 20 pounds per square inch plus or minus 5 pounds. In observing the rinse pressure of the machine, Food Service Director #1 stated that the final rinse pressure was below the recommended amount. Food Service director #1 stated that the Environmental Services was responsible for the cleanliness of the nutrition areas, but the temperature logs were the responsibility of the dining ambassador. When asked about the missing dates of the temperature logs, Food Service Director #1 stated that people were not doing their jobs, and they would make sure they were completed daily. During an interview on 2/14/2025 at 11:45 AM, Environmental Services Director #1 stated that their staff were responsible for the overall cleaning in the nutrition areas. They stated that the cleanliness of the areas had been lacking. They stated that they were in the process of developing a duty list of responsibilities the environmental service individuals were to complete daily. In showing the areas of concern, Environmental Service Director #1 stated that the areas should have been cleaned and that was the reason they wanted to develop the lists. 10 New York Codes, Rules, and Regulations 415.14(h)

Based on record reviews, and interviews conducted during a recertification survey, the facility did not ensure that Quality Assessment and Assurance Committee consisted at a minimum of the Director of Nursing, Medical Director or designee, Administrator, and Infection Preventionist. The failure to meet to coordinate and evaluate the need for performance improvement projects had the potential to affect all residents of the facility. Specially, Director of Nursing was also the Infection Preventionist. This is evidenced by: A review of the facility's undated Quality Assurance and Performance Improvement Plan, revealed that the Quality Assurance and Performance Improvement Plan provides leadership through its committee. The Quality Assurance and Performance Improvement committee shall be comprised of the Administrator, Medical Director, Director of Nursing, Assistant Director of Nursing, Registered Nurse Manager, Registered Nurse Supervisors, Chief Executive Officer, [NAME] President of Operation, and other ancillary department heads. The Administrator is the chairperson of the Quality Assurance and Performance Improvement committee and is responsible for ensuring that Quality Assurance and Performance Improvement are implemented throughout the facility. The Quality Assurance and Performance Improvement Committee shall meet monthly to review reports, evaluate the significance of data, and monitor quality-related activities of all departments, services, or committees. The overall responsibility of the steering committee is to develop and modify the Quality Assurance and Performance Improvement, identify teams who will problem solve as well as set priorities for the Performance Improvement Projects. A Review of the Policy and Procedure titled Infection Prevention and Control created in November 1977 and revised in August 2024 documented under Mission/Goal of the Infection Control Program: Through oversight of the Quality Assessment and Assurance Committee, the Infection Prevention and Control Committee, shall oversee the implementation of infection control policies and practices, and help department heads and managers implement infection prevention and control measures within their departments: and, inquiries concerning infection control policies, procedures, and facility practices should be referred to the Infection Preventionist or Director of Nursing Services. During the entrance interview conducted on 02/10/2025 at 10:30 AM, Director of Nursing #1 stated they were the current Infection Preventionist as well as the Nurse Educator. They stated that many staff members have multiple roles due to staffing issues. During an interview on 2/19/2025 at 11:15 AM, Administrator #1 stated that they held meetings every month and it was the responsibility of the staff to sign in for the meetings. They stated they were unaware that the Infection Control Preventionist was their own role and could not be a dual role with the Director of Nursing. 10 New York Code of Rules and Regulations 415.27(b)(3)

Based on observation and interviews during the recertification survey, the facility did not designate one or more individual(s) as Infection Preventionist (s) responsible for the facility's Infection Prevention Control Practices. Specifically, the facility did not have a specified designated individual as their Infection Control Preventionist, and the Director of Nursing had performed a dual role since May 10, 2023. This is evidenced by: A Review of the Policy and Procedure titled Infection Prevention and Control created in November 1977 and revised in August 2024 documented under Mission/Goal of the Infection Control Program: Through oversight of the Quality Assessment and Assurance Committee, the Infection Prevention and Control Committee, shall oversee the implementation of infection control policies and practices, and help department heads and managers implement infection prevention and control measures within their departments. Inquiries concerning infection control policies, procedures, and facility practices should be referred to the Infection Preventionist or Director of Nursing. The Infection Preventionist implements corrective action plans for infection control in affected problem areas with the assistance of the Chief Executive Officer, Medical Staff, Quality Assurance Performance Improvement Committee, and Nurse Executive. A review of the Infection Preventionist documentation of sufficient training documented that the Director of Nursing #1 completed their nursing home infection prevention training course on 05/10/2023. This was the day they assumed the role of the infection preventionist. A review of key personnel from May of 2023 documented that the designated Infection Preventionist listed for the facility was Director of Nursing #1. During the entrance interview conducted on 02/10/2025 at 10:30 AM, Director of Nursing #1 stated they were the current Infection Preventionist as well as the Nurse Educator. They stated that many staff members have multiple roles due to staffing issues. During an interview on 02/19/2025 at 11:15 AM, Administrator #1 stated that they were unaware that the Infection Control Preventionist was to have their own specific role and could not have a dual role with the Director of Nursing. 10 New York Code of Rules and Regulations 483.80 (b) (1)-(4) (c)

Based on record review and interviews conducted during the Recertification survey, the facility did not ensure that the resident and resident representative had the right to participate in the development and implementation of their person-centered plan of care by facilitating the inclusion of the resident and resident representative in the planning process for 1 1(Resident #6) of 1 resident reviewed for care planning. Specifically, for Resident #6, their family member was not afforded the opportunity to participate in quarterly care plan meetings. This is evidenced by: Facility policy titled Interdisciplinary Care Plan Committee effective 09/1992 last revised 04/2024 stated a comprehensive care plan was developed within seven days after the completion of a comprehensive assessment by the interdisciplinary team with participation of the resident and revised with significant changes. Care plans were reviewed at the interdisciplinary care plan meeting every three months and as indicated by a significant change or change in condition. The policy also stated the resident and/or their designated representative would be encouraged to participate in the development of initial, significant changes, and annual care plan. Resident #6 was admitted to the facility with diagnoses of history of cerebral vascular accident (a medical condition that occurs when blood flow to the brain is suddenly interrupted which can damage brain cells and lead to neurological damage), type 2 diabetes mellitus (a chronic condition when a person has persistently high blood sugar levels), and atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular beating of the atrial chambers of the heart). The Minimum Data Set (an assessment tool) dated 05/07/2024 indicated Resident #6 was cognitively intact, could be understood, and understand others. Resident was able to make decisions regarding tasks of daily life. Section Q of the Minimum Data Set documented that Resident #6 participated in the assessment and goal setting. Family did not participate with the assessment and goal setting. During an interview on 02/10/2025 at 3:34 PM, Family Member #1 stated they came to visit Resident #6 every day for five-six hours a day. They stated they came to one care plan meeting when Resident #6 was first admitted to the facility. They have not been made aware of or invited to quarterly care plan meetings. During an interview on 02/13/2025 at 3:49 PM, Director of Social Work #1 stated care plan meetings occur initially when a resident was admitted to the facility, quarterly, annually, and if a significant change occurred or if a family member requested a meeting. Residents and families were invited to attend the meetings initially, annually, and for significant changes. Director of Social Work stated Family Member #1 attended Resident #6's initial care plan meeting on 05/21/2024 and a follow up meeting pertaining to discharge planning on 06/10/2024. Director of Social Work #1 stated family members were not notified of quarterly care plan meetings. If the interdisciplinary team had a concern regarding the resident to discuss with a family member, they could reach out to the family member via phone call to discuss the concern. 10 New York Code Rules & Regulations 415.11 (c)(2)(ii)

Based on record review and interviews during a recertification and abbreviated survey (Case #sNY00368587 and NY00370779), the facility did not ensure that residents were free from neglect for 2 (Resident #s 10 and 19) of 25 residents reviewed. Specifically, (a.) Resident #10 was not monitored, turned and positioned or received personal care for at least one full shift on 11:00 PM-7:00 AM, 1/29/2025 - 1/30/2025; (b.) Resident #19 rolled out of bed and hit their head on furniture when receiving care by a Certified Nurse Aide on 1/21/2024 at 10:35 AM. This is evidenced by: The Facility's Policy and Procedure titled, Resident Abuse revised 8/2024, documented the facility would investigate all cases of suspected resident abuse, including allegations of neglect, misappropriation, mistreatment or injuries of unknown origin. Of those cases that the facility found reasonable cause and/or evidence that a resident has been abused, corrective action would take place with those involved: In the case of an employee involvement - the corrective action procedure would be initiated by the employee's immediate supervisor and may result in suspension and/or discharge without prior warning. The term neglect meant failure to provide timely, consistent, safe, adequate and appropriate services, treatment and/or care to a resident, while under the supervision of the facility, including, but not limited to: nutrition, medication, therapies, sanitary clothing and surroundings, and activities of daily living. (NY Public Health Law 2803-d). Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. [See Older Americans Act, 302 (a) (19)]. It may include, but not be limited to, being left to sit or lie in urine or feces, isolating dependent residents by leaving them in their rooms or other isolated locations apart from temporary monitored separation occurring in the context of assessment and care planning, or failing to answer call bells to provide assistance. Resident #10: Resident #10 was admitted with a diagnoses of malnutrition (a state of nutritional deficiency); anxiety (repeated episodes of sudden feelings of intense fear or terror), and atherosclerotic heart disease (buildup of fats, cholesterol and other substances in and on the artery walls). The Minimum Data Set (an assessment tool) dated 11/15/2024, documented the resident could understand and be understood by others. The facility's Investigative Report dated 1/30/2025, documented an aide told Registered Nurse #1 at 7:00 AM on 1/30/2025 that Resident #10 was soaked and there was no way they had been cared for. Two other staff were in the room and changing resident. Resident also had a bowel movement. Investigation revealed that the resident did not receive care by staff on the previous night shift (1/29/2025-1/30/2025). There was no injury related to this incident; however, staff should have recognized that the resident was not attended to. During an interview on 02/13/2025 at 11:11 AM, Registered Nurse #1 stated a Certified Nurse Aide reported to her that Resident #10 had no care during overnight shift. Registered Nurse #1 in turn reported the incident to Director of Nursing #1. Registered Nurse #1 stated they believed it was a miscommunication. Resident #10 was a no male caregiver. The Certified Nurse aide assigned to that hall was a male, Certified Nurse Aide #4. Certified Nurse Aide #3 was fairly new at time of incident, and it was not communicated to them that they were assigned to a resident on the opposites side of the unit. Both Certified Nurse Aides #3 and 4 were educated on the no male caregiver system, which was a pink dot on door of resident to indicate no male caregiver. In addition, Certified Nurse Aide #4 was counseled on documentation. Certified Nurse Aide #4 documented care was provided to Resident #10 on 1/29/2025 through 1/30/2025, when in fact they admitted they did not provide any care to this resident. During an interview on 02/13/2025 at 12:52 PM, Director of Nursing #1 stated the incident was a result of miscommunication. They stated Certified Nurse Aide #s 3 and 4 were 'very good aides,' and the assignment for Resident #10 should have been updated on the assignment sheet. They stated that Registered Nurse #3 wrote out the assignment prior to end of their shift, and at change of shift, Registered Nurse #4 was given a report. Director of Nursing #1 stated they educated both Registered Nurse #s 3 and 4 on the responsibility of making out assignments and in communication. Resident #19: Resident # 19 was admitted to the facility with diagnoses of diabetes type 2 (a disease of inadequate control of blood levels of glucose), diabetic retinopathy (having too much sugar in your blood that damages the part of the eye that detects light and sends signals to the brain), and a cataract (a clouding of the lens in the eye). The Minimum Data Set, dated dated dated [DATE], documented the resident was cognitively intact, could be understood and understand others. The Mobility Comprehensive Care Plan dated 1/2024, documented plan of care, Toileting Hygiene, Shower/Bathe, Self-Upper Body Dressing, Lower Body Dressing, Putting On/Taking Off Footwear, Personal Hygiene all Dependent Substantial/Maximal Assistance. Adaptive Equipment used: Mechanical Lift, Geriatric chair. The facility Investigate Report dated 01/21/2024 documented Resident #19 was receiving care (in bed with a soft mattress pad called an overlay). Resident was rolled to their left side and when they moved, the overlay moved causing them to slide to the floor. Resident assessment noted bump on eyebrow/forehead on Right side. Neurological checks completed as per protocol with changes noted. Resident was sent to the emergency department at 11:15 AM. A Computed Tomography Scan (CT) (imaging of the brain) was negative, and resident returned to facility. On 01/22/2024, Resident #19 complained of Left arm and shoulder pain. X-rays were ordered which revealed osteopenia/osteoporosis, and no fracture. The facility Investigative Summary documented Certified Nurse Aide #5 acknowledged that they should have had 2 for turning this resident. Attempts to reach Certified Nurse Aide #5 by phone were unsuccessful. During an interview on 02/14/2025 at 10:57 AM, Director of Nursing #1 stated Certified Nurse Aide #5 did not state why they did not use a second person when caring for Resident #19. Stated Certified Nurse Aide #5 was no longer employed at the facility, the overly went on top of the mattress, with four ends that tucked underneath the mattress. Director of Nursing #1 further stated that particular type of overlay was no longer in use at the facility following this incident. During an interview on 02/18/2025 at 12:09 PM, Administrator #1 stated they removed the overlay from Resident #19's bed. 10 New York Codes, Rules, and Regulations 415.4 (b)(1)(i)

