Every finding on record at Niagara Rehabilitation and Nursing Center

Based on observations, interviews, and record review conducted during the survey the facility failed to maintain an effective pest control program for the Main Kitchen and one (1) of three (3) resident floors. Issues included observations of rodent droppings in the dry storage room of the main kitchen, and complaints of rodent sightings in the main kitchen, resident rooms and halls. Additionally, on the exterior of the building, garbage and the contents of the kitchen grease traps, were stored in a manner that had the potential to attract rodents. Residents #3, 25, 47, 63, 65, 80, 94, 97, and #115 were involved. The findings include: The policy and procedure titled Pest Control, revised 11/2025 documented the facility maintained an on-going pest control program to ensure that the building was kept free of insects and rodents. It also documented that garbage and trash were not permitted to accumulate and were removed from the facility daily. The policy and procedure titled Kitchen Operations- Sanitization revised 10/2008 documented all kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects.The policy and procedure titled Food Receiving and Storage revised 10/2017, documented non-refrigerated foods will be stored in a designated dry storage unit which was temperature and humidity controlled, free of insects and rodents and kept clean. Review of the facility's Pest Control Company- Summary of Service documents provided by the facility dated 11/2025 to 04/2026 revealed they found rodent activity in the main kitchen and other areas of the facility, on each visit. During an observation on 04/01/2026 at 9:15 AM, the dry storage room of the main kitchen had a large amount of rodent droppings most surfaces, including but not limited to; on top of six (6) cardboard cases of thickened dairy drink, three (3) plastic totes containing assorted dry foods, on the lids of at least six (6) cartons of thickened drinks, and on top of several large (#10) cans of vegetables, pudding and fruit. During an interview at the time of the observation, the Food Service Director stated rodents were an ongoing issue in the kitchen. They stated Pest Control had been coming more often recently, and they thought the issue was improving. They stated the rodent droppings were unsanitary and they had the potential to make someone sick. The Food Service Director stated they wiped the surfaces of the cans and boxes every morning, and a staff member would wipe them in the evening. They stated the dry storage room was deep cleaned about two (2) weeks ago, and the main cooking area of the kitchen was power washed just last week.During an interview on 04/01/2026 at 9:20 AM, [NAME] #1 stated the rodent droppings were unsanitary, and they cleaned all their cooking and prep surfaces every morning. During an interview on 04/01/2026 at 12:08 PM, the Assistant Director of Nursing stated that rodent droppings on top of food items were an infection control problem and had the potential to get someone sick. They stated the cans needed to be sanitized and the cartons needed to be thrown out. Observation on 04/02/2026 at 8:00 AM, the dry storage room had visible rodent droppings on totes, cardboard boxes, and the tops of large cans. During an interview at the time of the observation, the Food Service Director stated they had wiped down all the cans and lids yesterday and were about to do that again.During an interview on 04/02/2026 at 8:16 AM, the Environmental Services Director stated they were aware of the rodent issue. They assisted with deep sanitation of the kitchen recently. They stated there had been evidence of rodents on the third floor, but they thought they were currently isolated in the kitchen. They stated the Pest Control company came in, set traps, and made recommendations. Maintenance responded to those recommendations, and housekeeping would assist in sanitation. During an interview at 04/02/2026 at 8:55 AM, Resident #80 who resided on the third-floor stated there had been rodent activity in their room and in the hallway of the unit. Resident #80 stated about a month or two months ago they saw a mouse run across the hallway into their room. They stated saw mice in the hallway and mice would get stuck to the glue on traps that maintenance department placed on the floor. Resident #80 added, they saw a little bitty mouse in the hallway the night before. A resident council meeting was held on 04/02/2026 at 10:00 AM. Residents #3, #25, # 47, #63, #65 and #94 were present. Resident #3 and Resident #65 stated they have seen mice in hallways and in rooms on the third floor. Resident #3 added, about one and a half (1.5) months ago they saw two (2) mice stuck to glue traps and they threw them into the garbage. Resident #47, #63, and #94 stated in the summer they saw mice in the main dining room on the first floor and believed the mice came into the building because the doors get propped open to let in the fresh air. The group expressed they did not want rodents where they were living, it was not dignified nor was it homelike. Resident #94 stated, we do not want a pet mouse and it made them nervous because the mice could run on top of them while they were sleeping. During an observation on the third floor on 04/02/2026 at 12:20 PM there was a hole in the wall behind the nightstand near the door of Resident room [ROOM NUMBER]. The hole was located between the wall and the vinyl baseboard and measured three (3) inches long by 1 (1) inch wide. Three (3) tufts of wall insulation were on the floor beneath the hole. Additional observation revealed the vinyl baseboard had pulled away from the wall in an area that was 12 inches long behind the window-side bed.During an interview on 04/02/2026 at 12:23 PM, Resident #115, a third-floor resident, stated two (2) live mice were caught on a glue trap in their room three (3) to four (4) days ago and last night a mouse ran across the floor in their room.During an interview on 04/02/2026 at 12:25 PM, Resident #97, a third-floor resident, stated they saw a rodent in their room about one (1) week ago.During an interview on 04/02/2026 at 12:30 PM, the Regional Maintenance Director stated a licensed exterminator was treating all floors of the building, including some resident rooms for rodent activity. The exterminators came weekly and utilized glue traps. The Regional Maintenance Director stated they were made aware of a rodent issue about one (1) to two (2) months ago and they did not know where the rodents were coming from. They stated the exterminator had made recommendations to seal certain holes, and Maintenance staff had done so, and they were not aware of the hole inside Resident room [ROOM NUMBER]. The Regional Maintenance Director stated they were aware of current rodent activity in the Kitchen, and the Kitchen's exterior door had been recently replaced, new door sweeps had been installed on exterior doors, and holes in the Kitchen were sealed.During an interview on 04/02/2026 at 3:45 PM, the Administrator stated staff first brought a rodent issue to their attention in January 2026. They stated they felt it was a neighborhood-wide issue. In January, the issue was discussed with their Quality Assurance Team, and an action plan was created. The action plan included weekly exterminator visits and identifying residents who liked to keep food in their room and providing them with plastic food storage bins. The Administrator stated they believed there was no further rodent activity upstairs, and their emphasis now was on the Kitchen. The Kitchen's exterior door had been replaced, and a new door sweep was added, but the door sweep had been repeatedly damaged by outside deliveries and had to be replaced multiple times. The Administrator also stated facility's PTAC units (Packaged Terminal Air Conditioners - self-contained, through-the-wall heating and cooling units) had some condensation drips, which could create soft spots in the drywall. They stated the facility's Maintenance staff was diligent in identifying and repairing the drywall in those areas. The Administrator stated they were aware of the recommendations written on the most recent exterminator's report, dated 03/25/2026, and they believed that all the items were done and closed because the facility did a deep cleaning of the Kitchen on 03/30/2026.During an observation on 04/03/2026 at 7:51 AM, the dry storage room had visible rodent droppings on most every surface. Two (2) containers of salt and pepper packets, without lids, were observed with several rodent droppings at the bottom of each of them. The breakfast tray line was in progress, and the Food Service Director was not at the facility yet. There were no salt and pepper packets observed on the tray line. During an interview on 04/03/2026 at 7:55 AM, Dietary Aide #1 stated they had seen a live mouse in the dry storage room about a month ago, and they were aware of the droppings. They did not know how long the issue had been going on. They stated they would wear gloves and wipe off anything they took from the dry storage room. They stated they had not used the salt and pepper packets for at least a few days. During an observation and interview on 04/03/2026 at 8:30 AM, the Director of Quality Assurance observed the rodent droppings in the dry storage room and removed the two (2) containers of salt and pepper packets. They stated the rodent droppings could make someone sick. They were aware there was an issue with rodents but did not realize it was that bad. During an observation at the exterior of the facility on 04/03/2026 at 9:45 AM it was revealed that the grease dumpster had a thick, tan-colored substance that appeared to be greasy food debris on the lid. There were three (3) areas of the substance on the lid; one (1) was approximately 3 inches long by 2 inches wide by 1/2 inch deep, another was approximately 4 inches long by 1 inch wide by 1 inch deep, and another was 7 inches in diameter and 1 inch deep. Further observation revealed there were some splatters of the tan-colored substance mixed with dirt on the ground in front of the grease dumpster, each approximately 2 inches in diameter.Additional observation at the exterior of the facility revealed there were two (2) televisions, a bed frame, a toilet, and multiple wood pallets and empty crates on the ground in the vicinity of the garbage dumpsters.During an interview at the time of the observation, the Regional Maintenance Director stated Maintenance staff cleaned the grease trap monthly and it must have splashed when they were trying to get it into the grease dumpster. They stated the substance on the top of the grease dumpster was grease, it looked like it was spilled recently, and it should be cleaned with a scraper. The Regional Maintenance Director also stated the toilet was placed there on 04/01/2026 and they were waiting for a metal recycler to pick up the bed frame.During an interview on 04/03/2026 at 11:15 AM, Dietary Aide #2 stated they had seen a live mouse in the dry storage room recently. They did not know how long it had been going on. During additional observations on 04/06/2026 at 7:40 AM and 04/07/2026 at 9:25 AM, the dry storage room had visible rodent droppings on multiple surfaces. During an interview on 04/06/2026 at 10:47 AM, Licensed Practical Nurse #1, Resident Care Coordinator stated they had not personally seen a mouse in over a month, but they had been informed of recent staff and resident sightings. During an observation on 04/06/2026 at 3:45 PM, the grease dumpster still had the white substance on the lid and in front as described in the previous observation. Additionally, the same white greasy substance, containing food debris (specifically yellow corn), was observed on the ground behind the dumpster in an area approximately 2 feet in diameter. During an observation and interview on 04/07/2026 at 12:12 PM, the Regional Maintenance Director observed the grease dumpster and the surrounding area. They stated the grease traps were emptied and dumped into the dumpster, monthly, and it was last done two (2) days ago. They stated it was maintenance staff that emptied the grease traps and dumped the grease, and they were responsible for cleaning any debris that was spilled. They should have cleaned it immediately. The Regional Maintenance Director stated the debris could draw rodents to the area. During an interview on 04/07/2026 at 9:17 AM, the Administrator stated the dumpster area should be kept clean at all times because food debris could draw rodents to the area. They were aware of the issue with the rodents in the facility, but they were not aware of the amount of activity in the dry storage area. They stated that rodent droppings in the dry storage area had the potential to make someone sick. The Administrator stated they had actively been addressing the recommendations made by the Pest Control company, but they did not close them out on their end. They stated the last time they came was 04/03/2026, and they specifically asked them to, at least, comment on the recommendations that had been addressed, instead of just leaving them open.During an interview on 04/08/2026 at 9:07 AM, Licensed Practical Nurse #1, Resident Care Coordinator, stated the third flood did have mice sightings about a month ago and the facility had an exterminator come into the building. They stated a staff member reported they saw a mouse go from one room into another about two and a half (2.5) weeks ago. Licensed Practical Nurse #1 stated they were not sure what room it was but most of the sighting had been in the short hallway that goes from rooms 326 to 335. Licensed Practical Nurse #1 stated many of the residents, in the short hall, have families that bring in outside foods and there were also a couple residents in that hallway that hoard items in their rooms. They stated they believed that the rodent sightings had decreased, and the residents were now storing their food items in plastic bins. Licensed Practical Nurse #1 stated residents should not be living with mice because rodents are gross and dirty. 10 New York Code Rules and Regulations 415.29 (j)(5)