Based on record review and interviews during a recertification and abbreviated survey (Case #NY00370103) , the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately, but not later than two hours after the allegation was made, to the State Survey Agency for 1 (Resident #7) of 1 resident reviewed for reportable incident. Specifically, an injury of unknown origin was discovered for Resident #7 on 01/23/2025. This injury of unknown origin was not reported until 01/25/2025 at 10:51 AM. This was evidenced by: The Policy titled Resident Abuse effective 10/24/2022 last reviewed 09/2023 documented resident abuse and/or misappropriation of resident property should not be tolerated by the facility. The facility shall investigate all cases of suspected resident abuse, including allegations of neglect, misappropriation, mistreatment, or injuries of unknown origin. Each covered individual (anyone who is an owner, operator, employee, manager, agent, or contractor of the facility) shall report immediately, but not later than two hours after forming the suspicion, if the events that cause suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. In addition, the facility must report alleged violations related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property and report the results of all investigations to the proper authorities within prescribed timeframes. In addition, employees are required to immediately report any resident incident, including all suspected cases of resident abuse, mistreatment or neglect including injuries of unknown source and misappropriation of resident property to their supervisor, department head, and/or administrator. Resident #7 was admitted to the facility with diagnoses of dementia (loss of memory, language, problem solving, and other thinking abilities that are severe enough to interfere with daily life), history of cerebral vascular accident (a medical condition that occurs when blood flow to the brain is suddenly interrupted), and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles). The Minimum Data Set (an assessment tool) dated 04/03/2024 documented Resident #7 had severe cognitive impairment, could be understood, and understand others. Skin check work list for Resident #7 dated 01/23/2025 completed by Licensed Practical Nurse #3 documented there was a purple/blue area on the right foot. Nursing home facility incident report submitted to the Department of Health on 01/25/2025 at 10:51 AM by Director of Nursing #1 with incident date of 01/25/2025 and the time of occurrence as 8:56 AM indicated that a Certified Nurse Aide noted during morning (AM) care that Resident #7 had a discolored purplish -blue area on the 4th and 5th toe on the top side of the right foot. An investigation was in progress. No non-residents were accused of abuse, mistreatment, neglect, or misappropriation. There were no witnesses to this incident. Progress note dated 01/25/2025 by Provider #1 indicated Resident #7 was seen due to right foot swelling and discoloration. The resident was not able to recall when they noticed swelling in their foot and could not recall an injury or something that could have occurred to cause the swelling. Assessment included an x-ray to rule out fracture. It was unclear if Resident #7 had an injury as there were no reports of any falls or trauma at that time. Accident and incident form completed on 01/25/2025 stated at incident time of 8:45 AM during AM care, Resident was noted to have an edematous right foot. Top of the right foot was discolored, and the 4th inner toe and little toe were purple in color. Provider #1 was notified on 01/25/2025 at 10:45 AM and an x-ray of the right foot was ordered. This form indicated this was a reportable incident of quality of care due to an injury of unknown origin. emergency room History and Physical stated Resident #7 was treated in the emergency roiagnom on [DATE] at 3:46 PM for further treatment of right foot fracture. Mechanism of unknown injury. Resident #7 developed bruising and swelling to right foot which prompted imaging. Resident #7 sustained an impact fracture of the 4th and 5th metatarsal (five long bones in the midfoot that connect the ankle to the toes). Follow up undated investigation report completed by Administrator #1 and Director of Nursing #1 documented Resident #7's 4th and 5th toe on the right foot were discolored and edematous and were x-rayed on 01/25/2025. Impression was severe osteopenia (loss of bone density). Resident #7 sustained a displaced slightly impacted fracture of the 4th and 5th metatarsal necks. Resident #7 had moderate osteoarthritis (a degenerative joint disease in which the tissues in the joint break down over time). Provider #1 stated on 1/26/2025 that Resident #7 had fairly significant osteopenia, and the fracture was likely due to minimal impact against the geri chair/bed and Resident #7 continued to be at risk for these kinds of fractures from minimal impact on turning and when sleeping. The report documented it could not be determined how the injury occurred. It was determined that this area was initially found on 01/23/2025 by Licensed Practical Nurse #3 during a routine skin check but Licensed Practical Nurse #3 failed to report the discovery to a Registered Nurse for further assessment. During an interview on 02/14/2025 at 12:50 PM, Director of Nursing #1 stated they were on call on 01/25/2025 when Resident #7's foot was noted to be purple in color by the 4th and 5th toe. They reported the incident to the Department of Health on 01/25/2025 within 2 hours of them being notified as it was an incident with unknown source and they started the investigative process. Director of Nursing #1 stated Licensed Practical Nurse #3 should have immediately notified a Registered Nurse after completing the skin check work list on 01/23/2025 so the Registered Nurse could have completed an assessment of Resident #7 and determined what to do. Director of Nursing #1 stated this incident should have been reported to the Department of Health two days earlier when it was discovered on 01/23/2025. 10 New York Codes, Rules, and Regulations 483.12 (c) (1)

Based on record review and interviews conducted during the recertification survey, the facility did not ensure written notice of the facility's bed hold policy was provided to the resident and/or the resident's representative upon transfer to the hospital for 1 (Residents #12) of 1 resident reviewed for notice of bed hold policy before/upon transfer. Specifically, for Resident #12 a written notice of the facility's bed hold policy was not provided to the resident and/or their representative upon transfer to the hospital on 12/06/2024. This is evidenced by: The policy titled Admission, Discharge and Transfer effective 10/24/2022, last revised 03/2024 documented facilities must develop and implement policies for bed-hold and permitting residents to return following hospitalization or therapeutic leave. When residents were sent emergently to an acute care setting, these scenarios were considered facility-initiated transfers, -not discharges, because the resident's return was generally expected. For facility-initiated transfers or discharge of a resident, prior to the transfer or discharge, the facility must notify the resident and the resident's representative(s) of the transfer or discharge and the reason for the move in writing and in a language and manner they understand. Resident #12 was admitted to the facility with diagnoses of dementia (loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), history of cerebral vascular accident (a sudden interruption of blood flow to the brain which can damage brain cells and lead to neurological damage), and type 2 diabetes (a chronic condition that happens when a person has persistently high blood sugar levels). The Minimum Data Set (an assessment tool) dated 11/19/22 documented Resident #12 had severe cognitive impairment. It further documented Resident #12 made decisions regarding tasks of daily life. Physician order dated 12/06/2024 documented Resident #12 was to be transferred Emergency Department due to a fall and possible fracture. There was no documented evidence that a written notice of the facility's bed hold policy was provided to the resident and/or the resident's representative upon transfer to the hospital on 12/06/2024. During an interview on 02/14/2025 at 10:57 AM and 12:50 PM, Director of Nursing #1 stated nursing, social work, and the business office were all responsible for making sure the bed hold policy notification was completed. When a resident was transferred to the hospital, the notice of discharge was completed which included the bed hold policy notification. Director of Nursing #1 acknowledged the notice of discharge had not been done consistently and they were working on putting together a better plan to make sure it was completed. 10 New York Codes Rules Regulations 415.3(h)(4)(iii)(a)

Based on observation, record review, and interviews during the recertification survey, the facility did not ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 1 (Resident #10) of 25 residents reviewed. Specifically, Residents #10 did not consistently attend meaningful, accommodating activities to maintain their highest practicable quality of life. This is evidenced by: The Facility's Policy and Procedure Titled, Recreational Therapy, revised 9/2024, documented the Department of Recreational Therapy was responsible for providing meaningful leisure time programs for all residents on a seven-day-per-week basis. Each resident, regardless of their physical and cognitive status, would be offered an activities program designed to meet, in accordance with the comprehensive resident assessment, his or her interests and to encourage quality of life, preservation of leisure skills and maintenance of an optimal level of psychosocial functioning among residents. The activities should be designed to promote the physical, social and mental well-being of residents and to maintain contact and interaction with the community. Residents would be encouraged to voluntarily participate in planned group and individual programs of their choice, reserving the right to refuse to participate in any program. Such programs would consist of both individual and group activities at various times of the day, evening and weekends and shall include but would not be limited to animals, children and other community agencies. Resident #10 was admitted with a diagnoses of malnutrition; anxiety (repeated episodes of sudden feelings of intense fear or terror), and atherosclerotic heart disease (buildup of fats, cholesterol and other substances in and on the artery walls). The Minimum Data Set (an assessment tool) dated 11/2024, documented a Brief Interview for Mental Status (BIMS) score of 99- unable to complete. It further documented resident could understand and be understood by others. During observations on 2/10/2025 at 12:45 PM, 2/11/2025 at 10:30 AM, and 2/12/2025 at 11:00 AM, Resident #10 was noted to be in bed, mattress wedges alongside of bed and double mattresses on floor of each side of bed. Resident arousable, but non-verbal. Resident was wearing a hospital gown. Resident had an extremely thin, frail appearance. Resident was observed all three days in same position. The lights and television were off. On 2/13/2025 at 11:00 AM resident was sitting up in bed, more alert on this day, television was on. The Comprehensive Care Plan for Social Work dated 4/29/2024 documented, Resident will continue to have ongoing needs met through next review, Resident/family will recognize need for 24-hour care, to maintain present level of functioning. Encourage resident to voice concerns, encourage participation in activities of choice, encourage interest in daily routine, Encourage participation in activities of daily living. Resident will have increased ability to cope with feelings of anxiety. Encourage activities of resident's choice in and out of their room, Offer 1:1 to provide socialization and support as needed. During an interview on 02/12/2025 at 2:22 PM, Activities Director #1 stated resident #10 was assessed upon admission of likes and dislikes for activities. The Activities Department provided activities 7 days per week, which were posted on announcement board. For those residents who were unable to attend group activities, 1:1 visits were held with resident. Activities Director #1 provided an attendance roster for group activities, but unable to provide any documentation of 1:1 activity visits for Resident #10. Activities Director #1 stated at that time 1:1 visits were not documented, but going forward would document 1:1 visits. Activities Director #1 stated the radio and television are turned on for Resident #10. During an interview on 02/13/2025 at 12:52 PM, Director of Nursing #1 stated they were informed that Activities Department had not been documenting 1:1 activities. They stated going forward each visit would be documented. 10 New York Codes, Rules, and Regulations 415.5(f)(1)h

Based on record review and interviews during a recertification and abbreviated survey (Case #sNY00368587 and NY00370779), the facility did not provide needed care and services that were resident centered and in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for 1 (Resident # 62) of 25 residents reviewed. Specifically, Resident #62 sustained a fall; 3 Certified Nurse Aides assisted resident from the floor and did not notify a nurse or report the incident, and no assessment or interventions were put into place after the fall and prior to discharge. This is evidenced by: Resident #62 was admitted to the facility with diagnoses of diabetes mellitus (a disease of inadequate control of blood levels of glucose), chronic obstructive pulmonary disease(a common lung disease causing restricted airflow and breathing problems), and end stage renal disease (the final, permanent stage of chronic kidney disease, where kidneys can no longer function on their own). The Minimum Data Set (an assessment tool) dated 10/2024, documented resident had mild cognitive impairment, could be understood, and understand others. The facility Investigate Report dated 01/10/2025 documented Resident #62 reported they fell on [DATE] prior to discharge to home on 01/02/2025. It was not report, however staff responded. During an interview on 02/18/2025 at 02:56 PM, Director of Nursing #1 stated the family of Resident #62 called Social Worker #1 on 01/06/2025 and notified them that resident had a fall prior to discharge. Director of Nursing #1 stated they were unaware of fall and at that time they initiated an investigation. They watched the video footage and identified staff who were involved that included Certified Nurse Aides #6, 7, 8 and 9, and Licensed Practical Nurse #3. Certified Nurse Aide #8 lead the other Certified Nurse Aides during the incident. Certified Nurse Aide #6 was seen entering room then left after noting other staff were in the room. They stated they obtained statements from staff involved. The video revealed Certified Nurse Aides #7, 8 and 9 entering into Resident #62's room, and Resident #62 was on floor leaning against the door frame. They placed gait belt around resident and got them up into wheelchair at the direction of Certified Nurse Aide #8. Certified Nurse Aide #8 then informed Licensed Practical Nurse #3 that Resident #62 was short of breath, but did not report resident had been on the floor. Director of Nursing #1 stated Certified Nurse Aide #8 received a final written warning and was still employed at the facility. All staff involved received education and counseling on reporting. Random care audits were now conducted. During an interview on 02/18/2025 at 03:20 PM, Certified Nurse Aide #9 stated they were walking by and heard Resident #62 yelling for help. They went into the room along with two other Certified Nurse Aides #7 and 8. Resident was on the floor sitting on buttocks resting on hands, in the doorway. Certified Nurse Aide #8 told them to get resident up from floor and put them in the wheelchair. Certified Nurse Aid #9 stayed in the room a few minutes with resident and assumed that someone had reported the incident. After they got resident up from the floor resident was a little short of breath, but there was no pain or any signs of bruising. Certified Nurse Aide #9 stated this was their first Certified Nurse Aide job. They were told during orientation that if a resident falls or was found on the floor that it should be reported to a nurse. They were not to move resident until a nurse came to assess resident. They were following the direction of Certified Nurse Aid #8 because they were more experienced aide. During an interview on 02/18/2025 at 03:33 PM, Licensed Practical Nurse #3 stated Certified Nurse #8 reported Resident #62 was short of breath, but never mentioned resident was found on the floor. They stated Resident #62 had a history of shortness of breath with an order for nebulizer treatments as needed. After they were told resident was short of breath, they went into resident's room. Resident #62 was sitting in wheelchair, but also did not mention they had fallen. Resident #62 was anxious to go home and had been for several days. They attributed the shortness of breath to be related to patient's anxiety, which they had in the past. They noted resident respirations to be 20 and administered nebulizer treatment as orders. They stated resident had good affect and was discharged the following morning. Licensed Practical Nurse #3 stated if they had known resident was found on the floor, they would have notified the Registered Nurse Supervisor. During an interview on 02/18/2025 at 03:42 PM, Social Worker #1 stated they placed a follow up call per protocol to resident who had been discharged on [DATE]. It was at that time Resident #62's wife informed them that resident was in the hospital and that they had a fall the day before discharge. Resident #62 was discharged to home with home care services. The home nurse visited resident, resident had persistent shortness of breath and home care nurse sent resident to the emergency room where resident was admitted . Resident had since been discharged back to home and was in stable condition. Social Worker #1 notified Director of Nursing of the call and reported fall incident. During an interview on 02/18/2025 at 03:58 PM, Certified Nurse Aide #8 stated they heard the sound of a fall and went into Resident #62's room and found them on the floor leaning against the bathroom door. They stated resident had history of shortness of breath and was not wearing their oxygen. They stated because patient had noted shortness of breath, they immediately got resident off the floor so that they could place their oxygen back on. Certified Nurse Aide #8 stated they thought one of the other aides notified supervisor and they did notify Licensed Practical Nurse #3 that resident was short of breath. They were not aware they could initiate the incident and accident report. Certified Nurse Aide #8 stated they were aware that when a resident was found on the floor, they are to call nurse to assess resident. They stated they were just worried about resident's shortness of breath and getting oxygen placed, so they got resident off floor as soon as possible. They acknowledge they should have called for nurse and took full responsibility. 10 New York Codes, Rules, and Regulations 415.12

Based on record review and interviews conducted during a recertification survey, the facility did not ensure that residents received proper treatment and assistive device to maintain vision abilities for 1 (Resident #19) of 1 resident reviewed. Specifically, Resident #19 did not receive an eye exam, glasses, and or a follow up ophthalmology appointment. This is evidenced by: Regulation 483.25(a) Vision and hearing, documented the facility is responsible to ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident 83.25(a)(1) In making appointments, and S483.25(a)(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices. Resident # 19 was admitted to the facility with diagnoses of diabetes type 2 (a disease of inadequate control of blood levels of glucose), diabetic retinopathy (having too much sugar in your blood can damage your retina - the part of your eye that detects light and sends signals to your brain), and significant right eye cataract (a clouding of the lens in your eye). The Minimum Data Set (an assessment tool) dated 11/2024, documented resident was cognitively intact, could be understood, and understand others. During an interview on 02/11/2025 at 11:24 AM, Resident #19 stated they had difficulty with vision. They stated they did not wear their glasses anymore because they really do not help. The glasses were really old, and they had been asking to see the eye doctor, but no appointment had been made. Ophthalmology consult dated 7/27/2020 documented diagnosis of diabetic retinopathy, significant right eye cataracts and corneal dystrophy (eye diseases that involve changes in the cornea). Recommended follow up in three months. The Comprehensive Care Plan dated 12/2024, for Resident #19 did not include a plan for vision and or glasses. During an interview on 02/14/2025 at 10:57 AM, Director of Nursing #1 stated resident was seen by ophthalmology in 2020, which was prior to their admission the facility. Resident had not been seen by ophthalmology since admission. They stated residents were seen by specialist as needed, but generally once per year. It was the responsibility of the unit manager to coordinate follow up specialist visits. During an interview on 02/14/2025 at 12:47 PM, Registered Nurse #1 stated Resident #19's Comprehensive Care Plan did not include vision and or glasses. They stated were not aware resident wore glasses and would update the care plan. 10 New York Codes, Rules, and Regulations 415.12(2)(b)

Based on observation and staff interview during the recertification survey, the facility did not provide effective housekeeping and maintenance services. Specifically, the facility did not ensure that on two (2) of 2 resident units wheelchairs and floors were clean, and resident room walls were in good repair. This is evidenced as follows: During observations on 05/05/2022 at 10:55 AM, the floors were soiled in resident rooms numbered 2, 9, 10, 12, 17, 19, 31, 32, 39, and 40, and the corridor floors were soiled next to walls and by all door thresholds on the East Unit and West Unit. Walls and/or doors were scraped in resident rooms numbered 2, 4, 9, 10, 12, 17, 19, 31, 32, 39, and 40. The wheelchairs assigned to the residents in resident rooms numbered 4, 9, and 25 were soiled with dust, dirt, and/or drip marks. During an interview on 05/05/22 at 11:35 AM, the Environmental Services Supervisor stated that the facility is aware that the floors need stripping and resealing, but the facility has been having trouble getting vendors or the needed staff to complete the work. The Environmental Services Supervisor stated that staff are supposed to notify the Environmental Service Department when wheelchairs require cleaning. During an interview on 05/05/22 at 11:35 AM, the Director of Engineering stated that the resident rooms are being remodeled to fix the wall scrapes, but COVID has slowed the process down. During an interview on 05/05/22 at 2:30 PM, the Administrator stated that the wheelchairs and floors identified will be cleaned, and the scrapped walls and doors identified will be touched up. The Administrator stated contractors have been brought in either to refinish or replace floors, but the floor work is not finished in every resident room. 483.10(i)(3); 10 NYCRR 415.5(h)(4)

Based on observation, record review, and staff interview during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety. Automatic dishwashing machines are to operate according to the manufacture specifications, and equipment and floors are to be kept clean. Specifically, the dishwashing machine final rinse water pressure was too high, and the cooking line table fan, cooking line shelf, floor below the cooking line, and the 4 fire extinguishers in the main kitchen and microwave ovens, refrigerators, and floors on three (3) of 3 resident unit kitchenettes were soiled with food particles, grime, or dirt. This is evidenced as follows: During an inspection of the main kitchen on 05/02/2022 at 10:23 AM, the automatic dishwashing machine final rinse water pressure was 44 pounds per square inch (psi); the manufacturer's instructions require the final rinse water pressure is to be 20 psi. The cooking line table fan, cooking line shelf, floor below the cooking line, and the 4 fire extinguishers were soiled with food particles or grime. During an inspection of the resident unit kitchenettes on 05/03/2022 at 9:44 AM, the microwave ovens and refrigerators were soiled with food particles and the floors were soiled with dirt. During an interview on 05/02/2022 at 4:04 PM and again on 05/05/22 at 12:27 PM, the Nutritional Services General Manager stated that the dishwashing machine manufacturer final rinse water pressure was too high but can be adjusted. The Nutritional Services/EVS General Manager stated that the resident unit microwave ovens, refrigerators, and floors will be cleaned. During an interview on 05/05/2022 at 2:45 PM, the Administrator stated that the dishwashing machine water pressure will be adjusted, and the soiled areas identified will be cleaned. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.110, 14-113(a), 14-1.170

Based on observation, record review, and interviews during a recertification survey dated 05/02/2022 through 05/06/2022, the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident consistent with the resident rights and that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 3 (Resident #'s 9, 19, and #46) of 15 residents reviewed. Specifically, for Resident #9, the facility did not ensure personalized interventions were included in the dementia care plan, for Resident #19, the facility did not ensure personalized interventions were included in the depression/anxiety care plan, and for Resident #46, the facility did not ensure a care plan was developed for discharge. This was evidenced by: The Policy and Procedure (P&P) titled Interdisciplinary Care Plan Committee dated 04/2017 documented, each discipline along with the resident/family member will be responsible for identifying a problem/concern if any exist for their discipline and identifying an intervention for any problem/concern that is relevant to their discipline and can assist in achieving a goal for each resident. Resident #9: Resident #9 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's note dated 04/18/2022 documented; patient being seen for [CONDITION(S)] medication evaluation and to assess behavior. The resident is being evaluated for the [MEDICATION(S)] (treats [CONDITION(S)], [CONDITION(S)], and depression) nightly therapy. Resident #9 continues to do well with not as many behaviors although she still does have behaviors which include kicking at staff and other residents and pushing tables and other objects. The resident has some occasional verbal outbursts, but not many. The Comprehensive Care Plan (CCP) titled Dementia dated 02/07/2022 documented: I have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Certified Nurse Aide (CNA) Care Card (used by the CNAs to know what care the resident required) dated 05/03/2022, documented under the title behaviors; resident can be verbally abusive, hits and shoves during care, unpredictable disruptive behavior, noisy/screams, sometimes attempts to kick at staff and push things out of the way with her feet when independently wheels in scoot chair. The CCP did not include documentation of personalized interventions for staff to utilize when caring for the resident when the resident exhibits the behaviors described on the CNA Care Card. Resident #19: Resident #19 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's note dated 05/03/2022 documented, patient seen today for annual evaluation and behavioral/[CONDITION(S)] medication evaluation. Nursing staff report that patient has had increased episodes of yelling and accusatory behavior with foul mood. Patient had [MEDICATION(S)] reduced from every 12 hours to just at bedtime greater than two months ago. Patient also continues to be on [MEDICATION(S)] (antianxiety) twice daily as this helps with her anxiety. The Comprehensive Care Plan (CCP) titled Depression/Anxiety dated 02/14/2022 documented; I have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no personalized interventions documented for staff to utilize when caring for the resident. Resident #46: Resident #46 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Social Work Note dated 04/05/2022 documented, called daughter to schedule a meeting to discuss discharge planning. The resident's daughter said they would be in one day this week but was not sure when. The document titled Discharge Documentation dated 04/15/2022, documented the discharge date of [DATE] at 1:30 PM. Discharge destination was to be home with a family member. A review of the CCP and a request for the Discharge Planning CCP made on 05/04/2022, revealed there was no CCP for discharge planning. During an interview on 05/06/2022 at 10:45 AM, Registered Nurse Manager #2 stated the nurse managers write the nursing care plans, the other disciplines do their own. The things that we are trying with Resident #9 to calm were a warm blanket, and lollipops work well, Resident #19 likes sweets, these should be on the care plan. The personal interventions should be on the care plan. The interventions for behaviors should also be on the certified nurse aide (CNA) Kardex. Resident #46 was here for short term rehab. Part of the admission process is the question were they short term or long term. There should have been a discharge care plan done by Social Work for Resident #46. During an interview on 05/06/2022 at 11:06 AM, the Administrator (Adm) stated Resident #46 was a planned discharge from the beginning of the stay. Prior to the admission Resident #46 was living alone, across the street from the daughter. We saw the resident would need more care after discharge and spoke with the daughter about it. The Adm stated they were covering the Social Work role until the new Social Work started but thought they had done a care plan for discharge. During an interview on 05/06/2022 at 12:01 PM, the Director of Nursing (DON) stated the Registered Nurse Managers review the care plans and the DON tries to help review them. The care plans are reviewed at the care plan meetings. The care plans interventions for Resident #9 and Resident #19 should have been more detailed. 10 NYCRR 415.11(c)(1)