Based on interview and record review conducted during the survey the facility failed to ensure that services provided or arranged by the facility met the current professional standards of quality for one (1) (Resident #15) of five (5) residents reviewed for psychotropic medications. Specifically, Licensed Practical Nurse administered multiple doses of an antianxiety medication to Resident #15 without an active and valid physician's order. The findings include:Refer to 757 scope and severity= DThe policy and procedure titled Administering Medications dated 04/2019 documented medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescribers' orders, including any time frame. The individual administering the medication initials the resident's Medication Administration Record on the appropriate line after giving each medication and records in the residents' medical record: the date and time the medication was administered; the dosage; route of administration; any complaints or symptoms for which the drug was administered; and any results achieved.The policy and procedure titled Documentation of Medication Administration dated 11//2022 documented a nurse or certified medication aide documents all medications administered to each resident on the resident's medication administration record and the medication is to be documented immediately after it is given.Resident #15 had diagnoses that included depression, diabetes mellitus, and cerebral infarction (type of stroke). The Minimum Data Set (a resident assessment tool) dated [DATE] documented Resident #15 had moderate cognitive impairment, was understood and able to understand others. There were no behaviors documented on the Minimum Data Set.The Order Recap Report dated [DATE] - [DATE] documented a physician order for Lorazepam oral tablet 2 milligrams, give one tablet by mouth every eight (8) hours as needed for agitation for three (3) days. The physician order documented the start date as [DATE] and an end date of [DATE]. Further review of the Order Recap Report revealed there were no additional physician orders for Lorazepam after [DATE].The Medication Administration Record dated [DATE] - [DATE] documented Resident #15 received one dose of Lorazepam on [DATE] at 6:54 PM and the order completion date was [DATE]. Further review of the medication administration record revealed there were no additional orders for Lorazepam after [DATE]. There was no documentation in the Resident #15's medication administration record they received Lorazepam on [DATE], [DATE] and [DATE].The controlled substance log form revealed Resident #15's Lorazepam medication was received from the pharmacy on [DATE], and the order instructions documented to give one (1) tablet by mouth every eight (8) hours as needed for agitation for three (3) days. Further review of the form revealed the medication continued to be signed out as administered on [DATE] at 10:00 PM, [DATE] at 4:00 PM, [DATE] at 11:30 PM, [DATE] at 6:00 AM, and [DATE] at 6:00 PM. The Facility Investigation Summary completed on [DATE] and signed by the Director of Nursing documented Resident #15 was ordered the controlled substance (Lorazepam) for three days only. Resident #15 had increased behavior and agitation after the medication was discontinued, nurses administered the discontinued medication and did not check the electronic medication administration record prior to administration.During an interview on [DATE] at 11:54 AM, Licensed Practical Nurse #5 stated they had administered one dose of Lorazepam to Resident #15 on [DATE] because the resident had become agitated and combative with care. Licensed Practical Nurse #5 stated they signed off the medication in the narcotic book and did not check for an active order in the electronic medication administration record. They stated they should have checked for an active order prior to administration and notified the physician if needed to obtain a new order.During an interview on [DATE] at 12:10 PM, Resident Care Coordinator Licensed Practical Nurse #7 stated nurses were to always check for active physician orders prior to administering any medications.During a telephone interview on [DATE] at 4:23 PM, Licensed Practical Nurse #2 stated they were concerned for Resident #15's safety and checked the narcotic book to see if they had any orders for anxiety medication. Licensed Practical Nurse #2 stated they saw an order for Lorazepam on the narcotic log sheet and pulled the medication from narcotic cabinet to administer to Resident #15. They stated when they looked in the electronic medication administration record there was no place to sign out the medication and just signed off on the controlled substance log that the medication was administered. Licensed Practical Nurse #2 stated they should have checked for an active order in the medication administration record prior to administering the medication.During an interview on [DATE] at 4:57 PM, Licensed Practical Nurse #6 stated they did not check the electronic medical record to ensure there was still an active order prior to administering the medication.During an interview on [DATE] at 5:18 PM, the Director of Nursing stated nurses were supposed to check and ensure there was an active physician order in place in the electronic medical record for all medications, and they expected the nurses to review the five (5) medication rights prior to administration for safety reasons and to prevent errors from occurring. The Director of Nursing stated there was no active Lorazepam order for Resident #15 after [DATE] and the medications should not have been administered.During an interview on [DATE] at 12:25 PM, Medical Provider #1 stated they would expect the nursing staff to check and follow all physician orders. If a medication order had expired, they would expect the nurses to contact them to have the order extended. They stated they expect staff to follow formal protocols and check for active physician orders prior to administering medications to prevent harm or injury.During a telephone interview on [DATE] at 12:38 PM, the Pharmacy Consultant stated the nurses should have ensured there was an order in place prior to administering the medication10 New York Code Rules and Regulations 415.12 (l) (2) (b)

Based on observation, interviews and record review conducted during the survey, the facility failed to ensure that a resident received foot care and treatment in accordance with professional standards of practice for one (1) (Resident #82) of two (2) residents reviewed for foot care. Specifically, Resident #82 was observed to have long, thick, discolored toenails during multiple observations and the resident was not provided with foot care and treatment to address their toenail care. The findings include: The policy titled Foot Care dated October 2022 documented that residents are provided with foot care and treatment in accordance with professional standards of practice. Residents are assisted in making appointments with transportation to and from specialists (podiatrist). The policy documented that trained staff may provide routine foot care (toenail clipping) within professional standards of practice for residents without complication in disease processes. Resident #82 was admitted to the facility with diagnoses of Huntington's Disease (a progressive break down of nerve cells in the brain impacting movement, cognition and mental health), adult failure to thrive (a syndrome affecting older adults characterized by rapid decline in physical, mental and functional health) and seizures. The Minimum Data Set (a resident assessment tool)dated 02/20/2026 documented Resident #82 was moderately cognitively impaired, usually understood and understands, had no behaviors or refusals of care and required maximal assist for bathing and minimal assist for personal hygiene. The Comprehensive Care Plan revised on 03/26/2026 documented that Resident #82 had an activity of daily living self-care performance deficit and was an extensive staff assist for personal hygiene, and a total staff assist for showering. The care plan documented Resident #82 was high risk for skin breakdown and interventions included to perform weekly skin assessments and check nail length and trim, clean nails on bath days when necessary.The Kardex Report (guide used by staff to provide care) dated 04/08/2026 documented Resident #82 required extensive assistance of one staff to perform personal hygiene and a total assist of one staff for showering. The Kardex documented to ensure the residents' nails are clean and filed down weekly. Review of the Order Recap Report dated 04/08/2026 revealed Resident #82 had medical provider orders for:-Podiatry consultations as needed dated 11/21/2025-Weekly skin monitoring every Wednesday during the 7:00 AM-3:00 PM shift for skin integrity and document in the assessment tab dated 02/24/2026 Review of the electronic treatment administration record from 03/01/2026-04/06/2026 revealed Registered Nurse #1 signed that they completed a skin check on 03/04/2026 and 04/01/2026. Licensed Practical Nurse #2 documented they performed a skin check on 03/11/2026. The 03/18/2026 and 03/25/2026 entries were blank.Review of Resident #82's electronic medical record, including progress notes and consultant notes from 11/21/2025-04/06/2026 revealed there was no documented evidence that the resident had their toenails trimmed or a podiatry visit. There were no documented refusals of toenail care.During an observation on 04/01/2026 at 10:41 AM and on 04/02/2026 at 10:51 AM, Resident #82 was in the dining area in their wheelchair. Resident #82 was not wearing any socks and the resident's toenails were thick, discolored, and appeared to be about a 1/2 inch long past their toe pads.During a morning care observation on 04/06/2026 at 10:17 AM, Resident #82 was in bed wearing jeans, a sweatshirt with a gown over them and gripper socks. Certified Nurse Aide #1 removed Resident #82's gripper socks and Resident #82's toenails continued to appear around a 1/2 inch long past their toe pads, thick and discolored.During an interview on 04/06/2026 at 10:57 AM, after AM care was completed for Resident #82, Certified Nurse Aide #1 stated the aides in the facility do not cut residents toenails, and it was the responsibility of the nurses. They stated the facility only allows the aide to file and clean residents fingernails, not cut them. Certified Nurse Aide #1 stated Resident #82's toenails appear to be long, and they needed to be cut. They stated they were not sure if the length of Resident #82's toenails hassled the resident or not because the resident does not wear shoes and only wears gripper socks. Certified Nurse Aide #1 stated they would describe Resident #82 toenails length to be about a 1/2 inch past their toenail pads. During an interview on 04/06/2026 at 11:10 AM, Unit Clerk #1 provided an untitled facility document dated April 2026 of residents that were on the podiatry list for April 2026. Resident #82 was not on the provided list, and they stated they have never been told that Resident #82 needed to be seen by the podiatrist. They stated the process for when a resident needed to be seen by the podiatrist, was that usually the resident themselves would tell them they needed to be seen by the foot doctor and then they would notify the Medical Records Director to add that resident to the list. Unit Clerk #1 stated the Medical Records Director was responsible for creating the facility's foot doctor visit list. During an observation and interview on 04/06/2026 at 1:50 PM, Registered Nurse #1 stated they cared for Resident #82 often and the last time the resident was on their assignment was 04/01/2026. Registered Nurse #1 removed Resident #82's gripper socks and observed Resident #82's toenails. Resident #82 toenails continued to appear long, discolored and thick. Registered Nurse #1 stated they did not feel Resident #82's toenails were too bad, but they did need to be cut. Registered Nurse #1 stated Resident #82's toenails were dry, white and had one centimeter growth past their toe pads. Registered Nurse #1 stated they would need to put in a referral for a podiatry visit because it appeared Resident #82's skin was starting to grow into the nail. They stated they had not put a referral in prior to this observation because they felt Resident #82's toenails were not too bad. They stated that if a resident did need their toenails cut, they would tell the certified nurse aide to cut them or tell the nursing supervisor on duty. During an observation and interview on 04/06/2026 at 2:00 PM, Resident #82 was in their room in bed, Registered Nurse #2 removed Resident #82's gripper socks, looked at the resident's toenails and stated that they were long and needed to be cut. Registered Nurse #2 stated that a resident's toenails should be assessed on their weekly shower day when their weekly skin check was completed. They stated that if the cart nurse was comfortable cutting the toenails, then they should, if not then the resident needed to be put on the podiatry list. Registered Nurse #2 stated that the facility allowed the nurses to cut toenails but not the certified nurse aides. They stated that after looking at Resident #82 toenails, they would not feel comfortable cutting the resident's toenails due to them being too thick, too long and the skin was starting to grow into the nail. Registered Nurse #2 stated the resident should have been put on the podiatry list prior to today's observation. During an interview and record review on 04/08/2026 at 9:54 AM, the Medical Records Director stated the process for adding a resident to the podiatry list was a supervisor or the unit manager would notify them that a resident needed to be seen and then they added the residents to the list with the date they were added. The Medical Records Director stated they had not been notified Resident #82 needed to be on the list prior to 04/06/2026. During an interview on 04/08/2026 at 12:42 PM, the Director of Nursing stated they expect weekly skin checks to be completed weekly on a resident's shower day. They stated that if the nurse noted that a residents' toenails needed to be cut on assessment then the toenails should be trimmed at that time. The Director of Nursing stated they did not have an expectation of the length of when toenails should be cut. It was more of a personal judgement, a personal preference and depending on risk factors a resident had such as scratching. The Director of Nursing stated they were familiar with Resident #82 and that the resident had spastic movements due to their disease process and was at risk for scratching. 10 New York Codes Rules and Regulations 415.12(k)(7)

Based on observations, interviews, and record review conducted during the Survey completed on 04/08/2026 the facility failed to store all drugs and biologicals in locked compartments for one (1) (Second floor) of two (2) medication rooms. Specifically, a controlled substance was not secured in the lock box in the medication refrigerator and both nurses had keys to refrigerator allowing unauthorized access to the medication.The findings include: The policy and procedure titled Medication Labeling and Storage dated February 2023 documented that controlled substances and other drugs subject to abuse are separately locked in permanently affixed compartments, except for when using single unit package drug distribution systems in which the quarterly stored is minimal and a missing dose can be readily detected. During an observation of the medication room on the Second floor on 04/08/2026 at 11:27 AM, Licensed Practical Nurse #3 unlocked the refrigerator in the medication room on the Second floor. As they opened the door, the lid to a metal box that was attached to the door fell open. Inside of the metal box was an open bottle of liquid Lorazepam (controlled substance to treat anxiety) 2 (two) milligrams per milliliter for Resident #136. A second clear plastic box was also affixed to the bottom of the refrigerator and did not contain any medications. Licensed Practical Nurse #3 stated, this is the problem. During an interview at this time Licensed Practical Nurse #3 stated the keys to the plastic box had been lost and the metal box does not lock because the lock was broken. They stated they were not responsible for Resident #136, and that Licensed Practical Nurse #4 was. During an observation and interview on 04/08/2026 at 11:30 AM, Licensed Practical Nurse #3 retrieved Licensed Practical Nurse #4. Licensed Practical Nurse #4 stated they were responsible for Resident #136, and they counted the Lorazepam at the beginning of their shift at 7:00 AM. The Lorazepam bottle was open and the medication count reconciled with the narcotic sign off sheet. Licensed Practical Nurse #3 stated the medication refrigerator had two lock boxes and neither were usable. Licensed Practical Nurse #3 stated that everyone knew the lock box did not lock including the former Director of Nursing. They added the former Director of Nursing left the facility in September 2025. Licensed Practical Nurse #3 and #4 both confirmed the Lorazepam was not stored appropriately since each of them had the keys to the pad lock of medication refrigerator and therefore both had access to the medication During an interview on 04/08/2026 at 11:33 AM, Registered Nurse #2 stated they were the Nursing Supervisor and a cart nurse at times on the Second floor. They stated they were aware that the narcotic lock box in the medication refrigerator had missing keys and the second lock box did not lock. Registered Nurse #2 stated they thought that the Lorazepam was properly stored because the refrigerator was locked down and the outside door to the refrigerator was locked. Registered Nurses #2 then stated if two nurses each had keys to the locked medication refrigerator then both nurses would have access to the lorazepam and that would not be appropriate. Registered Nurse #2 stated that former Director of Nursing, the maintenance department and the Administrator were all aware the keys were missing for the plastic lock box, and the mental box was unable to be locked During an interview on 04/08/2026 at 11:59 AM, the Director of Nursing stated that liquid Lorazepam should be stored in a locked box inside of a locked medication refrigerator. They stated they were aware that there was a medication refrigerator within the facility that the inside narcotic box could not be locked. The Director of Nursing stated it was still okay to store the Lorazepam in that refrigerator because the outside of the refrigerator was still locked. They stated it was not ideal that both floor nurses on the unit held keys to open the lock refrigerator and they each should have different access to different locked boxes. They stated they would know if there was any diversion to the medication because one nurse was still counting it upon key exchange. During a telephone interview on 04/08/2026 at 12:33 PM, the Pharmacy Consultant stated they would expect liquid Lorazepam to be stored double locked. The Pharmacy Consultant stated that the medication rooms were audited monthly but was unsure who did the monthly inspection. During an interview on 04/08/2026 at 12:22 PM, the Administrator stated they would expect all narcotics to be stored per the facilities policy and procedure. If the liquid Lorazepam was not locked inside of the medication refrigerators, it would not be appropriate storage. They stated they were not aware the medication refrigerator on the Second floor had missing keys to the narcotic storage box inside the refrigerator and the second lock box did not lock. 10 New York Code Rules and Regulations 415.18 (e)(2)