Based on record review and interviews during a recertification survey from 5/2/2022 through 5/6/2022, the facility did not ensure that a resident who required [CONDITION(S)] received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (Resident #51) of 1 resident reviewed for [CONDITION(S)]. Specifically, for Resident #51, the facility did not ensure there was a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This is evidenced by: Resident #51: Resident #51 was admitted with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 4/8/2022, documented the resident was cognitively intact, could understand others and could make self understood. The Policy and Procedure (P&P) titled [CONDITION(S)] Care of Resident dated 2/2018, documented the resident must have written provider's orders stating facility name, nephrology doctor (MD) and frequency of [CONDITION(S)] treatment. Communication would be maintained with the communication log book that would be sent with the transfer for treatment. The P&P documented pre-[CONDITION(S)], to perform and document a baseline resident assessment. Obtain pre-treatment vital signs and post-[CONDITION(S)], the RN would do a full assessment upon [CONDITION(S)] return including vital signs every shift x 3, the RN was to check the catheter site every shift x 24 hours, and/or inspect access graft/fistula to assess for bleeding. The Comprehensive Care Plan for [CONDITION(S)] dated 4/19/2022, documented the resident was admitted with [CONDITION(S)] and was currently receiving [CONDITION(S)] 3x a week. The interventions included: 1. Medications as ordered, 2. Monitor labs as ordered, 3. Monitor for s/s of acute [CONDITION(S)] such as anorexia, confusion, disorientation, muscle twitching, lethargy, and [CONDITION(S)], 4. Monitor output as ordered, and 5. Monitor for [CONDITION(S)] disequilibrium syndrome due to rapid shift of fluid and electrolyte levels. The physician orders did not include an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During a record review from 4/20/2022 to 5/3/2022, the medical record did not include documentation that: -a Registered Nurse consistently checked the catheter site every shift x 24 hours post [CONDITION(S)] and/or consistently inspected the graft/fistula in accordance with the facility policy, -pre [CONDITION(S)] assessments were completed, and -there was ongoing communication from the facility to the [CONDITION(S)] center in the medical record. The [CONDITION(S)] Communication Book did not include documentation from the nursing home to the [CONDITION(S)] center. During an interview on 5/5/2022 at 11:07 AM, Licensed Practical Nurse (LPN) #2 stated the LPNs obtained a set of vital signs when the resident returned from [CONDITION(S)]. The vital signs were documented in the progress notes and the RNs would also document vital signs under the Vital Sign tab in the electronic medical record. The LPN stated the [CONDITION(S)] book was for the [CONDITION(S)] center to document the resident's pre and post vital signs. The [CONDITION(S)] book was kept at the nurses' station for the nursing staff to review upon the resident's return from [CONDITION(S)]. The facility staff did not document in the [CONDITION(S)] book. Any communication the facility had with the [CONDITION(S)] center was done by phone. The LPN stated prior to sending the resident to [CONDITION(S)], the staff did not take vital signs because the [CONDITION(S)] center obtained vitals before and after [CONDITION(S)]. During an interview on 5/6/2022 at 12:01 PM, the Director of Nursing (DON) reviewed the resident's physician orders and stated there was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated the order for [CONDITION(S)] should include the days of the week the resident went to [CONDITION(S)], the name of the [CONDITION(S)] center, and the time of the resident's [CONDITION(S)]. The DON stated fistula monitoring would be a nursing protocol. The assessment of the fistula/graft site should be done, but the DON was not sure what the policy meant when it documented to check the catheter site every shift x 24 hours. The DON stated the [CONDITION(S)] care plan for Resident #51 should have been more detailed. The RNUMs were to review the care plans and the DON also tried to help review care plans. Care plans were also reviewed in the care plan meetings. The DON stated they had not seen nursing do pre-assessments prior to a resident going to [CONDITION(S)]. The DON stated a lot of the communication with [CONDITION(S)] was done on the phone. The resident's [CONDITION(S)] needs were coordinated between the facility, the [CONDITION(S)] center, and the physicians but was not documented in the medical record. During an interview on 5/6/2022 at 1:17 PM, the Registered Nurse Unit Manager (RNUM) #1 stated the physician orders should include an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The RNUM stated they relied on the [CONDITION(S)] center to do the pre [CONDITION(S)] assessment. The facility staff did not complete a pre [CONDITION(S)] assessment prior to sending the resident to [CONDITION(S)]. The RNUM stated the nursing home staff did not write in the [CONDITION(S)] book to communicate with the [CONDITION(S)] center. If there was something abnormal going on with the resident, they would call the [CONDITION(S)] center to let them know. The RNUM stated they were struggling with care plans, and it was very hard to make them resident specific. 10NYCRR 415.12

Based on observation, record review and interviews during the recertification survey and abbreviated survey (Case #NY 316) from 5/2/2022 through 5/6/2022, the facility did not maintain medical records in accordance with accepted professional standards and practices that were accurately documented and complete for 2 (Resident #'s 36 and #368) of 2 residents reviewed for catheter use. Specifically, for Resident #36, who had an indwelling catheter and history of urinary tract infections (UTIs), the facility did not ensure the Comprehensive Care Plan for an indwelling catheter's interventions for catheter care every shift, and that urinary catheter assessments were consistently documented in the medical record. Additionally, for Resident #36, the medical record did not include documentation that the resident was experiencing pain and discomfort related to their indwelling catheter on 5/4/2022; and for Resident #368, who had an indwelling catheter and history of UTIs, the facility did not ensure catheter care was documented every shift and urinary catheter assessments were consistently documented in the medical record. Additionally, for Resident #368, the medical record did not include documentation the provider was notified when the resident's catheter, ordered to be changed on 12/25/2021, was not changed until 12/29/2021, did not ensure the resident's medical record did not include inaccurate documentation on 12/28/2021 when it was documented the resident was on an antibiotic for a [CONDITION(S)], and did not ensure the medical record included documentation the provider was notified when Resident #368 was complaining of pain in the bladder area and had a small amount of urinary output after their catheter was changed on 12/30/2021. This is evidenced by: The Policy and Procedure (P&P) titled Foley Catheter Irrigation dated 10/2010 documented catheters would be irrigated by the nursing staff as ordered by the physician and staff were to document tolerance, color, and any abnormalities in the nurses notes and notify the physician of any signs or symptoms of infection or decreased urine flow. The P&P titled Urinary Catheter Care dated 2/2019, catheter care would be delivered by the Certified Nursing Assistant (CNA) once a shift and as necessary for bowel incontinence to prevent urinary tract infections and to promote optimal urine flow. The Foley catheter bag was to be emptied at 5 AM, 1 PM, and 9 PM and to report the amount to the nurse. The nurse was to be immediately notified of any blood, sediment, mucous in urine or any decrease flow of urine. The CNAs were to report all findings to the nurse and record on the Team Report Sheet. The P&Ps did not address the nurses' responsibility to complete the Assess/Manage Urinary Catheter section in the medical record. Resident #36: Resident #36 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 3/8/2022, documented the resident had moderately impaired cognition, could usually understand others and could make self understood. During an observation on 5/4/2022 at 10:33 AM, Resident #36 was crying out and moaning. The resident stated they could not urinate, and the pressure hurt so bad they could not stand it. The pain was unbearable. Urine was not observed in the tubing of the catheter. The resident stated the nurses were aware but did not know of anything being done. The Comprehensive Care Plan (CCP) for ESBL (extended spectrum beta-lactamase- an enzyme found in some strains of bacteria that can be found in the urinary tract), dated 4/5/2022, documented the resident had been diagnosed with colonized ESBL in their urine. Care plan approaches included: contact precautions to prevent the spread of infection, monitor for temp elevation and treat accordingly, and to notify the physician of any concerns. The CCP for Indwelling Foley, dated 3/13/2022 documented the resident had a Foley catheter to related to outlet obstruction and urinary retention. Care plan approaches included Catheter care every shift; to note amount, color, consistency, and odor and report abnormalities; and to change the urinary catheter per facility policy and/or physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility did not provide a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] A Nursing Assistant note dated 4/30/2022, documented the resident's Foley was leaking and the staff member was unable to obtain an output. A review of nurses' progress notes from 4/29/2022 through 5/4/22 did not include documentation that the resident's Foley was leaking on 4/30/2022 and did not include documentation of the resident's complaint of feeling pressure and pain related to feeling the inability to urinate on 5/4/2022. A review of Assess/Manage Urinary Catheter in the medical record from 4/29/2022 through 5/3/2022, did not include an assessment on 2 (4/30/2022 and 5/1/2022) of 5 days. An Assess/Manage Urinary Catheter dated 5/4/22 at 1:45 PM, documented the resident's Foley catheter was changed at 11:30 AM. A review of Certified Nursing Assistant (CNA) documentation from 4/29/2022 through 5/3/2022, did not include documentation that Indwelling Urinary Catheter Care was provided on 6 of 15 shifts. During an observation and interview on 5/4/2022 at 10:41 AM, Registered Nurse Unit Manager (RNUM) #2 went into Resident #36's room with the Surveyor. The resident was crying out and stating they were in pain due to feeling pressure and feeling like they were unable to urinate. The RNUM checked the Foley bag and stated there was very little urine in the bag, but stated they did not know when the bag was last emptied. RNUM #2 stated the Foley needed to be flushed and they would have a nurse flush it. During an interview on 5/6/2022 at 10:21 AM, CNA #5 stated the CNAs emptied the Foley catheter bags and measured the output. The CNA stated Foley care was completed 2 times a shift but documented once a shift. The CNAs were to report any changes to the nurse. Changes would include low urinary output, blood in the urine or blood or irritation around the catheter site. During an interview on 5/6/2022 at 10:29 AM, CNA #4 stated Foley care was done once every shift by the CNAs but did not think Foley care was documented in the medical record. The CNA stated catheter care was part of the resident's routine care. The CNAs also emptied and measured the urine output about 2 hours prior to end of the shift and as needed. The CNAs verbally told the nurses the resident's output and documented it in the medical record. The CNAs were to report it to the nurse if there was a small amount of urine in the bag, if the urine was dark in color, had a strong odor, or they noticed blood or irritation. During an interview on 5/6/2022 at 12:39 PM, RNUM #1 stated Assess/Manage Urinary Catheter in the medical record was auto populated by the order for the Foley catheter. RNUM #1 was unsure how often the nurses were supposed to document under the Assess/Manage Urinary Catheter section in the medical record. During an interview on 5/6/2022 at 1:34 PM, the Director of Nursing (DON) stated Foley catheters were emptied by CNAs or LPNs and the CNAs were responsible for catheter care every shift and were to document the care every shift. The CNAs would report any issues to the nurses. The DON was currently responsible for the monitoring of the care documented but that responsibility would eventually be passed down to Unit Managers to oversee the care was being documented. The DON stated it was an area to work on. The DON stated they tried to monitor the care and documentation the best they could. The DON stated Assess/Manage Urinary Catheter could be documented by any of the nurses and should be completed but was not sure of the frequency it should be documented. The DON stated Resident #36 sometimes had issues with their Foley and it would have to be replaced or flushed. The nurses should document in the nurses note if they had to flush the Foley or if there were any issues with the Foley. During a subsequent interview on 5/6/2022 at 1:43 PM, RNUM #2 stated they did not know what the outcome was with Resident #36's Foley on 5/4/2022. RNUM #2 stated they did not know if the catheter was kinked or had to be flushed. RNUM #2 stated they had another nurse take care of the resident's Foley on 5/4/2022 and they did not see anything documented under nursing notes from that date. RNUM #2 stated the nurse should have written a note about what was done with the Foley on 5/4/2022. The nurse had not reported back to the RNUM with what the issue was on the morning on 5/4/2022. RNUM #2 stated the CNAs provided catheter care and documented catheter care under Activities of Daily Living. The CNAs also documented urinary intake and output. The RNUM stated Resident #36 had ESBL in their urine and the nurses were responsible for changing the resident's catheter, flushing the catheter, and documenting any issues related to the catheter. The RNUM reviewed the medical record and stated they did not know the frequency for documenting under the heading Assess/Manage Urinary Catheter. The RNUM stated it was an area where the nurses were to document about the resident's catheter. Resident #368: Resident #368 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 11/9/2021 documented the resident had severely impaired cognition, could usually understand others and could make self understood. The Comprehensive Care Plan (CCP) for Urinary Tract Infection ([CONDITION(S)]) dated 11/10/2021, documented the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Care plan approaches included: to monitor for complaint of burning, frequency, painful urination, color, and amount of voiding; administer medications as ordered and monitor for temp elevation and treat accordingly. The CCP for Foley Catheter dated 11/16/2021, documented the resident had a Foley catheter due to urinary retention. Care plan approaches included: Monthly catheter changes and antibiotic prior to each scheduled medication, catheter care every shift, noted amount, color, consistency, odor and report abnormalities, and leg bag in place when out of bed. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was completed on 12/29/2021. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Assess/Manage Urinary Catheter from 12/25/2021 to 12/31/2021 did not included documentation on 5 (12/26/2021, 12/27/2021, 12/28/2021, 12/29/2022 and 12/31/2022) of the 7 days. A review of Certified Nursing Assistant (CNA) documentation from 12/25/2021 through 12/31/2021, did not include documentation Indwelling Urinary Catheter Care was provided on 13 of 21 shifts. A review of progress notes dated 12/25/2021 to 12/31/2021 documented: -12/25/2021 at 10:09 PM, the resident was very combative and aggressive. Provider notified and a new order for [MEDICATION(S)] (antipsychotic) 10 milligrams (mg) Intramuscular (IM). Foley to be changed using Urojet (local anesthetic agent) and Urinalysis (UA) and Culture and Sensitivity (C&S) to be obtained and sent to lab. -12/27/2021 at 4:53 AM, the resident was very restless and wandering around. The nurse was unable to change the resident's Foley catheter due to the resident not going to bed. - 12/28/2021 at 5:21 AM, UA (urine analysis) C&S (Culture and Sensitivity) sent. Resident is on antibiotic for the [CONDITION(S)]. Note in doctor's (MD) book to look at results. - 12/28/2021 at 2:56 PM, the provider was on the unit, reviewed chart, reviewed clinical data, examined resident. The resident will start on long-acting pain medication. The provider did not document the resident's exam, the chart review, or the clinical data review in the resident's medical record. -12/30/2021 at 10:07 PM, Resident #368 complained of pain in bladder area. There was no urine output and irrigated without success. The Foley was removed with a small (sm) clot in the tip. The Registered Nurse Supervisor (RNS) attempted another #18 French coude (catheter specifically designed to maneuver around obstructions or blockages in the urethra) without any urine returns. The RNS inserted a #16 French with 5 cubic centimeters (cc) balloon and obtained 10 cc of clear yellow urine. A small amount of urine was coming thru but the resident continued to complain of the need to urinate. They attempted to administer the antibiotic prior to the Foley change but the resident spit them out. [MEDICATION(S)] 5 mg IM was administered due to agitation and combativeness. The note documented continuing to monitor the resident for output and agitation. -12/31/2021 at 10:58 PM, the nurse was called to assess the resident as resident was not themself. Upon entering the room, the resident had their eyes closed and was shaky all over. The resident was nonresponsive to verbal or tactile stimulus. The catheter was draining clear yellow urine. The Nurse Practitioner (NP) was aware. The resident will be monitored through the night and will call the NP if the resident further deteriorates. During an interview on 5/6/2022 at 10:21 AM, CNA #5 stated the CNAs emptied the Foley catheter bags and measured the output. The CNA stated Foley care was completed 2 times a shift but documented once a shift. The CNAs were to report any changes to the nurse. Changes would include low urinary output, blood in the urine or blood or irritation around the catheter site. CNA #5 was not aware if Resident #36 had any issues with their catheter. During an interview on 5/6/2022 at 10:29 AM, CNA #4 stated Foley care was done once every shift by the CNAs but did not think Foley care was documented in the medical record. The CNA stated catheter care was part of the resident's routine care. The CNAs also emptied and measured the urine output about 2 hours prior to end of the shift and as needed. The CNAs told verbally the nurses the resident's output and documented it in the medical record. The CNAs were to report it to the nurse if there was a small amount of urine in the bag, if the urine was dark in color, had a strong odor, or they noticed blood or irritation. CNA #4 stated Resident #368 would pull on their catheter and pull it out. The resident wore a leg bag when they were out of bed to help prevent the resident from pulling on the catheter. During an interview on 5/6/2022 at 10:51 AM, Licensed Practical Nurse (LPN) #1 stated prior to going to the hospital on 1/1/2022, the resident was receiving an antibiotic for their toe. The resident was not receiving an antibiotic for a [CONDITION(S)], The LPN stated the LPN did not document daily catheter checks for residents with catheters. They documented in the medical record if there was an issue with a resident's catheter, if they had to flush the catheter, or if the catheter had to be changed. During an interview on 5/6/2022 at 11:46 AM, RNS #2 stated Foley care was provided by the CNAs once a shift and the RNS was not sure if the CNA documented that care. The RNS stated they would look at a resident's Foley if an issue was brought to their attention. They would notify the provider. The progress note from 12/30/2021 was reviewed with RNS #2. RNS #2 stated they would have notified the PA right then and they would have also notified the PA if they could not change the resident's catheter on 12/25/2021. In both situations, on 12/25/2021 and 12/30/2021, the RNS stated they would have documented the response of the PA. During an interview on 5/6/2022 at 11:59 AM, RNS #1 stated they notified the provider only if there was an issue with a resident that did not resolve during their shift. The progress note from 12/30/2021 was reviewed with RNS #1 and RNS #1 stated they normally would have called the physician and documented that they called the physician. RNS#1 stated Resident #368 prone to UTIs and had conversations with the physician that the resident's UTIs were becoming more and more resistant to antibiotics. The conversations were not necessarily documented in the medical record. The RNS stated the CNAs emptied the Foley bags, measured the output, and notified the nurse. The RNS stated after a UA C&S was obtained, they would notify the physician and then the physician would decide what antibiotic would work. The RNS stated Resident #368 had constant UTIs. The RNS stated that the Assess/Manage Urinary Catheter in the medical record was done every shift and documented in nursing notes. During an interview on 5/6/2022 at 12:39 PM, RNUM #1 stated the nurse should notify the provider if they were unable to change Foley on 12/25/2021. RNUM #1 stated the Assess/Manage Urinary Catheter in the medical record was auto populated by the order for the Foley catheter. RNUM #1 was unsure how often the nurses were supposed to document under the Assess/Manage Urinary Catheter section in the medical record. RNUM #1 reviewed the medical record and stated they did not see that the Physician Assistant (PA) documented their visit with the Resident on 12/28/2021 and the PA should have documented their exam of the resident. RNUM #1 stated the resident was not on an antibiotic for a [CONDITION(S)] as documented on 12/28/2021. The RNUM #1 stated the provider should have been notified and documented by the nurses when catheter was unable to be changed on 12/25/2021 and on 12/30/2021 when there was difficulty with the catheter. During an interview on 5/6/2022 at 1:11 PM, the Director of Nursing (DON) stated Foley catheters were emptied by CNAs or LPNs and the CNAs were responsible for catheter care every shift. The CNAs were to document the care every shift. The CNAs would report any issues to the nurses. The DON was currently responsible for the monitoring of the care documented but that responsibility would eventually be passed down to unit managers to oversee the care was being documented. The DON stated it was an area to work on. The DON stated the nursing staff should have notified the provider if they were unable to change the resident's Foley in 12/25/2021. The DON stated the resident was not on an antibiotic for a [CONDITION(S)] as documented in the nursing note dated 12/28/2021. The DON stated the only antibiotics ordered at that time were for the resident's toe and for the resident's monthly catheter changes. The DON stated the PA should have a corresponding note in the medical record to the nursing note on 12/28/2021 that documented the resident was examined by that provider. The DON stated the provider should have been notified on 12/30/2021 based on the nursing progress note. The DON stated normally nursing would call the physician to notify them of any changes or concerns. The DON stated there should also be documentation if the resident's urine came back and the decision whether to treat or not with an antibiotic. The DON stated there may be verbal discussions with the provider, but those discussions should also be documented. The RNUM reviewed the medical record and stated they did not know the frequency for documenting under the heading Assess/Manage Urinary Catheter. The RNUM stated it was an area where the nurses were to document about the resident's catheter. The DON stated they saw there was a lack of documentation in the resident's medical record. During an interview on 5/6/2022 at 2:03 PM, PA #1 stated if they saw a resident, they documented their visit in the medical record. The PA stated there should have been a note written by them if they examined Resident #368 on 12/28/2021. 10NYCRR415.22(c)

Based on medical record review and staff interviews conducted during a complaint investigation (Case # NY 616), it was determined that for one (Resident # 1) of one resident reviewed, the facility did not notify the resident's physician (MD #1) in a timely manner when the resident had increased swelling, weeping and the presence of blisters on her left arm. Specifically, on 12/25/11 the resident was noted to have an increase in swelling of the left arm and hand and the start of weeping from the left upper arm and a decrease in mentation. This was a significant change in condition for the resident. The MD was not notified until approximately 2:00am on 12/26/11. This resulted in actual harm that is not immediate jeopardy. This is evidenced by the following: Resident # 1 The resident was admitted to the facility for rehabilitation on 11/30/11 with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] assessed the resident was cognitively intact. Nurses notes dated 12/26/11 documented Resident #1's progress; at 2:06am the registered nurse supervisor (RNS) documented that she was called to assess the resident and found the resident's left arm and hand with 4+ [MEDICAL CONDITION], skin taught and shiny with a baseball size area to left antecubital space that is black and blue and fluid filled and a smaller fluid filled area slightly above the antecubital space that is also black and blue. The left upper arm area towards the shoulder was also black and blue; at 3:30am the RNS documented that radiology was in to do an ultrasound (U/S) and the resident was yelling out in severe pain. An order was obtained to send Resident #1 to the emergency department (ED). At 3:58am the RNS documented the MD was called and advised that staff were unable to obtain a blood pressure (BP) and the resident had mottling (blotchy discoloring of the skin indicating decreased oxygen to the area ). An order was obtained to cancel ED and give [MEDICATION NAME] 4mg q2h prn (every 2 hours as needed) for pain; at 4:20am the family is notified of change in resident's condition and at 4:54 am Resident #1 was without an apical pulse for 5 minutes. Time of death was documented as 4:54am. In a second nurses note dated and timed for 12/26/11 at 1:58pm, written by a registered nurse (RN#1) and called " Late entry from 12/25/11" registered nurse (RN#1) documented that report was received from the 11:00pm-7:00pm nurse that Resident #1's left arm was extremely [MEDICAL CONDITION]. Upon assessment at 8:00am the left arm and hand were [MEDICAL CONDITION], skin was taught, there was no drainage, and no blisters were noted. At 2:30pm, RN#1 documented: called to resident's room as there was drainage noted under left arm on the sheets. No blisters noted but upper left arm weeping yellowish drainage. Report was given to the 3:00 pm-11:00pm staff that left arm had weeping [MEDICAL CONDITION] and pads were placed under the arm for drainage. During an interview on 1/10/12 at approximately 4:00pm a registered nurse (RN#1) stated that she worked the day shift (7:00am to 3:00pm) on 12/25/11 and was told in shift -to-shift report at 7:00am that the resident's arm had increased swelling. RN#1 checked on the resident at approximately 8:30am and noted the resident's arm was more swollen than she had seen it in the past and she elevated the arm on a pillow. She checked on the resident again around noontime and the residents' arm was more swollen then in the morning. RN# 1 recalled hearing the resident moaning on occasion that day and also calling out for her Aunt Mary. When the resident was asked, she denied having pain. RN #1 stated that after one of the CNA's reported to her that the resident's arm was draining or weeping at approximately 2:30pm, she went to check and noted the arm was now more swollen than at noon and it was weeping primarily from the back of the resident's upper arm. She placed an incontinence pad under the arm to absorb the drainage and then went to give report to the registered nurse (RN#2) and the licensed practical nurse (LPN#1) coming on duty for 3:00pm - 11:00pm shift. RN #1 stated that she told RN#2 and LPN#1 that the swelling in the resident's arm had increased and that it was draining. RN #1 stated she did not call the doctor about the increased swelling and drainage because she thought she would wait until the next morning. During an interview on 1/10/12 at 4:30pm LPN #1 stated that she received report on 12/25/11 at approximately 3:00pm from RN#1 and was told that Resident # 1 had a lot of swelling in her arm and that her arm and fingers were also swollen. She checked on the resident around dinner time but stated she did not remove the resident's long sleeve shirt. She looked at her lower arm and hand and they were very puffy but she did not see the resident's upper arm. LPN #1 recalled the resident didn't eat dinner and that she was much sleepier than usual and was sleeping through dinner. LPN #1 stated she remembered hearing the resident moaning on and off throughout the evening. When questioned, LPN # 1 stated she did not call the doctor that evening to report Resident # 1's condition but she thought she heard someone say that they would call the doctor the next day. LPN #1 stated she should have checked on the resident more often that night and should have talked to the nurse about her condition. During an interview on 1/24/12 at approximately 3:00pm, a registered nurse (RN#2) stated that she had worked 3:00pm - 11:00pm on 12/25/11 and was told in report that Resident # 1's arm was more swollen and was weeping and the day shift nurse had put an incontinence pad under the arm. She recalled that several times during the night she thought about going to look at the resident's arm but she was always distracted by something. RN#2 stated she did not see the resident's arm throughout her shift and when she gave report to the night shift nurses at 11:00pm she did not mention that the resident's arm was swollen and weeping and she did not call the doctor that night to describe the resident's arm. RN#2 stated that on that night no one told her that the resident had a change in mentation. During an interview on 1/10/12 at approximately 2:30pm a certified nursing assistant (CNA #1) stated that she was assigned to care for Resident # 1 on 12/25/11 from 3pm to 11:00pm. She recalled that when she came on duty that day she was told by the day shift CNA that the resident's arm was very swollen, was weeping and that an incontinence pad had been placed under the resident's arm to absorb the drainage. CNA # 1 stated the resident' arm had been swollen for about a week but on the evening of 12/25/11 the swelling had increased and " Her hand was really, really swollen. It was huge, shiny. It was purple. It was a lot more swollen than the night before." CNA #1 recalled that sometime after dinner on 12/25/11 she had asked RN#2 to look at the resident's arm because she was concerned about the arm and the resident. CNA #1 stated that in addition to the increased swelling, Resident # 1 was not as alert (on 12/25/11) as she had been the evening before. On Christmas Eve the resident could answer questions. Christmas night she wasn't answering questions; she wasn't really talking to me and she was moaning a lot and calling out for her mother. CNA # 1 stated that when she made rounds at the end of her shift she told the night-shift CNA that she was sure when she came back to work in two days that Resident # 1 wouldn't still be there. The CNA stated, I could tell that she wasn' t doing well and probably wasn't going to make it. During an interview on 1/5/12 at approximately 4:45pm, a registered nurse supervisor (RNS) stated that on 12/26/11 at around 2:00am she was called by an LPN (LPN#2) and asked to look at Resident #1's arm. The RNS had not been told in her report about the condition of the resident's arm and there was no mention of the resident's arm on the twenty-four hour report sheet. The RNS stated that when she arrived at the room she saw that the resident's arm and hand were extremely [MEDICAL CONDITION], hard and shiny and her upper arm was ecchymotic up to the shoulder. Just above the antecubital space, there was a large fluid filled blister and two smaller fluid filled blisters above that. The RNS immediately called the resident's doctor (MD#1) who was very upset that he was just now hearing about the condition of the residents' arm. During an interview on 1/12/12 at approximately 9:45am, Resident # 1's physician (MD #1) stated that he was called during the night around 2:00am on 12/26 and told the resident had increased swelling, ecchymosis and blisters to her left arm. He recalled the resident had swelling of the extremity earlier in her stay but that it had actually improved. He did not know when the swelling had returned. MD#1 stated that yes, he was upset and concerned that he had not been called earlier and made aware of the condition of the resident's arm. MD # 1 stated that when he was called that night (12/26/11) he asked the nurse to get an ultrasound (U/S), thinking perhaps there was a blood clot. MD # 1 stated the technician attempted the U/S but was unable to give me any good information and the nurse told me the resident was deteriorating and so I gave an order to send the resident over to the ED. The nurse called back a short time later and told me that the resident had mottling of the lower extremities and felt the resident was actively dying. At that time I gave orders for [MEDICATION NAME] and to keep her comfortable. Later that morning I received another call and was told the resident had passed away. MD # 1 stated he could not recall having a conversation with the nurse (RNS) during that night regarding the resident's advanced directives. He stated if I had known at the time that she wanted to be resuscitated but was a "do not intubate", I would have sent her to the ED. I would have honored her wishes. 10NYCRR 415.3(e)(2)(ii)(b)