Based on observation, interview, and record review conducted during an Abbreviated survey completed on 12/30/24 (Complaint # NY00312953) the facility failed to protect a resident from sexual abuse for one (Resident #1) of three residents reviewed. Specifically, Resident #1 received explicit sexual text messages and a nude picture from a facility Housekeeper #1. The finding is: The policy titled Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigation dated 9/2022 documented all reports of resident abuse, neglect, exploration or theft of a resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Review of the State Operations Manual Appendix PP revised 8/8/24 documented allegations of staff to resident sexual abuse, nursing home staff are entrusted with the responsibility to protect and care for the residents of that facility. Nursing home staff are expected to recognize that engaging in a sexual relationship with a resident, even an apparently willingly engaged and consensual relationship, is not consistent with the staff member's role as a caregiver and will be considered an abuse of power. Resident #1 had diagnoses including illegal polysubstance abuse, hypertension (high blood pressure), and right knee infection. The Minimum Data Set (a resident assessment tool) dated 2/14/23 documented Resident #1 was cognitively intact, was understood, and understands others. There were no behaviors documented during the assessment period. Resident #1's comprehensive care plan documented the following: 3/21/23 they were at risk for victimization. They have been exposed to a nude photo and sexually explicit texts via cell phone. 3/25/23 they will occasionally say things that are not true to avoid accepting responsibility for their actions. 3/25/23 they have a behavior problem of sharing their cell phone number with employees despite being advised to avoid doing so. Review of the facility Investigation Summary dated 3/19/23 documented Licensed Practical Nurse #1 was called to the resident's room to see something. The resident explained they were getting messages from Housekeeper #1 that were making them uncomfortable. Resident #1 showed Licensed Practical Nurse #1 a sexually explicit text message and a nude photo including Housekeeper #1's face. The Supervisor, Director of Nursing, and the police were notified. A Progress Note dated 3/21/23 at 5:05 PM, documented the Social Worker spoke with the resident to follow up on the recent incident. The resident stated they were not in any distress and stated they did not want to receive any counseling at that time. They would continue to monitor the resident's mood and behavior for any changes. Review of the local police department Incident Report dated 3/19/23 documented an officer reported to the facility and met with Registered Nurse Supervisor #1 and Resident #1. Resident #1 stated Housekeeper #1 had been continuously harassing them. The first incident happened on 3/15/23, Resident #1 stated they felt violated when Housekeeper #1 woke them up by rubbing their leg but did not touch them sexually, it did alarm them to the point Resident #1 was annoyed. The second incident occurred when Resident #1 gave Housekeeper #1 their cell phone number. Resident #1 stated they received several text messages stating that Housekeeper #1 wanted to engage in sexual relations. The resident never told Housekeeper #1 to stop they just ignored the messages. During an interview on 11/18/24 at 12:42 PM, the Director of Quality Assurance stated they were in the process of completing their annual in-house re-education on abuse and neglect with the staff and had finished the staff education after the incident. During a telephone interview on 11/20/24 at 9:41 AM, Housekeeper #1 stated they worked at the facility back in 2023 as a cleaning person which included resident rooms. They left employment because they were terminated for texting a resident at the facility on their personal phone during non-working hours, Housekeeper #1 did not recall the resident's name who they texted, and they did not recall Resident #1. Housekeeper #1 stated they sent the resident a picture of themself, they believed it was of their face, and the facility thought it was inappropriate and part of their policy that's why they were terminated. Housekeeper #1 could not recall the content of the text message. On 11/20/24 at 10:10 AM, an attempt was made to contact Resident #1 via phone and it was unsucessful. During a telephone interview on 11/20/24 at 10:58 AM, Detective #1 from the local police department stated the case reported in 3/2023 involving Resident #1 was not investigated by the department and the case was closed. During a telephone interview on 12/17/24 at 12:54 PM, Licensed Practical Nurse #1 stated they no longer worked at the facility but was employed by the facility at the time of the alleged incident. They were a floor nurse at the time, they stated they were called into the resident's room and Resident #1 showed them a picture of Housekeeper #1 exposed from the waist down with an erection and the housekeeper's face was in the picture. There were also explicit sexual text messages, Licensed Practical Nurse #1 could not recall if the resident responded back to the text messages. They brought the resident's phone to the Supervisor. Resident #1 did not seem like they were in distress or upset at the time. They wrote a statement and had no other involvement in the incident. Afterwards staff were re-educated on abuse. Licensed Practical Nurse #1 stated the incident was inappropriate, but did not feel it was abuse. During a telephone interview on 12/17/24 at 2:22 PM, Registered Nurse Supervisor #1 stated Resident #1 was involved in a texting issue with a staff member. The resident was discharged shortly after. They also stated there was abuse education provided to the staff after the incident. They believed the resident was a consenting participant. During a telephone interview on 12/30/24 at 12:32 PM, the Medical Director stated the situation was inappropriate, but they were two consenting adults and would not consider it abuse. Based on the following corrective actions it was determined the facility implemented corrective actions to correct the non-compliance: Upon entrance to the facility on [DATE] at 8:30 AM, the Human Resource Director had terminated the staff member involved. The facility Director of Nursing at the time had re-educated facility staff on abuse and neglect. During the Abbreviated survey completed on 12/30/24 it was verified through staff interviews and record review that the facility re-educated facility staff on abuse and neglect. 10 NYCRR 415.3 (d)(1)(vii)

Based on observation, interview, and record review conducted during an Abbreviated survey (Complaint #NY00354751), the facility did not ensure any individual working in the facility as a nurse aide on a full time basis for more than 4 months was competent to provide nursing and nursing related services and that individual has completed a training and competency evaluation program or a competency evaluation program approved by the State meeting the requirements for two (certified nurse aide trainee #1 and #2) of seven staff members reviewed for training. Specifically Certified Nurse Aide Trainee #1 and #2 had been employed by the facility and functioned in the role of a nurse aide for greater than 4 months without receiving a nurse aide certification. The finding is: Review of the policy and procedure titled Nurse Aide Qualifications and Training Requirements dated October 2017, documented the facility will not employ any individual as a nurse aide for more than 4 months full time, temporary, per diem, or otherwise, unless that individual is competent to provide designated nursing care and nursing related services, and has completed a training program and competency evaluation program approved by the state. Additionally, the policy documented that nursing assistants failing to successfully complete the required training program within the first 4 months of their date of employment may be terminated or may be reassigned to non-nursing related services. Review of the Certified Nursing Assistant Trainee job description dated 4/1/98, documented the qualifications included that the trainee would complete the approved 100-hour Nurse Aide Trainee program, clinical, and written competency examination within 120 days from the date of hire. Review of Certified Nurse Aide Trainee #1's employee file documented that they had transitioned from the dietary department to the nursing department on 6/2/24 and was a full-time employee. Review of Certified Nurse Aide Trainee #1's CNA Training Program Checklist, revealed they had enrolled in the training program on 6/3/24 and had completed training on 6/24/24. There was no documented evidence in the employees file of exam scheduling attempts, success, or failed exam attempts. Review of Certified Nurse Aide Trainee #2's employee file, documented that their date of hire was 5/30/24 and that they were a full-time employee. Review of Certified Nurse Aide Trainee #2's CNA Training Program Checklist, revealed that they had enrolled in the training program on 6/3/24 and had completed training on 6/24/24. There was no documented evidence of exam scheduling attempts, success, or failed exam attempts. During an interview on 11/18/24 at 10:05 AM, Certified Nurse Aide Trainee #1 stated they had completed their training in June 2024 and had not yet been scheduled for testing. Certified Nurse Aide Trainee #1 stated they did not have another staff member overseeing the care they provided to residents. They provided care to residents that were a one assist level of care which included toileting, dressing and transfers. Certified Nurse Aide Trainee #1 stated that at times they had been given a full assignment due to staffing shortages. During an interview on 11/18/24 at 10:31 AM, Licensed Practical Nurse #1 stated the nurse aide trainees should not get full assignments, would assist the certified nurse assistants with their assignment and could provide care to residents that required only a one-assist level of care. During an interview on 11/19/24 at 3:23 PM, Certified Nurse Aide Trainee #2 stated that they had completed their nurse aide training at the end of June 2024 and had not yet been scheduled for testing. They stated while working as a trainee they did not get a full assignment, would be assigned 7 or 8 residents that were independent and would oversee their care, which included answering call lights, passing meal trays, and assisting with toileting. During an interview on 11/20/24 at 10:15 AM, Licensed Practical Nurse #2 stated they believed the nurse aid trainees worked alongside the certified nursing assistants. They stated they were unsure what duties they could perform independently and they did not have to sign off for the care the nurse aide trainees had provided to residents. During an interview on 11/20/24 at 10:50 AM, Licensed Practical Nurse Care Coordinator #1 stated certified nurse aide trainee's job duties included cleaning rooms, passing trays, and grooming. They stated they could not provide any hands-on care without another certified nurse assistant present. Licensed Practical Nurse Care Coordinator stated there was no documentation for the nurses or certified nurse assistants to sign off for supervision of the trainees. During a telephone interview on 11/20/24 at 1:34 PM, the Senior Nurse Aide Evaluator for (name of educational testing service) stated they had just spoke to the facility's Director of Quality Assurance and had forwarded documentation from the New York State Nursing Home Nurse Aide Training Program and Certification dated January 2017. Review of the email documentation provided by (name of educational testing service) Senior Nurse Aide Evaluator on 11/20/24 at 1:42 PM, included the New York State Nursing Home Aide Training Program and Certification manual dated January 2017 that documented if an individual had not passed the certification examination within three attempts and /or within 120 days of their first day of training or employment, the individual may no longer work as a nurse aide trainee in the nursing home. During an interview on 11/20/24 at 1:45 PM, the Director of Nursing stated they had been the previous Certified Nurse Aide Trainer and were responsible to submit all nurse aide trainee's testing applications to (name of testing site for nurse aide certification examinations) and would have been responsible to schedule their test dates. The Director of Nursing stated testing applications were submitted when the nurse aid trainee class was completed and that they would need to have at least four trainees available to schedule testing. They stated they currently had five trainees in the facility that were waiting to test. The Director of Nursing stated they were under the impression nurse aide trainees had up to 24 months to obtain their certification and could continue working as a trainee up until that time. They stated they were just informed as of 11/20/24 that the nurse aide trainees should have completed testing within 120 days of their training. The Director of Nursing stated that both Certified Nurse Aide Trainee #1 and Certified Nurse Aide Trainee #2 had finished their training on 6/24/24 and had not completed their certification testing within the required timeframe. During an interview on 11/20/24 at 2:17 PM, the Director of Quality Assurance, stated they were not previously aware that the nurse aide trainees needed to complete testing within 120 days of their training. They stated that Certified Nurse Aide Trainee #1 and Certified Nurse Aide Trainee #2 should have been removed from the nursing department and assigned to another department with nonresident contact duties after they passed the timeframe required to test. During an interview on 11/20/24 at 2:27 PM, the Administrator stated based on the (name of the educational testing service) guidelines they were under the impression that nurse aide trainees had 24 months to complete their certification testing. They stated if they had been aware nurse aide trainees needed to completed testing within 120 days of training they would have expected testing to have been scheduled and completed. 10NYCRR 415.13 (d)(2)(iii)

Based on observation, interview, and record review conducted during a Complaint investigation (NY00344362 and NY00345636) conducted during a Standard survey completed on 7/15/24, the facility did not ensure that housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for three (Second, Third, and Fourth Floors) of three resident units and one of one main dining room. Specifically, multiple windows had dried leaves, dead insects, spider webs white and grey colored debris on the inside and outside on windowpanes and brown/black debris on the window sash in between the panes of glass; privacy curtains with reddish brown stains; tan stains and cracks on the ceilings; water dripping from the ceiling into a resident's room on the Third Floor; bathroom lights were dim and not in proper working order; resident room walls were in disrepair; and window shades had brownish reddish stains. The findings are: The policy and procedure titled Cleaning and Disinfecting of Environmental Surfaces dated 6/09 documented that housekeeping surfaces such as floors will be cleaned on a regular basis, when spills occur, or when visibly soiled. The policy documented that walls, blinds, and curtains in resident areas would be cleaned when surfaces were visibly soiled or contaminated. An undated facility document titled Housekeeping Cleaning Check List documented that staff were to wipe tables and windows in the dining room. An undated facility document titled Housekeeping Deep Cleaning Check List documented that resident windows were to be cleaned with Blue (a window cleaner) and the window seal to be cleaned with [NAME] (a multi surface disinfectant cleaner). The facility job description for a Housekeeper dated 4/23/12 documented that the responsibilities of a Housekeeper include cleaning a resident's room, other interior and exterior facility areas, and assisting in maintaining a clean and attractive environment for residents. The facility job description for Maintenance Assistant dated 4/23/12 documented that the responsibilities of a Maintenance Assistant include assisting in maintaining the physical plant, grounds, equipment, and assists in coordination of repairs. Observation on the Third Floor on 7/8/24 at 12:56 PM, revealed in Resident room [ROOM NUMBER] the light over the sink did not function properly. The light was dim, and the sink area was not fully illuminated. Observation on 7/11/24 at 8:03 AM revealed the light over the sink area was not fully illuminated. During this observation, an interview with the Maintenance Assistant stated that the light needed to be fixed and they were not aware of the issue. Observation on the Third Floor on 7/8/24 at 3:14 PM, revealed Resident room [ROOM NUMBER] walls were in disrepair with one hole measuring four inches by three inches deep with exposed yellow insulation, a three-inch-deep gouge into the wall and another hole measuring two feet by six and a half inches and three inches deep with exposed yellow insulation. The resident stated that the staff knew about the wall for a month, and it bothered them. Observation on the Fourth Floor on 7/9/24 at 11:55 AM, revealed the privacy curtain in the center of Resident room [ROOM NUMBER] had brown and reddish-brown stains throughout, and each stain was approximately one inch in diameter. At the time of the observation, the Maintenance Director stated the curtain needed to be taken down and washed. Observation on the Second Floor on 7/9/24 at 12:22 PM, revealed the textured solid ceiling of Resident room [ROOM NUMBER] had water stains that were various shades of tan in an area that measured approximately two feet long by two feet wide, above the sink. The area appeared cracked, patched, and re-cracked. The Maintenance Director stated it looked as if it was an old water leak. Observation on the Second Floor on 7/9/24 at 12:25 PM, revealed the textured solid ceiling of Resident room [ROOM NUMBER] had five water stains that were various shades of tan. The Maintenance Director stated it looked as if it was an old water leak. Observations on the Third Floor on 7/11/24 from 8:00 AM to 8:15 AM, revealed in Resident rooms [ROOM NUMBER], multiple windows had grey and white debris on the inside and outside of the windowpanes; multiple spider webs with dead insects on the webs; dried leaves, dead insects, brown and black debris. During these observations, the residents who resided in the rooms stated the windows were dirty and needed to be cleaned. The residents also stated the windows had been dirty for a long period of time and that the window shade was also dirty, and they would like it cleaned. Observation on the Third Floor on 7/11/24 at 8:20 AM, revealed in Resident room [ROOM NUMBER] the window had spider webs with dead insects. During this observation, the resident stated that the window didn't bother them anymore because they got used to it. Observation on the Third Floor on 7/11/24 at 8:30 AM, revealed Resident room [ROOM NUMBER] had a six-inch spider web from one wall to another outside the bathroom door, six areas on the ceiling with tan brownish colored stains, windowpanes with white and grey debris on the inside and outside with brown debris on the window sash, and floor tiles that were in disrepair with one floor tile off the floor and black debris on top of the tiles. During this observation, the resident stated that the windows had not been cleaned since they have stayed in that room for two years. The resident pointed to the ceilings at the tan brownish colored stains and stated it looked like they painted a smiley face there. During an interview on 7/11/24 at 8:52 AM with Housekeeper #1, they stated that room [ROOM NUMBER]'s floor was dirty and needed to be cleaned. Housekeeper #1 also stated that they could clean the inside of the windows, that spider webs should not be there, and they were not sure who was responsible for cleaning the window shades. Observation on the Third Floor on 7/11/24 at 9:55 AM, revealed Resident room [ROOM NUMBER] had water dripping from the ceiling onto the windowsill. During this observation, the Housekeeping Director stated that the air conditioner on the Fourth floor was leaking and leaked into room [ROOM NUMBER]. The Housekeeping Director stated that this should not be happening, and it should be fixed. During an interview on 7/11/24 at 9:55 AM with the Housekeeping Director, they stated that the floors should be cleaned on a regular basis. They stated that window cleaning contractors had come to the facility for estimates, but no one was hired. Observations of the main dining room on 7/11/24 at 12:31 PM, revealed multiple windows with grey and white debris on the inside and outside of the panes of windows; multiple spider webs with dead insects on the webs; dried leaves, dead insects, brown and black debris. Observations of the main dining room on 7/12/24 at 8:23 AM, revealed multiple windows with grey and white debris on the inside and outside of the panes of windows; multiple spider webs with dead insects on the webs; dried leaves, dead insects, brown and black debris. During this observation, Resident #17 stated that there's spider webs all over the windows in the dining room and they needed to be cleaned. During an interview on 7/12/24 at 11:02 AM with Housekeeper #2, they stated that sometimes they cleaned the windows, and the windows were dirty. Housekeeper #2 stated that they were not sure who was responsible for cleaning the windows. During an interview on 7/12/24 at 12:40 PM with the Maintenance Director, they stated that Maintenance and Housekeeping were responsible for cleaning and maintaining the resident rooms. The Maintenance Director stated that the facility could clean the inside of the window, but the outside of the windows had to be cleaned by a window cleaning contractor due to safety reasons. The Maintenance Director stated that window cleaning contractors were contacted for estimates by the former Housekeeping Director approximately two or three years ago. The Maintenance Director stated that the air conditioners will leak due to condensation from staff opening windows while running the air conditioner. They stated that they needed to do an education with staff about keeping windows closed when running the air conditioners. The Maintenance Director stated that staff can contact them through the computer-based system to report any maintenance issues. They also stated that staff can also have them paged for any maintenance issues. During an interview on 7/12/24 at 1:16 PM with the Administrator, they stated that they expected the staff to clean the resident rooms. They also stated that they expected staff to report any maintenance issues to the maintenance department. 10 NYCRR 415.5(h)(2)

Based on interview and record review conducted during the Standard survey completed on 7/15/24, the facility did not ensure that services provided by the facility as outlined in the comprehensive care plan, met professional standards of quality for one of (Resident #23) of six residents reviewed. Specifically, medications were known to be transcribed erroneously which resulted in duplicate orders. The medication orders were not clarified or reported to a medical provider. In addition, the nursing staff signed both of the medications as being administered on multiple occasions. The finding is: The policy and procedure titled Medication and Treatment Orders with revised date July 2016, documented that orders for medications and treatments would be consistent with principles of safe and effective order writing. Resident #23 had diagnoses that included end stage renal disease, dependence of renal dialysis and hypertension. The Minimum Data Set (a resident assessment tool) dated 6/13/24 documented the resident was understood, understands, and was cognitively intact. Review of the Comprehensive Care Plan with date initiated 6/12/24, documented that Resident #23 had hypertension. Interventions include to give antihypertensive medications as ordered and obtain blood pressure readings. Review of the Order Summary report dated 7/15/24 documented that Resident #23 had an order for: Isosorbide mononitrate extended release 30 milligrams in the morning for hypertension with order date of 5/30/24. -Additionally, there was a second order for Isosorbide mononitrate extended release 30 milligrams in the morning for hypertension with order date of 5/30/24. labetalol HCL 200 milligrams every 12 hours for hypertension -Additionally, there was second order for labetalol HCL 200 milligrams every morning and at bedtime for hypertension with order date of 5/30/24. The medication administration records from 5/30/24-7/11/24 documented that Resident #23 had the following orders: -Isosorbide mononitrate extended release 30 milligrams daily at 7:00 AM -Isosorbide mononitrate extended release 30 milligrams daily at 9:00 AM -labetalol 200 milligrams every 12 hours at 9:00 AM and 9:00 PM -labetalol 200 milligrams in the morning and at bedtime at 7:00 AM and 7:00 PM Nursing staff erroneously signed off both medications as being administered for a total of 99 doses. Review of Interdisciplinary Notes from 5/29/24 through 7/15/24 revealed there was no documented evidence the medical provider was notified of duplicate orders and need for clarification for isosorbide mononitrate and labetalol HCL. During an interviews on 7/11/24 between 3:20 PM and 3:42 PM, Licensed Practical Nurse #8, Licensed Practical Nurse #9 Resident Care Coordinator, and Licensed Practical Nurse #1 all stated they knew Resident #23 had two orders (duplicative) for the isosorbide and labetalol. They stated they did not notify anyone to clarify the medication orders but should have. They also stated they may have signed for the administration of the second doses, but they did not actually administer the second doses. Additional in person and telephone interviews: 7/12/24 at 1:29 PM, Licensed Practical Nurse #10 stated they did not notify the medical provider or supervisor for clarification of Resident #23 duplicate orders but should have. They stated that there was a potential of nursing staff to administer two doses of isosorbide and labetalol but everyone should know it was a duplicate order. 7/15/24 at 3:03 PM, Licensed Practical Nurse #6 stated double orders on the medication administration record had happened before because there must be a glitch in the system. They stated they did not notify the supervisor or medical provider for order clarification but should have. Licensed Practical Nurse #6 stated there could be a potential for other nurses to administer double doses but hoped they would know it was just glitch in the system. 7/15/24 at 10:01 AM, Licensed Practical Nurse #12 Nursing Supervisor stated they did not notify the medical provider for clarification of the duplicative medication orders but should have. Licensed Practical Nurse #12 stated no residents should have orders like that and the order should contain blood pressure parameters. 7/15/24 at 10:49 AM, Licensed Practical Nurse #2 stated they did not administer two doses of isosorbide and labetalol. They stated that residents have duplicate orders at times, and when that happens, they only administer one dose. Licensed Practical Nurse #2 stated they did not notify the medical provider for clarification. They stated that duplicate orders could cause confusion for other nursing staff and if they were to administer two doses it could result in Resident #23's blood pressure going too low. During a telephone interview on 7/15/24 at 10:18 AM, Consultant Pharmacist #2 stated on 5/31/24 and 6/18/24 the Consultant Pharmacist #1 sent the Director of Nursing Nursing Referral Findings notification via email about Resident #23 duplicate orders for isosorbide and labetalol. Consultant Pharmacist #2 stated it was a clerical error in transcription of the orders. During a telephone interview on 7/15/24 at 11:38 AM, Medical Provider #1 stated they were never notified of the transcription error/duplicative orders for Resident #23 and should have been as soon as the nursing staff were aware of the error. Medical Provider #1 stated there was a potential for Resident #23 to receive double doses of the medications. They further stated there should have been a double check so these types of errors would not occur. During an interview on 7/15/24 at 12:01 PM, the Director of Nursing stated they could not locate the Nursing Referral Findings that Consultant Pharmacist #1 sent on 5/31/24 and 6/18/24 to discontinue Resident #23's duplicate orders for isosorbide and labetalol. The Director of Nursing stated that they had entered the initial order for Resident #23's labetalol and isosorbide on admission. Later that day, Licensed Practical Nurse #12 re-entered another order for labetalol and isosorbide. The staff nurses should have notified them or the nursing supervisor as soon as the double order was noted. The Director of Nursing stated that the nurses could have administered a double dose where the adverse effects to Resident #23 would not be good. During an interview on 7/15/24 at 12:14 PM, the Director of Quality stated Resident #23's labetalol and isosorbide orders were transcribed twice upon admission. They stated their expectation was that the medical provider would be notified for order verification. The Director of Quality stated that there was a potential for Resident #23 to be overdosed causing negative health outcomes and low blood pressures. 10 NYCRR 415.11(c)(3)(i)