Based on medical record review and staff interviews during a complaint investigation (Case # NY 616), it was determined that the facility did not provide the necessary care and services for one (Resident #1) of one resident reviewed. Specifically, the facility did not ensure that Resident #1 was treated in a timely manner when on [DATE] it was noted that the resident had developed drainage and increased swelling of her left arm and hand; the resident was not closely monitored after being given [MEDICATION NAME] to make her comfortable and the resident did not receive cardio [MEDICAL CONDITION] resuscitation (CPR) when she was noted to be without respirations and heart rate. This resulted in actual harm that was not immediate jeopardy. The following evidence supports the statement of deficiency: Resident # 1 The resident was admitted to the facility for rehabilitation on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] assessed the resident was cognitively intact. A facility policy dated [DATE] with the most recent revision being [DATE] instructed that CPR was to be done by nursing facility personnel who are trained in basic life support (BLS) and that all Registered Nurses's (RN) and Licensed Practical Nurses's (LPN)are required to maintain their BLS certification. A medical record form titled " Advanced Directives, " dated [DATE], documented that Resident #1 is a " do not intubate" (DNI- the resident should have CPR but do not intubate). Nurse's notes dated [DATE] documented Resident #1's progress; at 2:06am the registered nurse supervisor (RNS) documented that she was called to assess the resident and found the resident's left arm and hand with 4+ [MEDICAL CONDITION], skin was taught and shiny with a baseball size area to left antecubital space that was black and blue and fluid filled and a smaller fluid filled area slightly above the antecubital space that was also black and blue. The left upper arm area towards the shoulder was also black and blue. At 3:30am the RNS documented that radiology was in to do an ultrasound (U/S) and the resident was yelling out in severe pain. An order was obtained to send Resident #1 to the emergency department (ED). At 3:58am the RNS documented the physician (MD) was called and advised that staff were unable to obtain a blood pressure (BP) and the resident had mottling (blotchy discoloring of the skin indicating decreased oxygen to the area). An order was obtained to cancel the transfer to the ED and give [MEDICATION NAME] 4mg q2h prn (every 2 hours as needed) for pain; at 4:20am the family was notified of the change in the residents' condition and at 4:54 am Resident #1 was without an apical pulse for 5 minutes. Time of death was documented as 4:54am. A nurse's note dated [DATE] at 1:58pm, written by a registered nurse (RN#1) and called " Late entry from [DATE] " documented that Resident #1's left arm was extremely [MEDICAL CONDITION]. Upon assessment at 8:00 am the left arm and hand were [MEDICAL CONDITION], and skin was taught. There was no drainage, and no blisters were noted. At 2:30pm RN#1 was called to the resident's room as there was drainage noted under lthe eft arm on the sheets. No blisters were noted but the upper left arm was weeping yellowish drainage. Report was given to 3:00pm-11:00pm staff that left arm had weeping [MEDICAL CONDITION] and pads were placed under the arm for drainage. During an interview on [DATE] at approximately 4:00pm RN#1 stated that she worked the day shift (7:00am to 3:00pm) on [DATE] and was told in shift -to-shift report at 7:00am that the resident's arm had increased swelling. RN#1 checked on the resident at approximately 8:30am and noted the resident's arm was more swollen than she had seen it in the past and she elevated the arm on a pillow. She checked on the resident again around noontime and the resident's arm was more swollen then in the morning. RN# 1 recalled hearing the resident moaning on occasion that day and also calling out for her Aunt Mary. When the resident was asked, she denied having pain. RN #1 stated that after one of the CNA's reported to her that the resident's arm was draining or weeping at approximately 2:30pm, she went to check and noted the arm was now more swollen than at noon and it was weeping primarily from the back of the resident's upper arm. She placed an incontinence pad under the arm to absorb the drainage and then went to give report to the registered nurse (RN#2) and the licensed practical nurse (LPN#1) coming on duty for the 3:00pm - 11:00pm shift. RN #1 stated that she told RN#2 and LPN#1 that the swelling in the resident's arm had increased and that the arm was draining. RN #1 stated she did not call the doctor about the increased swelling and drainage because she thought she would wait until the next morning. During an interview on [DATE] at 4:30pm LPN #1 stated that she received report on [DATE] at approximately 3:00pm from RN#1 and was told that Resident # 1 had a lot of swelling in her arm and that her arm and fingers were also swollen. She checked on the resident around dinner time but stated she did not remove the resident's long sleeve shirt. She looked at her lower arm and hand and they were very puffy but she did not see the resident's upper arm. LPN #1 recalled the resident didn't eat dinner and that she was much sleepier than usual and was sleeping through dinner. LPN #1 stated she remembered hearing the resident moaning on and off throughout the evening. When questioned, LPN # 1 stated she did not call the doctor that evening to report Resident # 1's condition but she thought she heard someone say that they would call the doctor the next day. LPN #1 stated she should have checked on the resident more often that night and should have talked to the nurse about her condition. During an interview on [DATE] at approximately 3:00pm, a registered nurse (RN#2) stated that she had worked 3:00pm to 11:00pm on [DATE] and was told in report that Resident # 1's arm was more swollen and was weeping and the day shift nurse had put an incontinence pad under the arm. She recalled that several times during the night she thought about going to look at the resident's arm but she was always distracted by something. RN#2 stated she did not see the resident's arm throughout her shift and when she gave report to the night shift nurses at 11:00pm she did not mention that the resident's arm was swollen and weeping and she did not call the doctor that night to describe the resident's arm. RN#2 stated that on that night no one told her that the resident had a change in mentation. During an interview on [DATE] at approximately 2:30pm a certified nursing assistant (CNA #1) stated that she was assigned to care for Resident # 1 on [DATE] from 3pm to 11:00pm. When she came on duty that day she was told by the day shift CNA that the resident's arm was very swollen, was weeping and an incontinence pad had been placed under the resident's arm to absorb the drainage. CNA # 1 stated the resident's arm had been swollen for about a week but on the evening of [DATE] the swelling had increased and " Her hand was really, really swollen. It was huge, shiny. It was purple. It was a lot more swollen than the night before." CNA #1 recalled that sometime after dinner on [DATE], she had asked RN#2 to look at the resident because she was concerned about her and her arm and in addition Resident # 1 was not as alert as she had been the evening before. CNA#1 stated that on Christmas Eve the resident could answer questions but on Christmas night she wasn't really talking and she was moaning and calling out for her mother. As she was making rounds at the end of her shift, CNA #1 told the night-shift CNA that she was sure when she came back to work in two days, Resident # 1 wouldn't still be there. CNA #1 stated that she could tell that the resident was not doing well and probably was not going to make it. During an interview on [DATE] at approximately 4:45pm, a registered nurse supervisor (RNS) stated that on [DATE] at around 2:00am she was called by an LPN (LPN#2) and asked to look at Resident #1 ' s arm. The RNS had not been told in her report about the condition of the resident's arm and there was no mention of the resident's arm on the twenty-four hour report sheet. The RNS stated that when she arrived at the room she saw that the resident's arm and hand were extremely [MEDICAL CONDITION], hard and shiny and her upper arm was ecchymotic up to the shoulder. Just above the antecubital space, there was a large fluid filled blister and two smaller fluid filled blisters above that. The RNS immediately called the resident's doctor (MD#1) who was very upset that he was just now hearing about the condition of the resident's arm. He ordered blood work for the morning and a doppler-ultrasound of the resident's arm. RNS # 1 stated that after discussing the resident's condition with LPN#2 they were not comfortable waiting for morning for the ultrasound and the RNS called the radiology department in the adjacent hospital, requesting it be done that night. The technician was called in, but when she arrived she was not comfortable doing an ultrasound over the top of blisters and also because the resident was now moaning in pain from her arm being moved about. Another call was placed to the doctor, who ordered the resident sent to the emergency department (ED). As staff were transferring the resident to a stretcher for transport to the ED, they noted the resident had mottling of the lower extremities. Another call was placed to the MD # 1 and after updating him on the resident's condition, RNS recalled that she asked the MD about " Comfort Care." The MD gave orders to cancel the ED and keep the resident at the nursing home, to keep her comfortable and to administer [MEDICATION NAME] for pain. The RNS instructed LPN #2 to administer [MEDICATION NAME] to the resident but did not instruct the LPN to go back afterward and check on the resident periodically and did not go back herself to check on the resident again. The RNS was called back into at approximately Resident # 1's room after LPN #2 had observed that the resident had passed away. When the RNS entered the room and saw that Resident # 1 was not breathing, she never even thought about the resident's code status (advanced directives). The RNS stated, " It never entered my mind. I never even thought about resuscitating her. I don't know why. I just never thought about it " The RNS recalled that generally speaking, whenever MD #1 was called about any resident, he would always ask early in the conversation about the resident's code status (Do Not Resuscitate vs full code). However, the RNS did not recall telling the MD in any of their phone conversations during that night about the resident's wishes to be resuscitated but not intubated, should the situation arise. During an interview on [DATE] at approximately 9:45am, Resident # 1's physician (MD #1) stated that he was called during the night around 2:00am on ,[DATE] and told that Resident #1 had increased swelling, ecchymosis and blisters to her left arm. He recalled the resident had swelling of the extremity earlier in her stay but that it had actually improved. He did not know when the swelling had returned. When asked, MD#1 stated that yes, he was upset and concerned that he had not been called earlier and made aware of the condition of the resident's arm. MD # 1 stated that when he was called that night ([DATE]) he asked the nurse to get an ultrasound (U/S), thinking perhaps there was a blood clot. MD # 1 stated the technician attempted the U/S but was unable to give me any good information and the nurse told me the resident was deteriorating and so I gave an order to send the resident over to the ED. The nurse called back a short time later and told me that the resident had mottling of the lower extremities and felt the resident was actively dying. At that time I gave orders for [MEDICATION NAME] and to keep her comfortable. Later that morning I received another call and was told the resident had passed away. MD # 1 stated he could not recall having a conversation with the nurse (RNS) during that night regarding the resident ' s advanced directives. He stated if he had known at the time that the resident wanted to be resuscitated but was a Do Not Intubate (DNI) , he would have sent her to the ED. MD #1 stated, " I would have honored her wishes. " During an interview on [DATE] at approximately 9:30am, a licensed practical nurse (LPN#2) stated that around midnight on [DATE] she was told by a CNA that Resident #1 ' s arm was weeping and the evening shift had placed an incontinence pad under it. LPN #2 had been concerned about the increased swelling of the resident's arm and when she gave report at 7:00am on [DATE], she asked the day shift RN (RN#2) to look at it. When LPN #2 checked the resident's arm around 1:30am on [DATE] she noted the resident had a large, fluid filled blister at the antecubital space and just above that, two smaller blisters. LPN#2 called the RNS and recalled that when the RNS first saw the resident's arm she stated, " Oh my god, let me call the doctor! " When contacted , MD #1 gave orders for blood work and an U/S. After the U/S technician arrived and attempted the U/S without success, MD#1 was called again and he gave an order to send the resident to the ED. While transferring the resident to a stretcher for transport to the ED, the staff noted the resident's lower legs were mottled. The RNS called MD#1 again and the ED order was cancelled and [MEDICATION NAME] was ordered and administered by LPN # 2 at approximately 4:00am. LPN #2 stated she peeked in to see the resident about 15 minutes after she gave the [MEDICATION NAME], but she did not check on her again until doing a med pass at about 5:00am. It was at this time that LPN # 2 noted the resident did not appear to be breathing and she did not initiate CPR but ran to the desk to get the RNS. They both re-entered the resident's room and the RNS confirmed that the resident was deceased . LPN # 2 stated she did not start chest compressions or call a code when she first noted the resident was not breathing because she didn't know the resident's wishes were to have CPR but DNI (do not intubate). LPN#2 explained that at the facility, resident's name tags were color coded to indicate if the resident was to have CPR or DNI or DNR(do not resuscitate). The color coded name tags were placed over the resident's bed, on the door to the resident's room and on the spine of the resident's chart. LPN # 2 added that she did not start CPR when she found Resident #1 not breathing, because in the past she had the wrong color code information on name tags on resident ' s doors. She stated she did not look at the colored-coded name tag over the bed because she did not know if that information was correct. LPN # 2 could not recall a specific time when the color of a name tag was incorrect and she could not recall reporting that error to anyone in supervision. LPN #2 thought she might have asked a secretary at one time to change a name tag on the spine of a chart because the color was incorrect. She could not recall who the secretary was, when this had occurred or what resident was involved. LPN#2 stated because of this possible discrepancy, she would not initiate CPR but would call an RN and let the RN make the decision. LPN# 2 admitted she was aware that the facility policy instructed all RNs and LPNs to initiate CPR if they found a resident not breathing, without a pulse and the resident was a full code or a code with a DNI. LPN#2 stated she had been recertified in CPR about one year ago. 10NYCRR 415.12

Based on medical record review and staff interviews conducted during complaint investigations (Case #'s NY 939 & NY 783), it was determined that for one (Resident #1) of five residents reviewed, the facility did not notify the resident's physician (MD #1) in a timely manner when the resident had no urinary output through his Foley catheter (indwelling tube to drain urine from bladder) and when the resident's penis was noted to be [MEDICAL CONDITION]. Specifically, the facility did not ensure that the physician was notified timely when the resident had no urinary output over an eight-hour period on two consecutive evenings (3:00 pm-11:00 pm on [DATE] and [DATE]) and only 50 cubic centimeters (cc) urine output from 11:00 pm on [DATE], to 4:45 am on [DATE]. Additionally, when the resident's penis was noted to be swollen on [DATE] at approximately 2:00 pm, the physician was not notified until the following morning at approximately 10:30 am. This resulted in actual harm that was not immediate jeopardy. This was evidenced by the following: Resident #4 The resident was admitted to the facility on [DATE] for rehabilitation, following a hospitalization for bilateral [MEDICAL CONDITION] of his lower extremities. The Minimum Data Set ((MDS) dated [DATE] assessed the resident to have intact long and short term memory and was independent with decision making. Finding 1 Nurse's notes documented that for two consecutive evenings, on the 3:00 pm to 11:00 pm shift on [DATE] and [DATE], the resident had no urinary output through his Foley catheter and 50 cc output from 11:00 pm on [DATE] to 4:45 am on [DATE]. On [DATE] at 11:00 pm the nurse documented, "no urinary output, (Foley) irrigated without difficulty or pain. NS (normal saline) returned immediately, no distension. Report to oncoming shift." A note written [DATE] at 4:05 am described the resident's urine as "pyuric" (urine that contains pus). The note did not document the volume of urinary output for the shift. There was no nurse's note addressing urinary output written on [DATE] for the 7:00 am to 3:00 pm shift. The next note was entered at 4:45 am on [DATE], by the registered nurse supervisor (RNS) who documented, "Summoned to resident room as both legs mottled up to knees. Respiration 44 and labored. O2 Sat (oxygen saturation) 82% (normal 95% -100%) on oxygen at 2 Liters per minute. Rales (lung sounds) heard throughout. Gross [MEDICAL CONDITION] around scrotum. Resident had no urine output on 3:00 pm-11:00 pm and only 50 cc tonight until Foley repositioned. Urine pus-like and 1825 cc returned. Temp 99, pulse 129, respirations 44, blood pressure ,[DATE]. Dr. called and ordered resident sent to emergency room (ER) for evaluation." The hospital admission note dated [DATE] documented that the male patient at the extended care facility was found to be hypoxic (low oxygen), short of breath with rapid respirations of 44 (normal ,[DATE]), and had increasing rales and decreased urinary output over the last shift. In the ER he was found to be in acute [MEDICAL CONDITION], with a creatinine of 6.9 (normal is 0.6 to 1.2), potassium 6.3 (normal 3.7 to 5.2), hypotensive and pre-septic with a white cell count of 44,000 (normal 4,300 to 10,800). The resident was being admitted for urosepsis. The hospital history and physical, dictated at 9:41 am on [DATE], identified that the resident was admitted to the hospital with [REDACTED]. The note ended with, "Patient is in critical condition." During an interview on [DATE] at 3:00 pm, a registered nurse (RN #1) stated that she was the treatment nurse on the 3:00 pm to 11:00 pm shift on [DATE] and [DATE]. RN #1 stated that Resident #1 was being treated for [REDACTED]. She recalled that she was informed by a certified nurse aide (CNA) at approximately 11:00 pm, on both [DATE] and [DATE], that the resident had not had any urine output for the entire 3:00 pm to 11:00 pm shift. On [DATE] at approximately 11:00 pm, RN #1 stated she went into the resident's room as soon as the CNA told her there was no urine output and irrigated the resident's catheter. She recalled that although there was no urine output, the irrigation (solution) returned easily. She wrote a nurse's note at that time, but did not call the physician. On [DATE], when the CNA told her at approximately 11:00 pm, that again, the resident had no urine output for the shift, she irrigated the catheter; she stated that again, the irrigation (solution) returned, but there was no urine output. She stated that she did not call the doctor and did not write a nurse's note on that evening. RN #1 stated, that she now should have called the doctor on both nights and should have written a nurse's note. She stated she didn't because the resident's urine had looked pretty bad for a while. RN #1 stated, "if I had seen his mottled legs I would have called the doctor right away, because I would have known that his catheter was plugged. He had mottled legs one other time and he went out to the ER that night and in the ER they found that his catheter was plugged. During an interview on [DATE] at 2:30 pm, the Registered Nurse Supervisor (RNS) stated that she was the house supervisor on the 11:00 pm to 7:00 am shift from [DATE] to [DATE]. She was not notified during report (which she received at approximately 11:00 pm on [DATE]), that the resident had not had any urine output for the evening shift. She did not see the resident during her shift until approximately 4:30 am, when the LPN charge nurse (LPN #1) called her and told her the resident had not had any urine output through his Foley catheter for the shift. The RNS recalled that she told LPN #1 that she would be over to see the resident in a few minutes. Just a few minutes later the RNS received another phone call asking her to come and see the resident right away. The RNS stated that she went immediately to the resident's room and explained that the nurse's note she wrote in the medical record at 4:45 am on [DATE], very accurately described the resident just as she found him that morning. She stated the urine that was in his Foley tubing didn't even look like urine. She called the on-call doctor (MD# 2) and he didn't hesitate to give an order to send the resident to the hospital. The RNS stated, "frankly, I would have sent him anyway. He was a very sick man." A review of the hospital medical record revealed that the resident was to be admitted to the ICU. However, the resident expired at 2:20 pm on [DATE], in the ER before he was transferred to the ICU. Finding 2 The physician was not notified in a timely manner when the resident developed swelling of the penis and was later diagnosed by the urologist with a paraphimosis (defined below). In a [DATE] article, Jeffrey Donohoe M.D., FAAP, Professor of Pediatric Urology, at the Medical College of Georgia wrote, Paraphimosis is an uncommon condition in which the foreskin, once pulled back behind the glans penis, cannot be brought down to its original position, thus constituting one of the few urologic emergencies encountered in general practice. Paraphimosis occurs in uncircumcised or partially circumcised males. Paraphimosis may occur when the foreskin has been pulled back behind the head of the penis for an extended period and is often caused by well-meaning health professionals secondary to penile examination or urethral instrumentation. When paraphimosis is suspected, immediately obtain a urology consult for proper evaluation and diagnosis. Prompt attention and treatment of [REDACTED]. Nurse's notes on [DATE] at 2:10 pm documented, penis swollen (ice applied) with effect. On [DATE] at 11:00 pm, the nurse's notes documented that the resident's penis remained swollen and there was no change in the amount of swelling from the start of this shift to now. The patient complains of pain, if it is touched. A cold pack was applied and the penis was elevated with no effect. The resident's Foley was draining with some small blood clots noted. A nurse's note entered by LPN #1 on [DATE] at 7:05 am, documented that the resident refused to have vital signs (VS) taken and would not allow oxygen to be put on. She was unable to check the resident's penis until the morning, due to his combativeness and swearing. She noted his penis was still swollen and she applied an ice pack and reported it to the on-coming nurse. On [DATE] at 10:30 am, a nurse documented that the MD #3 (urologist) was made aware of the resident's [MEDICAL CONDITION] penis and on [DATE] at 12:00 pm, the nurse documented, urologist in to see resident. He was able to manually retract foreskin. In a progress note dated [DATE] at 11:40 am, MD #3 documented, the resident had an obvious paraphimosis that would need to be reduced at the bedside. The note documented the resident would have some discomfort. In a document titled, Report of Consultation, dated [DATE], MD #3 documented that the resident's "Foley should be changed every four weeks, be sure not to peel back the foreskin and leave it there-so the patient will not develop a painful paraphimosis." During an interview on [DATE] at approximately 1:30 pm, RN #2 stated that on [DATE] in the early afternoon during the day shift, a member of the staff informed her that the resident's penis was swollen. RN #2 recalled that she went in and assessed the resident and noted a swollen penis. She stated that she realized right away that it was a paraphimosis and that it was caused by his foreskin being retracted and not being pulled back down. She attempted unsuccessfully to pull the foreskin down. She tried placing an ice pack on the resident's penis thinking that it might reduce the swelling and allow her to pull the foreskin back down. When she was not able to, she left the ice on the resident and let the oncoming shift know about the paraphimosis. She stated she did not call the doctor. During an interview on [DATE] at approximately 2:00 pm, RN #3 stated she was pretty sure that MD #1 was called on [DATE] somewhere around 10:30 am and was told that the resident's penis was swollen. MD #1 ordered a consult with urology. RN #3 thought the urologist saw the resident that same morning. During an interview on [DATE] at approximately 1:00 pm, MD #3 stated that he had been called to see Resident #1, who had an obvious paraphimosis. He added that the condition was created when health care workers retract the foreskin of patients for medical reasons and then fail to pull the foreskin back down. He stated that he was not aware that the resident's condition had been identified the afternoon before he was called. He stated he would have expected to be contacted as soon as the condition was identified, because a paraphimosis needs to be treated promptly to prevent significant problems. MD #3 recalled that he had to reduce the resident's paraphimosis at the bedside and that it caused the resident "considerable pain" when he did. When MD #3 was asked about the resident's ongoing hematuria, abdominal distension and decreased or no urine output for shifts, he stated that, if a patient with a Foley catheter complains of abdominal distension, is having good results from enemas, but the abdominal distension was not alleviated, then one has to at least consider a blocked catheter. He stated, it appears they (nursing home staff) were slow to evaluate what was going on with this patient. 10NYCRR 415.3(e)(2)(ii)(b)