Based on observation, interview, and record review conducted during a Standard survey completed on [DATE], the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, two (Unit 2 and Unit 4) of three unit nourishment refrigerators, one of one main kitchen observed had issues. The nourishment room refrigerators contained undated, unlabeled, and out of date food and drink items. The kitchen walk-in, beverage reach-in and tray line coolers contained undated and unlabeled items. The beverage reach-in cooler contained potentially hazardous beverages that exceeded the safe holding temperature for cold beverages. The findings are: The policy and procedure titled Food Preparation and Service revised [DATE] documented the danger zone for food temperatures is between 41 degrees Fahrenheit and 135 degrees Fahrenheit and that this temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. Potentially hazardous foods include seafood, milk, yogurt, and cottage cheese. The policy and procedures titled Food Receiving and storage revised [DATE] documented all foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date) and refrigerated foods must be stored below 41 degrees Fahrenheit and food items and snacks kept in the nursing units must be kept below 41 degrees Fahrenheit and labeled with a use by date. All foods belonging to residents must be labeled with the resident's name, the item and the use by date. The policy and procedure titled Foods brought by Family/Visitors revised [DATE] documented food that is left with the resident to consume later will be labeled and stored in a manner that is clearly distinguishable from facility-prepared food and perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the use by date. The nursing and/or food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, past due package expiration dates). 1. An observation of the main kitchen on [DATE] at 10:02 AM revealed the beverage reach-in cooler in the alcove between the dining area and the kitchen displayed an internal temperature of 48 degrees Fahrenheit, and a thermometer placed inside the cooler displayed a temperature of 51 degrees Fahrenheit. There was a temperature log on the outside of the cooler. The cooler contained 7 unopened half gallons of whole milk, a box of single serve coffee creamers, a 22-quart white food grade square bucket with an orange liquid and a plastic 2-cup measuring cup floating in the liquid. The bucket was not covered. Review of the 2024 Fridge/Freezer/Cooler Temps log on the door of the cooler revealed that from [DATE] to [DATE] the temperature documented once daily exceeded 40 degrees Fahrenheit on 11 of the 69 days, there were 10 blank days, and the temperature documented on [DATE] was 44 degrees Fahrenheit. At the bottom of the log, it stated Refrigerator 40* or lower. During an interview and observation on [DATE] at 10:07 AM, Dietary Director #1 stated the milk and creamers were potentially hazardous foods and was not sure how long the temperature of the cooler had been above 41 degrees Fahrenheit. Dietary Director #1 used a facility food thermometer to obtain the temperature of the milk. The temperature of the milk was 47.5 degrees Fahrenheit. Dietary Director #1 stated the cooler temperature was documented once daily first thing in the morning by the dietary supervisor upon their arrival at the facility. Dietary Director #1 stated they were not aware this cooler had operated at a temperature exceeding 40 degrees Fahrenheit. During an interview on [DATE] at 10:54 AM, Dietary Supervisor #1 stated they arrived at the facility at 4:00 AM on their workdays and had worked on [DATE]. They stated the cook arrived at 5:00 AM and either they or the cook took responsibility of documenting the temperatures of coolers and freezers first thing in the morning. They stated that they documented the temperature of the outside display at that time and if the temperature exceeded 40 degrees Fahrenheit, they were supposed to notify Dietary Director #1 but did not. Dietary Supervisor #1 stated that the orange liquid in the bucket observed in the cooler on [DATE] should not have had a measuring cup floating in it, the measuring cup should have been washed and hung up. 2. An observation of the main kitchen on [DATE] at 10:10 AM revealed the French door fridge/freezer near the tray line contained an opened package of bologna inside a zipped plastic bag that was not labeled or dated. The walk-in cooler contained a food grade clear square container that was covered with clear plastic wrap and contained a light-yellow powdery substance that was labeled Cheese ,d+[DATE]. There was an opened 46-ounce container of thicken lemon water with no lid and an opened 46-ounce container of thickened apple juice. Both containers were not dated/labeled with use by date and the instructions printed on the containers documented they may be kept up to 7 days under refrigeration after opening. During an interview at the time of this observation, Dietary Director #1 stated the cheese was expired and should not be in the cooler. They stated opened items of food should not be kept more than 3 days past the date they were opened. 3. An observation in the Unit 4 nourishment room on [DATE] at 9:25 AM revealed one fish, cut into pieces, including the head, in a zipped plastic bag, a plastic container of about 1 cup of cooked rice, a plastic grocery bag with three plastic containers of food (macaroni and cheese, French fries, and fried chicken), and opened 16.9 ounce bottled water about two-thirds full, one commercially packaged burrito within manufacturer's best by date. All off these items were not labeled with a resident's name and identification of food item and were not dated. The freezer contained at least three flattened and misshapen popsicles with their packaging stuck to the bottom and sides of the freezer that could not be moved. A sign posted on the front of the nourishment refrigerator titled Refrigerator Rules documented no staff items were to be stored in this refrigerator, resident items were to be dated and labeled with their name, and any item that was in the refrigerator not dated, not labeled with a name, or was more than three days old would be discarded. During an interview and observation on [DATE] at 1:10 PM of the Unit 4 nourishment room, Certified Nurse Aide #15 stated resident food needs to be labeled, dated, and only kept up to three days in the nourishment refrigerator. If food items had no names and dates on them, staff would not know whose food it was, and they stated they had no idea who the fish belonged to and how long it had been in this refrigerator. During an interview and observation on [DATE] at 4:35 PM of the Unit 4 nourishment room, Dietary Director #1 stated the Refrigerator Rules were standard practice and should be followed. They stated the nourishment refrigerators were for resident food only. They assumed the fried chicken, macaroni and cheese, and French fries belonged to a resident, and they needed to ask the nurses if anyone knew who this food belonged to. If they thought it was greater than three days old or if it could not be identified with a date, it must be thrown out. Additionally, they stated the fish should have been labeled with a name and date and should be thrown out at this time. Dietary Director #1 stated they personally checked nourishment refrigerators each morning around 7:00 AM for a quick glance to guide the dietary staff for the day, and a dietary staff member checked these refrigerators at 7:00 PM each night to add nourishments. Dietary Director #1 stated, if a resident's family members brought in food for a resident, it must be labeled, but they were not certain whose responsibility it was to label it. During an interview and observation on [DATE] at 4:45 PM of the Unit 4 nourishment room, Certified Nurse Aide #10 stated staff food did not belong in the nourishment room refrigerators. Resident food should be labeled with a name, room number, and date. They further stated the food must always be labeled with a date because if the food was more than a couple of days old residents should not eat it. Certified Nurse Aide #10 stated they had not previously noticed the whole fish in the zipped plastic bag in this refrigerator, it looked raw to them, and they believed a resident should not eat raw fish for their safety. 4. An observation in the Unit 2 nourishment room on [DATE] at 10:40 AM revealed the nourishment refrigerator contained a 64-ounce bottle of coffee creamer, one quarter full with a manufacturer's best by date stamp of [DATE], several individual 2 ounce cups of a white creamy liquid and a clear brown liquid, one opened commercially packaged pudding cup, half full, two commercially packaged freezer meals (labeled with a room number), an opened 15.2 ounce bottle of brand-name orange juice, three quarters full, and one bag of .75 pounds of grapes. There were no names or dates on any of these items. At the time of this observation, Plant Operations Technician #1 stated the pudding cup needed to be thrown away and placed it in the trash. During an interview and observation on [DATE] at 4:50 PM in the Unit 2 nourishment room, Dietary Director #1 stated the commercially packaged freezer meals documented Keep Frozen on the packages, therefore they should not be in the refrigerator. They also stated they expected a name and date opened on the bottle of orange juice and the individual cups of white creamy and clear brown liquid and the coffee creamer needed to be thrown out. Additionally, they stated they expected the grapes to be labeled with a date and resident name. During an interview on [DATE] at 4:50 PM, Certified Nurse Aide #14 stated both Certified Nurse Aides and residents themselves could place food in this refrigerator and whoever placed the food in the refrigerator should label it. During an interview on [DATE] at 10:09 AM, the Administrator stated they were the person who wrote the Refrigerator Rules and placed them on the unit refrigerators in the nourishment kitchens. They stated they expected Certified Nurse Aides and Nurses to label food placed in these refrigerators and toss items over three days old. The Administrator stated dietary staff check the unit fridges for temperatures and it was important to label food items, date them, and discard them after three days, so no residents get sick from eating expired foods. NYCCR 415.14 (h) Subpart ,d+[DATE] Food Service Establishments ,d+[DATE].31(c), ,d+[DATE].40, ,d+[DATE].43(e)

Based on interview and record review conducted during a Standard Survey completed on 7/15/24, the facility did not ensure that all alleged violations including abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than two hours after the allegation was made to the facility's Administrator for two (Resident #26 and Resident #107) of nine residents reviewed. Specifically, Resident #26 was found to have an injury of unknown origin and Resident #107 had a resident to staff altercation which were not reported to the administrator immediately. The findings are: The policy and procedure titled Abuse Prevention Program revised December 2016 documented the facility develops and implements policies and procedures to aid the facility in preventing abuse, neglect, or mistreatment of residents. As part of the resident abuse prevention, the administration will require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. Identify and assess all possible incident of abuse and investigate and report any allegations of abuse within timeframes as required by federal requirements. The policy and procedure titled Accidents and Incidents - Investigating and Reporting revised July 2017 documented all accidents and incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The policy and procedure titled Abuse Investigating and Reporting revised July 2017 documented all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than two hours if the alleged violation involves abuse or resulted in serious bodily injury or 24 hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. 1. Resident #26 had diagnoses that include vascular dementia, rheumatoid arthritis, and post-traumatic stress disorder. The minimum data set (a resident assessment tool) dated 12/23/23 documented the resident usually understood, usually understands and was severely cognitively impaired. The Comprehensive Care Plan dated 11/16/18, documented that Resident #26 was at risk for falls and had a history of falls related to dementia with interventions added on 2/13/24 to include resident is known to lower self to floor and get themself back up into bed and to keep environment safe and free of clutter. Review of the 2603 Injury of dated 2/12/24 at 9:45 AM prepared by the Director of Nursing revealed writer was notified in morning report that Resident #26 had a bruise on their forehead. Writer assessed Resident #26's injuries and noted a bruise on the left side of their forehead, elbow, and lateral hands. A statement obtained on 2/12/24 from Certified Nursing Assistant #9 documented they worked on the 11th of February and noticed Resident #26 had a bruise on the side of the head. Certified Nurse Aide #9 reported it to Licensed Practical Nurse #6. A statement from Licensed Practical Nurse #5 on 2/12/24 documented they were informed by Certified Nursing Assistant #6 that morning (2/12/24) that there was a bump and bruise on the left side of Resident #26's head. The Certified Nursing Assistant also found more bruising around the left temple, left wrist, and elbow. A statement obtained from Licensed Practical Nurse #6 on 2/16/24 revealed Licensed Practical Nurse #6 was told by Certified Nursing Assistant #9 sometime on the elevator that Resident #26 had a bruise on the side of their head that they had not noticed the day before. When Licensed Practical Nurse #6 got back to the unit they checked over Resident #26 and then reported it to the next shift coming on and put them on the report sheet. Review of facility staffing sheet titled Niagara Rehabilitation and Nursing Center dated 2/11/24 documented Licensed Practical Nurse #6 worked 7 AM to 8 PM, Certified Nursing Assistant #9 worked 7 AM to 3 PM, and Licensed Practical Nurse #5 worked 11 PM to 7 AM. Facility staffing sheet dated 2/12/24 documented Certified Nursing Assistant #9 worked 7 AM to 3 PM. Licensed Practical Nurse #6 was not on the scheduled for 2/12/24. During a telephone interview on 7/11/24 at 10:19 AM Licensed Practical Nurse #6 stated they were told about the bruise on Resident #26's head in the elevator by Certified Nursing Assistant #9. They stated they reported it to Licensed Practical Nurse #5 the next morning. During an interview on 7/11/24 at 10:39 AM Licensed Practical Nurse #5 stated they were informed about the bruise the next morning (2/12/24) by Certified Nursing Assistant #9 and then reported it to the Director of Nursing. An accident and investigation were then completed. During an interview on 7/11/24 at 10:59 AM Certified Nursing Assistant #9 stated they could not recall who they reported the bruise to but knows they reported it right away. Certified Nursing Assistant #9 stated it is important to report anything right away so that they can find out what happened. During an interview on 7/11/24 at 11:48 AM the Director of Nursing stated the incident involving Resident #26 was reported to them on the morning of 2/12/24 by Licensed Practical Nurse #5. They did not know who reported it to Licensed Practical Nurse #5. The Director of Nursing stated they believed Licensed Practical Nurse #5 was made aware of the finding when they came in to work on 2/12/24. The Director of Nursing stated Licensed Practical Nurse #6 should have reported the finding to the supervisor on duty on 2/11/24 right after they were made aware of it. It is important to report findings right away so that they can be proactive and prevent circumstances from happening. The Director of Nursing stated their expectations would be that an assessment would have been done right away, and it should have been reported right away. During an interview on 7/12/24 at 11:48 AM the Administrator stated that they expect any findings to be reported right away to the Director of Nursing or someone in Administration so that an investigation can be started right away. The Administrator stated that if there was an allegation or accusation of abuse made, they would expect a thorough investigation to be completed right away to ensure compliance. 2. Resident #107 had diagnoses which included chronic obstructive pulmonary disease, anxiety disorder, and major depressive disorder. The Minimum Data Set, dated dated dated [DATE] documented that the resident understood, understands, and was cognitively intact. The Comprehensive Care Plan dated 8/15/23 documented that Resident #107 had a focus added on 11/14/23 to say the residents' strengths were that they had no cognitive deficits with an intervention to provide a safe and structured environment and enhance or support short term memory using calendars and verbal cues. During an interview on 7/9/24 at 8:34 AM Resident #107 stated there was an incident that occurred recently that they reported. Certified Nursing Assistant #16, while working on the overnight shift, refused to give them another soda and during the argument about the soda Certified Nursing Assistant #16 grabbed Resident #107's wrist. Resident #107 stated they grabbed Certified Nursing Assistant #16's wrist back and then they let go. Resident #107 stated there was no mark left on their wrist This incident was also witnessed by Resident #107s' roommate, Resident #114. Resident #114 was in the room during this interview and confirmed that Certified Nursing Assistant #16 grabbed Resident #107's wrist during this argument. Resident #114 stated they wanted to jump out of the bed and beat the Certified Nursing Assistant's explicit word stated. Resident #107 stated they reported the incident to Licensed Practical Nurse #5 the next morning. During an interview on 7/11/24 at 8:59 AM Licensed Practical Nurse #5 stated they were informed about the incident involving Resident #107 and the soda about a month ago. They were told Certified Nursing Assistant #16 would not give Resident #107 a soda because they pee a lot. Resident #107 did report to them that Certified Nursing Assistant #16 grabbed their wrist during this incident. Licensed Practical Nurse #5 stated they forgot to report that part when they reported the incident to the Director of Nursing. Licensed Practical Nurse #5 stated they did an assessment of Resident #107 directly after the incident was reported to them and saw no redness or bruising and the resident did not complain of any pain at the time. Licensed Practical Nurse #5 stated Certified Nursing Assistant #16 did not deny the incident occurred but said it happened differently than how Resident #107 reported it. Certified Nursing Assistant #16 wrote a statement regarding the incident and was told they could not take care of Resident #107. During a telephone interview on 7/11/24 at 9:22 AM Certified Nursing Assistant #16 stated they remembered the incident. They were caring for Resident #107 on the overnight shift and the resident had requested another soda after having two bottles that night already. Certified Nursing Assistant #16 stated they told Resident #107 they could not have another bottle because they were going to be getting their breakfast soon. Certified Nursing Assistant #16 stated they did not grab Resident #107's wrist, only refused to give them more soda. They stated they were given a write up to sign and was not allowed to take care of Resident #107 for a couple days. During an interview on 7/11/24 at 11:40 AM The Director of Nursing stated they were made aware of the incident that occurred on 6/20/24 by Licensed Practical Nurse #5 that morning. The Director of Nursing stated they were told the incident involved Certified Nursing Assistant #16 refusing to give Resident #107 a soda. The Director of Nursing stated Licensed Practical Nurse #5 did not report to them that there was a physical component involved in the incident so there was no investigation started. Certified Nursing Assistant #16 was given a write up for being discourteous and unprofessional. The Director of Nursing stated they would expect to be made aware immediately of any altercation or possible altercation/accusation, or as soon as staff is made aware. The Director of Nursing stated it is important to report these types of things to administration so that corrective actions can be made to prevent reoccurrence and to get notification out to the proper entities. The Director of Nursing stated any type of physical altercation or accusation of physical altercation should be submitted within 2 hours to the state after it's reported to staff. During an interview on 7/12/24 at 11:48 AM the Administrator stated that if there was an allegation or accusation of abuse made, they would expect a thorough investigation to be completed and the employee be suspended pending investigation to ensure compliance. The Administrator stated this incident should have been reported to the Director of Nursing and then the Administrator so that an investigation could have occurred. On 7/11/24 all accident and incidents involving Resident #107 were requested from the Director of Quality Assurance. The Director of Quality Assurance was unable to produce an accident or incident form and/or investigation for this incident that occurred on 6/20/24. 10 NYCRR 415.4(b)(4)