Based on medical record review and staff interviews during complaint investigations (Case #'s NY 939 & NY 783), it was determined that the facility did not provide the necessary care and services for one (Resident #4) of five residents reviewed. Specifically, the facility did not ensure that Resident #4 was treated in a timely manner when on ,[DATE]-[DATE] the resident was noted to have hematuria (blood in the urine), abdominal distension and discomfort. The resident was transferred to the emergency room (ER) and the resident's Foley catheter was found to be obstructed. On [DATE] and [DATE], the resident had no urinary output over two consecutive evening shifts (3:00 pm - 11:00 pm) and only 50 cc output from 11:00 pm on [DATE] until [DATE] at 4:45 am, at which time the resident was sent to the ER and found to be in acute [MEDICAL CONDITION]. Additionally, a urine culture and sensitivity (C&S) was ordered on [DATE] and was not collected and sent to the lab until [DATE]. This resulted in actual harm that was not immediate jeopardy. The following evidence supports the statement of deficiency: Resident #4 The resident was admitted to the facility on [DATE] for rehabilitation, following a hospitalization for bilateral [MEDICAL CONDITION] of his lower extremities. The Minimum Data Set ((MDS) dated [DATE] assessed the resident to have intact long and short term memory and was independent with decision making. admission orders [REDACTED]. The facility policy titled "urinary catheters" dated ,[DATE], does not include documentation to monitor the urine for amount, color, consistency, odor or to report and report abnormal, nor any other aspects associated with urine output. A comprehensive care plan (CCP) titled "indwelling Foley catheter" documented it was initiated on [DATE] (thirty-one days after admission) and re-evaluated on [DATE]. Documented problems are related to [MEDICAL CONDITION] with a history of [MEDICAL CONDITION]. Documented interventions are as follows: provide adequate fluid intake, change catheter every month, position Foley bag and tubing below level of bladder, check for kinks in tubing if catheter is leaking, position resident for proper drainage, irrigate Foley catheter if Foley bag is empty to ensure patency, catheter care every shift, note amount, color, consistency, odor and report abnormal, monitor lab values and asses for removal of Foley catheter. Finding #1 The facility did not ensure that the resident was treated in a timely manner when on ,[DATE], ,[DATE], ,[DATE] and [DATE] the resident was noted to have hematuria and/or abdominal distension and the abdomen was tender to touch and after transfer to the ER the resident's Foley catheter was found to be obstructed. Nurse's notes documented the following: on [DATE] at 9:00 am, 2:30 pm and 8:30 pm that the resident had hematuria. On [DATE] at 8:30 pm, a SSE (soap suds enema) was given with large results. On [DATE] at 2:55 pm, the resident's Foley was patent (draining) and his urine was light pink, with mucous. On [DATE] at 10:10 pm, RN #1 documented, "Certified Nurse Aide (CNA) reports only 50 ml (milliliters) of urine output" and that the resident's abdomen was very firm and tender to touch. His Foley was irrigated, urine returned that was cloudy and orange with sediment and the resident's temperature was 102.8. The on-call doctor (MD #4) was called and RN #1 documented, Pt (patient) had SSE with large results last night on 3:00 pm-11:00 pm and had a medium firm stool today. SSE to be given now. On [DATE] at 10:40 pm, RN #1 documented, large firm results from SSE and the resident's abdomen remains distended, he denies pain unless abdomen is palpated. Urine coming out of Foley. A note at 11:20 pm on [DATE] documented that the resident's temperature was 100.4 and MD #4 instructed the staff to get blood work and notify MD #1 (medical director) in the morning and to send the resident to the ER, if he gets worse. On [DATE] at 3:15 pm, the resident complained that his stomach "hurts" and MD #1 was aware of distension. At 8:15 pm on [DATE], RN #1 documented that the resident's urine had turned dark red and the resident requested to go back to bed, as his belly hurts when sitting up. His bowel sounds were hypoactive, his abdomen firm, distended and tender to touch. MD #1 was called and gave an order for [REDACTED]. On [DATE] at 8:30 pm RN #1 documented that MD #1 called back and ordered a chest x-ray and a scout film (x-ray film that is taken of a specific area before the patient ingests or is injected with contrast material) of the abdomen to be done that night, so when he came to see the resident in the morning he could determine if a surgical consult was needed. The resident was immediately taken to the x-ray department and returned at 9:15 pm. The next nurse's note was entered at 10:00 am on [DATE] when the nurse documented, a late entry. RN #3 documented that upon arriving at work at 6:45 am, she was asked by the night and day shift supervisor to assess the resident. Upon assessment she documented that the resident was lying in bed with his head up 30 degrees. He had oxygen on at 3 liters/minute. His respirations were shallow, rapid, congested and he had decreased responsiveness. His Foley catheter was draining bloody urine and his vital signs were; temperature 98.4, pulse116 and a blood pressure of ,[DATE], with an oxygen saturation of 88% (normal 95%-100%). The resident was sent out to the ER. On [DATE] at 1:10 pm nurse's notes continued, received call from ER resident being admitted to ICU. The hospital history and physical dictated by an ER MD (MD #5) at 12:30 on [DATE], while the resident was in the ER, documented that the patient had hematuria, with fever and decreasing sensorium, cough, congestion and was sent to the ER, where he was found to be in shock, urosepsis and subsequently admitted . The report documented that a cat scan done in the ER, revealed that the resident had a distended bladder. In a second ER report dictated at 12:05 pm, a second ER MD #6 dictated, that the emergency room nurse was having difficulty getting urine, which was basically blood/hematuria via the catheter and found that she could not irrigate the catheter. She removed the catheter and put in a new one, which was then followed by 2000 cc urine output with significantly less intensity of hematuria. The abdominal distension, which was moderate and mildly firm, improved significantly as well. The note continued, "we seem to have a source for at least, if not all, of the cause of the high creatinine and high BUN, namely the obstruction of the Foley, with significant [MEDICAL CONDITION], which had now been relieved as per the nurse and 2000 ml urine output." Under the [DIAGNOSES REDACTED]. The [DATE] hospital discharge summary, documented that the resident had been admitted to the ICU from the ER. He was treated with fluids and medications and closely monitored. He continued to have good urine output. His labs improved and he started eating, was transferred to the floor and then discharged back to the facility on [DATE]. During an interview on [DATE] at 3:00 pm, RN #1 stated that she was the treatment nurse on the 3:00 pm-11:00 pm shift on [DATE], [DATE] and [DATE]. She recalled that Resident #4 had been given an enema the evening of [DATE] with good results and had a bowel movement on [DATE] on the day shift. The resident was given another enema on [DATE], on the evening shift and had good results. RN #1 stated that the resident's bowel sounds were hypoactive at that time. On-call MD #4 was notified and he ordered blood work to be done in the morning and started the resident on antibiotics for diverticulitis (an inflammation of an abmormal pouch in the intestinal wall). When RN #1 came on-duty to work on the evening shift on [DATE] at approximately 3:00 pm, she was told that MD #1 was aware that the resident's abdomen was distended. RN #1 recalled that sometime after dinner the resident asked to go to bed, because he had pain in his abdomen. The resident was put in bed and was assessed by RN #1, who noted that his urine had turned dark red, his bowel sounds were hypoactive and his abdomen was distended and he was uncomfortable. MD #1 was contacted and ordered a clear liquid diet and another SSE. The enema was given with good results. A short time later MD #1 called back and told RN #1, to take the resident that night for an x-ray of his chest and abdomen and that he would look at the x-rays in the morning and decide if the resident needed a surgical consult. RN #1 stated she was concerned about the resident, because she thought there was something going on with him and she was glad something was getting done for him. During an interview on [DATE] at approximately 11:30 am, RN #3 stated that she came on duty on [DATE] at approximately 6:45 am. Before she signed in at the nursing office, she was told by the night shift and day shift supervisors that Resident #1 was not doing well and she was asked to go and assess the resident. RN #3 stated she went to the resident's room immediately and noted that the resident was alone in the room, he had oxygen on and his oxygen saturation was low, as was his blood pressure. The resident was not answering questions and was not responding when his name was called. She stated that she quickly determined that the resident should be sent out to the ER for evaluation immediately. RN #3 stated, "I thought it was important that we got him out to the ER as soon as possible." Finding #2 The facility did not ensure that the resident was treated in a timely manner when, on [DATE] and [DATE], the resident had no urinary output over two consecutive evening shifts (3:00 pm - 11:00 pm) and only 50 cc output from 11:00 pm on [DATE] until [DATE] at 4:45 am, when the resident was sent to the ER and found to be in acute [MEDICAL CONDITION]. On [DATE] at 4:45 am, the registered nurse supervisor (RNS) was called to see the resident and upon assessing the resident, contacted the on-call MD #2 who ordered him sent to the ER for evaluation. In the ER the resident was ordered to be sent to the ICU as his condition was deemed critical, however, the resident expired in the ER. Nurse's notes documented that for two consecutive evenings on [DATE] and [DATE], the resident had no urinary output through his Foley catheter and only 50 cc's output from 11:00 pm on [DATE] to 4:45 am [DATE]. There were no nurse's notes entered from [DATE] at 12:45 pm until 4:45 am on [DATE], when the RNS documented her assessment and that MD #2 was notified and the resident was sent out to the ER for evaluation. The nurse's notes dated [DATE] at 4:45 am written by the RNS documented, summoned to resident room as both legs were mottled (changes in the blood vessels causing a patchy appearance to the skin) up to knees. Respirations 44 and labored, O2 Sat (oxygen saturation) 82% (normal ,[DATE]%) on oxygen at 2 Liters per minute. Rales heard throughout. Gross [MEDICAL CONDITION] (swelling) around scrotum. Resident had no urine output on 3:00 pm-11:00 pm and 50 cc tonight, until Foley repositioned. Urine pus-like and1825 cc returned. Temperature 99, pulse 129, respirations 44, blood pressure ,[DATE]. MD #2 called and ordered resident sent to ER for evaluation. During an interview on [DATE] at 3:00 pm, RN #1 stated that she was the treatment nurse on the 3:00 pm to 11:00 pm shift on [DATE] and [DATE]. She recalled that she was informed by a CNA on both evenings at approximately 11:00 pm, that the resident had not had any urine output for the entire 3:00 pm to 11:00 pm shift. On [DATE], when the CNA told her at approximately 11:00 pm, that again there was no urine output. RN #1 stated that she irrigated the resident's catheter and the irrigation solution returned, but there was no urine output. She did not call the doctor and did not write a nurse's note. RN #1 stated, now I realize I should have called the doctor, on both nights and I should have written a note. I guess I didn't because his urine looked pretty bad for a while. If I had seen that he had mottled legs, I would have called the doctor right away, because I would have known that his catheter was plugged. He had mottled legs one other time and he went out to the ER that time and in the ER they found that his catheter was plugged. When they put a new catheter in him that night, they got back a lot of urine." In a written statement, provided by the facility DON, dated [DATE] at 4:20 am (after the Resident #1 had expired), LPN #1 documented that she was told in report at 11:00 pm on [DATE] that Resident #4 had not had any urine output on the 3:00 pm to 11:00 pm shift. In the first part of the shift she went into the resident's room and flushed the Foley catheter with 100 cc of normal saline. She documented that the Foley flushed easily and 50 cc of fluid returned. At 4:00 am, a CNA reported to her that the resident still had only 50 cc of urine in the bag. LPN #1 then called the RNS and made her aware that she was going to reposition the catheter and change it, if she was unable to get more urine out. When LPN #1 pulled the sheets back, she noticed that the resident's legs were mottled up to his knees and his scrotum was [MEDICAL CONDITION] to the degree of not being able to find the head of his penis, except for a small hole. She sent the CNA to call the RNS. The resident was alert with no complaints. LPN #1 removed 10 milliliters (ml) of saline from the Foley catheter balloon and inserted the catheter further. She documented that the catheter then drained 1825 cc. The RNS arrived and the resident's vital signs were documented as blood pressure ,[DATE], respirations 44 per minute and oxygen saturation was 82%. The resident's oxygen was increased to 4 liters per minute per instructions from the RNS and MD #2 was notified and the resident was sent to the ER. During an interview on [DATE] at 2:30 pm, the RNS stated that she was the house supervisor on the 11:00 pm to 7:00 am shift from [DATE] to [DATE]. She was not notified during report (which she received at approximately 11:00 pm on [DATE]), that the resident had not had any urine output for the evening shift. She did not go to see the resident during her shift until approximately 4:30 am, after the LPN charge nurse (LPN #1) called her and told her the resident had not had any urine output through his Foley catheter for the shift. The RNS recalled that she told LPN #1, that she would be over to see the resident, in a few minutes. The RNS stated that she received a second phone call, asking her to come to see the resident right away. The RNS stated she went immediately to the resident's room and that the nurse's note that she entered into the medical record that night, at 4:45 am on [DATE], described the resident just as she found him that morning. The RNS stated, I called the on-call MD #2 and he didn't hesitate to give an order to send him to the hospital, but frankly, I would have sent him anyway. He was a very sick man. During an interview on [DATE] at approximately 4:00 pm, MD #1 (medical director) stated that he would expect to be contacted by nursing staff, if a resident with a Foley catheter did not have any urine output for an entire eight hour shift or if any resident had swelling of the penis and a possible paraphimosis (an uncommon condition in which the foreskin, once pulled back behind the glans penis, cannot be brought down to its original position, thus constituting one of the few urologic emergencies encountered in general practice). When MD #1 was informed that Resident #1 had no urine output through his Foley catheter from 3:00 pm to 11:00 pm on [DATE] and again from 3:00 pm to 11:00 pm on [DATE], and only 50 cc of urine output from 11:00 pm on [DATE] to 4:45 am on [DATE], and had experienced swelling of his penis from 2:00 pm on [DATE] until approximately 12:00 noon on [DATE], MD #1 stated that he was shocked to hear that this had occurred and that he, or an on-call doctor, had not been informed of all of the above earlier. MD #1 added that, [MEDICAL CONDITION] might not have been the sole cause of the resident's urosepsis and acute [MEDICAL CONDITION], but it certainly did not help this gentleman. During an interview on [DATE] at approximately 4:00 pm, LPN #1 stated that her memory of the events surrounding the resident's hospitalization at the end of [DATE], were not real clear to her. She did recall that the resident was having complaints of abdominal distension and discomfort and that the nurses were trying to determine if it was caused because of constipation or if it was because the Foley was not draining properly. She recalled that on the night of [DATE], she was told in report by RN #1, that the resident had not had any urine output at all on the 3:00 pm to 11:00 pm shift. She could not recall if she passed that information on to the night shift supervisor. She stated that early in her shift (11:00 pm -7:00 am) sometime after midnight, she irrigated the resident's Foley and only some of the irrigation solution returned. She tried moving the resident around and turning him side to side, to see if she could get the Foley to drain, but was unsuccessful. She stated the resident was drinking throughout the night, but was not sure exactly how much he took in. She was told by the CNA sometime around 4:00 am, that the resident still had not had any urine output. LPN #1 stated that she went into the resident's room with the idea that the Foley might need to be changed. When she pulled back the blankets she noted that the resident's scrotum and penis were very [MEDICAL CONDITION] and his legs were mottled up to his knees. She remembered that his legs were mottled the last time he went out to the hospital, when his Foley had been plugged. She repositioned the Foley and it began draining a large amount of urine. LPN #1 stated the resident's urine always looked like pus. We had been asking for a urine culture to be done because, "his urine was disgusting, actually." When the RNS arrived on the unit that morning around 4:45 am, the resident's speech was slow. He was not responding as quickly as he usually did. He was acting a little foggy. His blood pressure was low and his breathing was fast. When the RNS arrived she told LPN #1 to get the stretcher, because the resident had to go over to the ER. A review of the hospital medical record revealed that the resident was to be admitted to the ICU. However, the resident expired at 2:20 pm on [DATE], in the ER before he was transferred to the ICU. Finding #3 The resident was not treated in timely manner when a urine C&S ordered on [DATE] was not sent to the lab until [DATE]. A review of the physician order [REDACTED]. Nurse's notes document on [DATE] at 9:40 am, MD #1 aware urine thick, mucousy, white, history of UTI. On [DATE] at 2:35 am, nurse's notes documented, resident's Foley catheter changed times 1 month this shift at 1:00 am. There was no documented nurse's note addressing the resident's urine output, the C&S specimen, or the Foley catheter until [DATE] at 11:40 am, when the nurse documented, U/A (urinalysis) C&S obtained and sent, mucous cream colored urine obtained from Foley catheter. Awaiting results. A urine culture report dated [DATE], on a specimen collected on [DATE], documented a UTI. The report indicated that the infection was sensitive (can be treated with) to the antibiotic, [MEDICATION NAME]. A physician's orders [REDACTED]. During an interview on [DATE] at approximately 3:30 pm, the Director of Nursing (DON) stated that the usual procedure for collecting a urine C&S, was for the night shift nursing staff to collect the specimen and send the specimens off to the lab during the early morning hours. The DON did not know why the resident's urine culture was not obtained from the resident's catheter, until 5 days after the order was written. During an interview on [DATE] at 1:30 pm, RN #2 stated that she recalled making out a lab slip for a urinalysis and a urine culture to be collected on Resident #4. She made out the slip on [DATE], the day the order was written by MD #1 and placed it on the calendar for the night shift to collect on the morning of [DATE]. She stated that this was the facility procedure at the time. The night shift always got the urine specimens in the morning. RN #2 did not know why the specimen was not collected until [DATE]. 10 NYCRR 415.12