Based on observation, interview, and record review conducted during a Standard survey completed on 7/15/24, the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for one (Resident #9) of six residents reviewed. Specifically, Resident #9 who was dependent on staff for hygiene was not assisted with removing unwanted facial hair. The finding is: The policy and procedure titled Activities of Daily Living (ADL) dated March 2018 documented appropriate care and services will be provided for residents who are unable to carry out activities of daily living independently, with the consent of the resident and in accordance with the plan of care. Resident #9 had diagnoses that included metabolic encephalopathy (disease of the brain), diabetes, and schizoaffective disorder (a mental health condition that changes a person's thoughts, mood, and behavior). The Minimum Data Set (MDS - a resident assessment tool) dated 6/26/24 documented Resident #9 was understood, understands, and had moderate cognitive impairment. The Minimum Data Set documented Resident #9 required set-up/clean up assistance for personal hygiene and had no behaviors to include refusals of care. The comprehensive care plan with a revision date of 6/23/22, documented Resident #9 had an Activity of Daily Living self-care performance deficit. Interventions included limited assistance of one staff member for personal hygiene. The Visual/Bedside Kardex Report (a guide for staff to provide care) dated 7/15/24 documented Resident #9 required limited assist of one staff member for personal hygiene. The Treatment Administration Record dated July 2024, documented that weekly skin monitoring one time a day every Monday was completed on 7/1/24 and 7/8/24. Review of Nursing Progress Notes dated 7/1/24 through 7/15/24 revealed there was no documented evidence that Resident #9 refused to be shaved. During an observation and interview on 7/9/24 at 9:06 AM, Resident #9 had multiple dark grey and white facial hairs (0.25 - 0.5 inches) on their upper lip and multiple long white hairs 0.5 - 1 inch present on chin and neck. Resident #9 stated they did not like the facial hair and had asked staff for razors in the past. During intermittent observations made on 7/10/24 at 10:31 AM, 7/11/24 at 11:43 AM, and 7/12/24 at 9:51 AM Resident #9 continued to have long facial hairs to their upper lip, chin, and neck. During an observation and interview on 7/12/24 at 9:51 AM, Resident #9 stated they had a bed bath and was not offered or provided with assist to remove their unwanted facial hair. During further observation on 7/12/24 at 9:59 AM, Resident #9 had their call light on, and a staff member answered the call light. Resident #9 was observed asking the staff member for a razor and stated they wanted to shave. During an observation of morning care on 7/15/24 at 8:54 AM, Resident #9 stated to Certified Nurse Aide #7 and Certified Nurse Aide #18 that they used to shave every two days, the hair on their upper lip would grow fast, and that they did not like having facial hair. During the observation Resident #9 verbalized to Certified Nurse Aide #7 that they needed their facial hair removed. Certified Nurse Aide #7 gathered the soiled linen bags and left the room without offering or providing assist to remove Resident #9's facial hair. Certified Nurse Aide #7 completed Resident # 9's morning care and left their room. During an interview on 7/15/24 at 9:48 AM, Certified Nurse Aide #7 stated they had completed morning care with Resident #9. Certified Nurse Aide #7 stated Resident #9 had long facial hairs and they should have been removed during morning care. Certified Nurse Aide #7 stated residents should be shaved on shower days or when facial hair was present. They stated it was important so the residents would feel more confident. During an interview on 7/15/24 at 9:54 AM, Licensed Practical Nurse #4 stated residents should be shaved/have facial hair removed on shower days and when needed. They stated Resident #9 had facial hair present to upper lip, chin, and neck with some length and it should have been removed. During an interview on 7/15/24 at 9:57 AM, Licensed Practical Nurse Care Coordinator #5, stated they expected their staff to shave residents on their shower days and when it was needed. They stated the Certified Nurse Aides were responsible to shave residents and expected the nurses to complete their shower checks. Licensed Practical Nurse Care Coordinator #5 stated it would be important to the resident's self-esteem and for them to feel good about themselves. During an interview on 7/15/24 at 10:41 AM, the Director of Nursing stated they expected staff to shave both male and female residents regularly and at minimum once a week on shower days. They stated the Certified Nurse Aide assigned to the resident would be responsible. The Director of Nursing stated it was a dignity issue for a resident to not be clean shaven if that was their preference. 10 NYCRR 415.5(a)

Based on observation, interview, and record review conducted during the Standard survey completed on 7/15/24, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, and prevent new ulcers from developing for one (Resident #68) of two residents reviewed. Specifically, Resident #68 was not provided with an air mattress (a mattress that provides air flow to relieve pressure) as ordered by the physician. Additionally, nursing staff were inaccurately documenting that the air mattress was provided. The finding is: The policy and procedure titled Pressure Ulcers/Skin Breakdown dated March 2014, documented the nursing staff and attending physician will assess and document an individual's significant risk factors for developing pressure sores, for example, immobility, weight loss, and a history of pressure ulcers. The physician will authorize pertinent orders related to wound treatments and will help identify medical interventions related to wound management. Resident #68 had diagnoses that included arthritis (pain and inflammation of the joints), chronic obstructive pulmonary disease (lung disease), and left fibula (bone in the lower leg) fracture. The Minimum Data Set (a resident assessment tool) dated 4/19/24, documented Resident #68 was cognitively intact, was understood and understands. The Minimum Data Set documented, Resident #68 required substantial/maximal assistance (helper does more than half the effort) for bed mobility. Additionally, it was documented that Resident #68 was at risk of developing pressure ulcers, had one Stage 2 (partial thickness skin loss) pressure ulcer, one Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer, and moisture associated skin damage. The comprehensive care plan (identified as current) dated 10/30/23 with a revision date of 1/5/24 documented Resident #68 had limited physical mobility, was non ambulatory and required extensive assist of two staff members for bed mobility. The resident had an actual pressure ulcer on the left foot. Interventions included heel booties, weekly skin assessment, and protect skin from moisture. The comprehensive care plan was not care revised to include pressure ulcer development, history, and/ or resolution except to the heel and did not include the use of an air mattress. Review of the current Visual/Bedside Kardex Report (a guide for staff to provide care) documented Resident #68 required extensive assist of two staff members for bed mobility, incontinent care was to be provided every 2-3 hours, barrier cream to be applied with incontinent care, and staff was to report any areas of breakdown to nurse. The Kardex did not include the use of an air mattress. Review of the Electronic Medical Record order created on 4/12/24 by the Assistant Director of Nursing documented an air mattress was ordered for skin integrity and was to be in place at all times to promote skin integrity. Review of the Order Summary Report dated 7/12/24, revealed the air mattress ordered 4/12/24 was still in place. Review of the most recent Braden Scale (a tool for predicting pressure ulcer risk) dated 4/16/24, documented Resident #68 had slightly limited sensory perception (ability to respond to pressure-related discomfort), skin was very moist, activity level was chairfast, had very limited mobility, and that there was a potential problem with friction and shear. The nursing progress note dated 6/17/24, completed by the Assistant Director of Nursing documented Resident #68's wounds were healed, remained incontinent, and was at high risk to continuously break down. Additionally, the Assistant Director of Nursing documented Resident #68 was put on a turn and positioning schedule along with monitoring for incontinence every 2-3 hours. Review of the Skin and Wound Evaluation dated 6/17/24, revealed Resident #68 had an in-house Stage 2 (partial-thickness skin loss) pressure ulcer that was documented as resolved. Further review of the Physician wound consultant notes documented Resident #68 was seen on 6/6/24, 6/11/24, and 6/17/24 for skin related concerns which included pressure ulcers and moisture associated skin damage. During intermittent observations made on 7/8/24 at 3:19 PM, and 7/12/24 at 11:23 AM, Resident #68 was in bed and did not have an air mattress in place as ordered to promote skin integrity. Further observations made on 7/10/24 at 10:27 AM and 7/11/24 at 11:35 AM, Resident #68 was out of bed in wheelchair and no air mattress was present on bed. Review of the Treatment Administration Record from 7/1/24 through 7/12/24 revealed the nursing staff had initialed (documented) the air mattress was in place every shift. There was no documented evidence in the Treatment Administration Record Resident #68 refused the air mattress. During an observation and interview on 7/12/24 at 12:10 PM, Licensed Practical Nurse #4 stated Resident #68 had chronic pressure ulcers to the right and left buttocks that would frequently open and close. They stated preventative measures used for Resident #68 were barrier creams, powders, wheelchair cushion, and heel booties. Licensed Practical Nurse #4 entered Resident #68's room and stated resident did not have an air mattress in place. Licensed Practical Nurse #4 stated Resident #68 should have had an air mattress due to high risk for skin breakdown as they would refuse incontinent care and turn and positioning. During an interview on 7/15/24 at 10:34 AM, the Assistant Director of Nursing stated they were responsible for completing weekly wound rounds. They stated Resident #68's pressure ulcers were healed and that there was a daily treatment in place to maintain skin integrity. The Assistant Director of Nursing stated Resident #68 remained high risk for skin breakdown, had limited mobility and was incontinent. They stated residents that were high risk for skin breakdown should have an air mattress in place and would be documented on the care plan. They stated Resident #68 did not have an air mattress. During an interview on 7/15/24 at 10:41 AM, the Director of Nursing stated they would expect any resident that was at high risk for skin breakdown would have an air mattress and would expect the care plan to be updated by the nurse manager. The Director of Nursing viewed Resident #68's treatment administration record and stated that the order for the air mattress was being signed off every shift as present. They stated they would have expected the nurses to notify their nurse manager, Director of Nursing, Assistant Director of Nursing, or maintenance that Resident #68 did not have an air mattress in place per the physician order. 10NYCRR 415.12 (c) (1)

Based on observation, interview, and record review conducted during a Standard survey completed on 7/15/24, the facility did not ensure that residents who receive a psychotropic medication have gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs for one (Resident #63) of five residents reviewed for psychotropic medication use. Specifically, Resident #63 had no attempted gradual dose reductions since Prozac (antidepressant medication) was ordered on 3/3/23 and there was a lack of adequate supporting evidence for its continued use. The finding is: The policy and procedure titled Tapering Medications and Gradual Drug Dose Reduction, revised date 7/22 documented residents who use psychotropic medications shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. The staff and practitioner will consider tapering of medications as one approach to finding an optimal dose or determining whether continued use of a medication is benefiting the resident. The policy documented that the staff and the practitioner will consider tapering medications under circumstances when the residents' clinical condition has improved or stabilized; the underlying causes of the original target symptoms has resolved, or non-pharmacological interventions have been effective. For any individual who is receiving a psychotropic medication the staff and practitioner shall attempt a gradual dose reduction for psychotropic medications in two separate quarters within the first year of admission or new order, with at least one month between attempts unless contraindicated. After the 1st year, the facility shall attempt a gradual dose reduction at least annually, unless clinically contraindicated. The policy documented that the tapering may be considered clinically contraindicated if the physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident's function or cause psychiatric instability. Resident #63 had diagnoses including cerebral infarction (stroke), diabetes mellitus type 2 and major depressive disorder. The Minimum Data Set (a resident assessment tool) dated 5/31/24, documented Resident #63 was cognitively intact, understands and was understood. The assessment documented that resident had mild depression, no behaviors were exhibited and received an antidepressant medication. The comprehensive care plan initiated on 6/5/18 documented that Resident #63's communication was a strength, and they were able to make needs known. The care plan documented the resident used antidepressant medication due to major depressive disorder. Interventions included to administer antidepressant medications as ordered and evaluate and monitor for gradual dose reductions per pharmacy and medical doctor's reviews. The Order Summary Report dated 7/15/24 documented that Resident #63 had an active order for Prozac 20 mg daily for depression with start date of 3/4/23. The Order Summary Report revealed no attempted gradual dose reduction of Prozac since the start date of 3/4/23. Review of the physician Progress Notes from 7/2/23 to 7/12/24 contained no documented evidence of a clinical rationale for the gradual dose reduction of Resident #63's Prozac being clinically contraindicated. There was no documented evidence that Resident #63 was having depression symptoms, and it was documented that the resident had appropriate mood and affect. Review of Resident #63's interdisciplinary Progress Notes dated 2/1/24-7/15/24 contained no documented evidence that Resident #63 was displaying any behaviors or depressive signs or symptoms. During intermittent observations on 7/8/24 to 7/12/24 from 10:35 AM to 3:03 PM, Resident #63 displayed no negative behaviors, was pleasant, calm, and appeared well groomed. During an interview and observation on 7/12/24 at 12:00 PM, Resident #63 was sitting in the main dining room. The resident was pleasant and well-kempt. Resident #63 stated that they were doing good and were not having any depressive symptoms. Resident #63 stated that the medical provider had not reduced the dosage of their Prozac in over a year and would be agreeable to have a dose reduction if asked. During an interview on 7/12/24 at 2:52 PM, Licensed Practical Nurse #4 stated that Resident #63 has had no recent signs of depression. They stated Resident #63 enjoyed reading the paper and spent their days socializing with other facility residents on the first floor in the main dining room. During a telephone interview on 7/12/24 at 3:52 PM, Medical Provider #1 stated that Resident #63 was seen for a provider visit last week and was stable and did not have any signs of depression. Medical Provider #1 stated they do not recall when the last time Resident #63 had a gradual dose reduction of their Prozac but one should have been attempted within the last year. Medical Provider #1 stated that they attempt a gradual dose reduction of psychotropic medications so that the resident would be on the lowest effective dose possible and are unsure why they did not attempt a reduction or discontinuation of Resident #63 Prozac. During a telephone interview on 7/15/24 at 9:37 AM, Consultant Pharmacist #2 stated that the consultant pharmacist would request the medical providers attempt a gradual dose reduction of psychotropic medications per federal regulations unless the resident has a medical diagnosis of major depressive disorder. Consultant Pharmacist #2 stated that Consultant Pharmacist #1 did not send the medical provider a request a gradual dose reduction for Resident #63 Prozac probably because Resident #63 had a diagnosis of major depressive disorder. During an interview on 7/15/24 at 10:59 AM, Licensed Practical Nurse #5 (Resident Care Coordinator for the 3rd floor) stated that Resident #63 did not demonstrate any signs and symptoms of depression and did not have any behaviors. Licensed Practical Nurse #5 stated they had not participated in any interdisciplinary meeting for Resident #63 to discuss a gradual dose reduction of their Prozac that was ordered on 3/4/23. They stated the reason a resident should have a gradual dose reduction was so that they were on the least amount of medication possible because the body gets used to the medication and the medication doesn't work anymore. During an interview on 7/15/24 at 11:04 AM, Social Worker #1 stated that Resident #63 did not present with any negative behaviors and a times would [NAME] the losses they have had in the past couple years. Social Worker #1 stated that the interdisciplinary team would meet quarterly to discuss resident's behaviors, the dosages of psychotropic medications and if a gradual dose reduction was needed. They stated the last time Resident #63 was reviewed at an interdisciplinary meeting was maybe at the beginning of 2024. Social Worker #1 stated that if a resident was at their baseline or their behaviors had improved then the team would start a gradual dose reduction of their psychotropic medications. Social Worker #1 stated that Resident #63 was at their baseline, and they should have had a dose reduction attempted of their Prozac within the last year. During a telephone interview on 7/15/24 at 11:24 AM, Nurse Practitioner #1 stated that they took over Resident #63 care about four months ago and is unsure why the resident has not had a gradual dose reduction in their Prozac. The Nurse Practitioner #1 stated they reviewed the medical provider's documentation for Resident #63 and that the resident did not have a gradual dose reduction attempt of Prozac in the past year and the documentation did not include a contraindication for a gradual dose reduction. During an interview on 7/15/24 at 11:48 AM, the Director of Nursing stated that the facility reviewed resident psychotropic medication in an interdisciplinary meeting every quarter with the consultant pharmacist, social worker, administrator, and therapy. The Director of Nursing stated they started working at the facility in December 2023 and Resident #63 was not reviewed during a psychotropic interdisciplinary meeting since then and the resident had no behaviors or signs/symptoms of depression. The Director of Nursing stated that a gradual dose reduction of a resident's psychotropic medication should be attempted quarterly to meet federal regulations. During an interview on 7/15/24 at 12:05 PM, the Director of Quality stated that the facility should be performing monthly gradual dose reduction meetings that would be documented in the electronic medical record. The Director of Quality stated that Resident #63 was ordered Prozac in March of 2023 and there were no psychoactive medication review notes documented in the past year in their electronic medical record. They stated that the resident's Prozac dose should had been reviewed with the pharmacist and interdisciplinary team for a possible gradual dose reduction. The Director of Quality stated the federal guidance for a reduction of a psychotropic medication would be an attempted reduction twice within the first year of admission or a new order and then annually or a medical provider should document the reason a reduction was contraindicated. 10 NYCRR 415.12(I)(2)(ii)

Based on observation, interview, and record review conducted during a Complaint Investigation (#NY00329637) completed on 2/22/24, the facility did not provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administration of all drugs and biologicals to meet the needs of each resident for three (Resident #1, 2 and 3) of nine residents reviewed. Specifically, the facility did not obtain regularly scheduled medications from the pharmacy for Residents #1, 2 and 3 as ordered by the physician which resulted in multiple missed doses. The findings are: The policy and procedure titled Pharmacy Services - Role of the Consultant Pharmacist dated April 2007, documented the Consultant Pharmacist shall provide consultation on all aspects of pharmacy services in the facility, including evaluating process of receiving and interpreting prescribers' orders, acquiring, receiving, storing, controlling, reconciling, compounding, dispensing, packaging, labeling, distributing, administering, monitoring responded to, and using and or disposing of all medications, biologicals, and chemicals. In addition, helping the nursing staff identify and evaluate medication related issues, advising about the coordination of pharmaceutical services, helping the nursing staff evaluate and optimize their medication administration and documentation process, helping the facility establish and implement effective quality assurance activities to identify, resolve, and prevent medication related problems. The Consultant Pharmacist should assist the facility in education and inform staff, practitioners, residents, and staff about medications and pharmacy services and participate on the interdisciplinary team to address and resolve medication related needs or problems. Appropriate communication of information to prescribers and facility leadership about potential or actual problems related to any aspect of medications and pharmacy services, including medication irregularities, and pertinent resident -specific documentation in the medical record, as indicated. 1. Resident #1 had diagnoses of anxiety, Guillain-Barre Syndrome (a disorder of the immune system where the nerves are attacked by immune cells that causes weakness and tingling in arms and legs) and major depressive disorder. The Minimum Data Set (a resident assessment tool) dated 12/30/23 documented Resident #1 was cognitively intact. Review of the Order Summary Report dated 11/1/23-2/29/24 revealed an order for Duloxetine of 60 milligrams daily depression with a start date of 12/8/23. Review of Resident #1's Medication Administration Record dated November 2023 revealed that Duloxetine HCI (antidepressant) 60 milligrams was not documented as administered on 11/24/23,11/25/23, 11/27/23, 11/28/23 and 11/29/23. Review of a nursing progress note dated 11/28/23 revealed Licensed Practical Nurse #1 documented the medication (Duloxetine HCI) was out of stock. During an interview on 2/21/24 at 9:48 AM, Licensed Practical Nurse #2 stated the facility used a pharmacy in Rochester and that sometimes there was a delay in medications being delivered on time. During an interview on 2/21/24 at 11:25 AM, Licensed Practical Nurse #1 stated they were administering medications on 11/24/23, 11/26/23, & 11/28/23 and that Resident #1 did not receive their Duloxetine as prescribed by their physician. Licensed Practical Nurse #1 could not recall why the resident did not receive their medication. During an interview on 2/21/24 at 1:32 PM, Pharmacist #1 stated that Resident #1's Duloxetine was reordered on 10/28/23 and the facility received 30 pills, and that should have been enough medication until 11/28/23. Pharmacist #1 stated the Duloxetine was received by the facility on 12/1/2023. During an interview on 2/21/24 at 3:40 PM, the Director of Nursing stated they were unsure why Resident #1 did not receive their Duloxetine. The Director of Nursing stated they were not working at the facility at the time but stated it was horrible and the nurse should have notified the Supervisor and the Physician. 2. Resident #2 had diagnoses of multiple sclerosis (an autoimmune disease that affects the central nervous system by attacking the protective layer around the nerve fibers), psychoactive substance-induced disorder, and depression. The Minimum Data Set, dated dated dated [DATE] documented that Resident #2 was cognitively intact. The Comprehensive Care Plan dated 1/24/24 documented Resident #2 used antidepressant medication. Interventions included to administer antidepressant medications as ordered by physician. Review of the Order Summary Report printed 2/21/24 revealed an order for Prozac 20 milligrams give 3 capsules (60 milligrams) daily for depression. Review of Resident #2's Medication Administration Record dated February 2024 revealed that Prozac (antidepressant) oral capsule of 20 milligrams, give 3 capsules (60 milligrams) daily was not administered on 2/12/24, 2/13/24, 2/14/24 and 2/16/24. Review of Resident #2's Progress Notes dated 2/12/24- 2/16/24 revealed the following: Licensed Practical Nurse #4 on 2/12/24 documented the medication (Prozac) was pending pharmacy. Licensed Practical Nurse #1 2/13/24 documented the medication (Prozac) was out of stock. Licensed Practical Nurse #2 documented on 2/14/24 documented the medication (Prozac) was pending pharmacy. Licensed Practical Nurse #5 on 2/16/24 did not document a reasoning as to why the medication (Prozac) was not administered. During an interview on 2/16/24 at 10:22 AM, Resident #2 stated they had missed 5 days of their Prozac because the facility did not have it. During an interview on 2/21/24 at 12:52 PM, Licensed Practical Nurse #6 stated they reorder medications directly on the medication administration record through the computer system. There could be multiple reasons for delays, such as insurance issues or pending pharmacy physicians' signatures. Licensed Practical Nurse #6 stated Resident #2 medications came in on 2/16/24. Licensed Practical Nurse #6 was unable to state when the Prozac was ordered. During an interview on 2/21/24 at 1:32 PM, Pharmacist #1 stated that Resident #2's Prozac 20 milligrams was ordered on 2/16/24 at 9:15 AM and sent out the same evening and received on 2/17/24 at 1:00 AM. Pharmacist #1 stated that Resident #2's medications were not reordered on 2/12/24, 2/13/24, 2/14/24, or 2/15/24. During an interview on 2/21/24 at 3:40 PM, the Director of Nursing stated they did not know the reason for the delay in receiving Resident #2's Prozac and stated they had contacted the pharmacy for delivery. They stated they expected the medication nurse to reorder medications when there was a week's supply left on their cart. 3. Resident #3 had diagnoses of end stage renal disease dependence on renal dialysis, diabetes mellitus type 2, and benign prostatic hyperplasia (BPH, prostate gland enlargement). The Minimum Data Set, dated dated dated [DATE] documented Resident #3 was severely cognitively impaired. Review of Resident #3's physician Order Summary Report identified as current by the Director of Nursing dated 2/21/24 documented active orders for Tamsulosin HCl (medication used to treat BPH) 0.8 milligrams by mouth at bedtime with a start date of 12/4/23 and Rosuvastatin Calcium (medication used to treat high cholesterol) 20 milligrams daily with a start date of 12/4/23. Review of Resident #3's Medication Administration Record dated February 2024 revealed Tamsulosin HCl capsule 0.8 milligrams at bedtime documented a code 9 on the following dates: February 2nd, 3rd, 4th, 6th, 7th, 9th, 13th, 16th, 17th, 18th, and 20th. In addition, Rosuvastatin Calcium 20 milligrams had a code 9 documented on the 19th, 20th and 1st. The Medication Administration Record Chart Codes documented Code #9 = other/see nurse notes. Review of Resident #3's Progress Notes dated 2/1/24 - 2/21/24 revealed the following: Licensed Practical Nurse #1 documented that Tamsulosin HCl 0.8 milligram capsule was out of stock on February 2nd, 3rd, 4th, 6th, 9th, and 13th. Licensed Practical Nurse #10 documented February 7th the Tamsulosin HCl was pending from pharmacy and on February 6th was coming from pharmacy. Licensed Practical Nurse #4 documented Rosuvastatin Calcium was pending from pharmacy on February 19th and 21st. During an interview on 2/21/24 at 11:25 AM, Licensed Practical Nurse #1 stated they administered medications on February 2nd, 3rd, 4th, 6th, 7th, 9th, 13th, 17th, 18th, and 20th and Resident #3 had not received Tamsulosin HCL and had not received Rosuvastatin Calcium on February 20th. They stated if a medication was not available, they document the number 9 on the administration record indicating they were unable to provide the resident with their medication and they were to enter a progress note in the resident's medical record of the reason why the medication was not available. Licensed Practical Nurse #1 stated they don't always enter a progress note. Licensed Practical Nurse #1 stated they don't review past documentation to determine if the medication had already been ordered or how long a medication had not been available. Licensed Practical Nurse #1 stated they should have notified their nursing supervisor or a physician when they identified the medication was not available to administer as ordered. During an interview and observation on 2/21/24 at 12:56 PM, Licensed Practical Nurse #4 stated Resident #3 does not have any Tamsulosin on the medication cart. They stated they do not know how long the medication had been out because they are unable to view the prior dates of the Medication Administration Record. Licensed Practical Nurse #4 stated it was the responsibility of the nurses' passing medications to recorder the medications timely. If the medication was not available, they were to notify the Nursing Supervisor and Physician. Licensed Practical Nurse #4 stated they were unable to administer Rosuvastatin Calcium on February 19th and 21st because it was not available. They stated they did not notify the Physician or the Nursing Supervisor and should have. During an interview on 2/21/24 at 1:07 PM, Registered Nurse #1 stated they had noticed Licensed Practical Nurse #1 documented that Resident #3's Tamsulosin was out of stock. Registered Nurse #1 stated they educated Licensed Practical Nurse #1 to let the Nursing Supervisor know when a medication was not available and to call the pharmacy. Registered Nurse #1 stated they had not notified the pharmacy or Physician that Resident #3's Tamsulosin HCl was not available and that they should have. Registered Nurse #1 stated that all residents should be receiving their medications as ordered and nurses passing medications were responsible to ensure medications were ordered timely. During an interview on 2/21/24 at 1:32 PM, Pharmacist #1 stated Resident #3's Tamsulosin HCl was last sent on 12/16/23 and Rosuvastatin Calcium last sent on 1/15/24 and according to their records Resident #3 was discharged on [DATE]. Therefore, Resident #3's orders were discontinued in their system and not reordered. They stated the process was that when a resident was sent to the hospital the facility was to discontinue the orders and reorder the medications upon their readmission. During an interview on 2/21/24 at 3:40 PM, the Director of Nursing reviewed Resident #3's medical record census information and stated it looked like the resident may have gone to the hospital and returned on the same day 1/20/24 and believed there was a glitch on the pharmacy side. The Director of Nursing stated they were unaware pharmacy discontinued medications based on a census report. Upon review of February 2024 Medication Administration Record the Director of Nursing stated it looked like Resident #3 had not received their Tamsulosin as ordered. During an interview on 2/21/24 at 4:48 PM, the Medical Director stated if Resident #3 was not given Tamsulosin for an extended period they may suffer from the inability to urinate. During an interview on 2/21/24 at 1:23 PM, Medical Doctor #1 stated it was imperative all residents receive their medications as ordered and would have expected the nurses to reorder medications timely and inform them if a medication was not available. They stated if a medication was not available, they could either consider a different medication or ask the nurse to contact the pharmacy to determine why it isn't available. During an interview on 2/21/24 at 2:47 PM, Consultant Pharmacist #2 stated they reviewed physician orders, and the medication administration records. Pharmacist #2 stated they were not aware of any pharmacy delivery issues or that medications were not being administered as ordered. They would have expected the nurses to inform their Supervisor, the Director of Nursing and to call the pharmacy. During an interview on 2/21/24 at 3:40 PM, the Director of Nursing stated that they have had informal meetings with staff nurses concerning medication reordering and the expectations for documentation in the resident's chart. The Director of Nursing stated they expected the Pharmacy Consultant #2 to review the resident's orders and medication administration records and to identify if a resident's medication was not being administered; determine why and would have expected them to contact them. The Director of Nursing stated the residents should have received their medications as ordered. During an interview on 2/21/24 at 3:52 PM, the Administrator they stated they expected the nurses to reorder medications timely, and if medications were not available, they should be notifying their Unit Manager, Nursing Supervisor or Director of Nursing, contacting the physician and pharmacy. The Administrator stated they would have expected Pharmacist #2 to have identified that medications were not being provided as ordered and notified them or the Director of Nursing immediately. During an interview on 2/22/24 3:47 PM, the Director of Quality and Assurance stated they do not have a written policy on how to re-order medications. 10 NYCRR 415.18(a)(b)(3)

Based on interview and record review conducted during a Complaint Investigation (#NY00329506) completed 12/21/23, the facility did not ensure that all alleged violations of abuse, were reported immediately, but not later than two hours after the allegation was made, to the administrator and other officials including the State Survey Agency for one (Resident #1) of three resident reviewed. Specifically, alleged resident to resident abuse was not reported, in the appropriate timeframe, to the New York State Department of Health. The finding is: The policy and procedure titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised in April 2021, documented that if alleged abuse is suspected, it must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as within two hours of an allegation involving abuse. Resident #1 had diagnoses that included dysphagia (difficulty swallowing), cerebrovascular disease (disease of the blood vessels in the brain), generalized weakness with difficulty walking. The Minimum Data Set (a resident assessment tool) dated 10/18/23 documented Resident #1 was moderately cognitively impaired, was usually understood and usually understands. The assessment documented the resident exhibited no behaviors. The comprehensive care plan, revised 11/20/23, documented Resident #1 was able to communicate and make needs known and had limited physical mobility related to decreased strength. The resident was non-ambulatory and required two staff members for bed mobility. Resident #2 had diagnoses that included type II diabetes, anxiety, and depression. The Minimum Data Set, dated dated dated [DATE] documented Resident #2 was cognitively intact, was always understood and always understands, exhibited no behaviors, and was independent with walking. The comprehensive care plan, revised 11/11/23, documented Resident #2 was independent for meeting emotional, intellectual, physical, and social needs, and they were independent with ambulation. Review of Resident #1's Progress Notes dated 12/7/23 at 10:51 PM, Licensed Practical Nurse #1, documented Resident #1 informed them this morning around 8:30 AM that they had been hit in the stomach by another resident and started to vomit. Licensed Practical Nurse #1 notified the supervisor on duty (Assistant Director of Nursing). Review of the incident report titled Alleged Abuse dated 12/8/23 at 9:15 AM, the Director of Nursing documented, Writer was notified that resident was struck in the stomach by another resident sometime yesterday. No witnesses were present to confirm the allegation. Residents were both assessed for injuries; investigation started. Review of the New York State (complaint tracking system) the Complaint/Incident Investigation Report was received on 12/8/23 at 11:07 AM and documented the alleged incident occurred on 12/7/23 at 8:30 AM. During an interview on 12/20/23 at 12:55 PM, Licensed Practical Nurse #1 stated that on 12/7/23 after 8:00 AM, Resident #2 came out of Resident #1's room, handed them a TV remote and stated Resident #1's TV was too loud. Licensed Practical Nurse #1 stated they went into Resident #1's room and Resident #1 reported to them that Resident #2 had hit them in the stomach. Licensed Practical Nurse #1 stated Resident #1 was vomiting at the time and recalled informing the Assistant Director of Nursing of Resident #1's allegations as well as Resident #1's medical condition. The Assistant Director of Nursing then went into Resident #1's room and assessed them. During an interview on 12/20/23 at 2:15 PM, the Assistant Director of Nursing stated they recalled they were notified of the abuse allegation between Resident #1 and Resident #2 shortly after 8:00 AM on 12/7/23 and recalled informing the Director of Nursing on 12/7/23 but could not recall the time. The Assistant Director of Nursing stated that a resident hitting another resident was an allegation of abuse and should have been reported immediately. The Assistant Director of Nursing stated they did not report the alleged resident to resident abuse because they were too busy. During an interview on 12/21/23 at 1:28 PM, the Director of Nursing stated they were informed of the allegation of abuse between Resident #1 and Resident #2 on 12/7/23 around 10:00 AM by the Assistant Director of Nursing. The Director of Nursing stated they were aware the facility was to notify the New York State Department of Health within two hours of an abuse allegation. The Director of Nursing stated the Administrator was responsible to report to the state agency. During an interview on 12/21/23 at 2:06 PM, the Administrator stated that they were made aware of the alleged allegation between Resident #1 and Resident #2 on 12/8/23. The Administrator stated that the Assistant Director of Nursing and the Director of Nursing should have notified them immediately on 12/7/23, and the abuse allegation should have been reported to the New York State Department of Health within 2 hours, as required. 10 NYCRR 415.4 (b)(2)

Based on interview and record review conducted during a complaint investigation (#NY00329506) completed 12/21/23, the facility did not ensure that all alleged of abuse, were thoroughly investigated for one (Resident #1) of three residents reviewed. Specifically, the facility did not complete a thorough investigation into an allegation of resident to resident abuse to include interviews with Resident #1 and staff. The finding is: The policy and procedure titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised in April 2021, documented that all allegations of abuse are to be thoroughly investigated. At a minimum, the investigation should include: an observation and interview of the alleged victim, an interview from the person reporting the incident and any witnesses, interviews from staff members (on all shifts) who have had contact with the resident during the period of the alleged incident and a review of all events leading up to the incident. The policy also documented that the investigation should be documented completely and thoroughly. Resident #1 had diagnoses that included dysphagia (difficulty swallowing), cerebrovascular disease (disease of the blood vessels in the brain), generalized weakness with difficulty walking. The Minimum Data Set (a resident assessment tool) dated 10/18/23 documented Resident #1 was moderately cognitively impaired, was usually understood and usually understands. The assessment documented the resident exhibited no behaviors. The comprehensive care plan, revised 11/20/23, documented Resident #1 was able to communicate and make needs known and had limited physical mobility related to decreased strength. The resident was non-ambulatory and required two staff members for bed mobility. Resident #2 had diagnoses that included type II diabetes, anxiety, and depression. The Minimum Data Set, dated dated dated [DATE] documented Resident #2 was cognitively intact, was always understood and always understands, exhibited no behaviors, and was independent with walking. The comprehensive care plan, revised 11/11/23, documented Resident #2 was independent for meeting emotional, intellectual, physical, and social needs, and they were independent with ambulation. Review of Resident #1's Progress Notes dated 12/7/23 at 10:00 AM, Assistant Director of Nursing documented, Late Entry, Resident #1 had some emesis (the forceful retrograde expulsion of gastric contents from the body) this AM. There was no documented evidence Assistant Director of Nursing initiated an investigation for Resident #1's complaint of them being hit in the stomach by Resident #2. Review of the incident report titled Alleged Abuse dated 12/8/23 at 9:15 AM, revealed the Director of Nursing documented, Writer was notified that resident was struck in the stomach by another resident sometime yesterday. No witnesses were present to confirm the allegation. Residents were both assessed for injuries; investigation started. Review of the staffing schedule, provided by the facility, revealed Licensed Practical Nurse #1, #2 and Certified Nursing Assistants # 1, #2, #3, #4, and #9 worked 7:00 AM to 3:00 PM (day shift) on 12/7/23, on the unit where Resident #1 and Resident #2 reside. During interviews on 12/20/23, Licensed Practical Nurse #1 at 12:55 PM, Licensed Practical Nurse #2 at 1:49 PM, Certified Nursing Assistant #3 at 1:55 PM and on 12/21/23, Certified Nursing Assistant #1 at 10:00 AM, Certified Nursing Assistant #4 at 10:48 AM, Certified Nursing Assistant #9 at 10:57 AM, and Certified Nursing Assistant #2 at 11:14 AM each stated they were not asked any questions or requested to write a statement related to the abuse allegation between Resident #1 and Resident #2. During an interview on 12/20/23 at 2:15 PM, the Assistant Director of Nursing stated they were notified of the alleged abuse allegation between Resident #1 and Resident #2 shortly after 8:00 AM on 12/7/23 but they were too busy to begin the investigation. During an interview on 12/20/23 at 2:49 PM, Social Worker #1 stated they were made aware of the alleged abuse allegation between Resident #1 and Resident #2 on 12/12/23. They stated that they should have been notified the day the alleged abuse allegation occurred because they could have interviewed the staff and other residents immediately. Social Worker #1 stated the facility did not thoroughly investigate the abuse allegation. During a telephone interview on 12/21/23 at 10:00 AM, Certified Nursing Assistant #1 stated they were aware that Resident #2 had been complaining about Resident #1's television being too loud. They stated that two days prior to Resident #1's alleged allegation of abuse, Resident #2 told them that if Resident #1 didn't turn down their television, they were going to go in and punch Resident #1. Certified Nursing Assistant #1 stated they had educated Resident #2 not to punch the other resident and encouraged Resident #1 to keep their television volume down, to not bother other residents. Additionally Certified Nursing Assistant #1 stated they had reported the verbal threat to Licensed Practical Nurse #6. During a telephone interview on 12/21/23 at 10:26 AM, Licensed Practical Nurse #6 stated that they were aware that Resident #2 had been complaining about Resident #1's television being too loud, but could not recall being informed that Resident #2 had voiced they were going to punch Resident #1. Licensed Practical Nurse #6 stated they would have notified the nursing supervisor immediately. During a telephone interview on 12/21/23 at 12:11 AM, Medical Doctor #1 stated they were aware that Resident #2 had been complaining about Resident #1's television being too loud. They were not aware of any verbal threats from Resident #2 towards Resident #1. In addition, Medical Doctor #1 stated if they were aware of the verbal threat, they would have placed additional interventions in place such as a complete assessment for mood behaviors or separating the residents by offering a room change to another floor. Medical Doctor #1 stated that the facility should have done a thorough investigation and interviewed other residents and staff to find out if they saw or knew anything. During an interview on 12/21/23 at 1:28 PM, The Director of Nursing stated they were informed of the abuse allegation between Resident #1 and Resident #2 on 12/7/23 around 10:00 AM by the Assistant Director of Nursing. The Director of Nursing stated they interviewed Licensed Practical Nurse #1, who informed them there were no eyewitnesses; they interviewed Resident #2 who denied hitting Resident #1 and they asked other staff but did not know who they had spoken to. The Director of Nursing stated they did not interview Resident #1 because they believed Resident #2 was being honest. The Director of Nursing stated they were not aware Resident #2 had voiced to staff they were going to punch Resident #1 if the television was loud, and they were not aware that other staff members, including Medical Doctor #1, knew Resident #1's television volume bothered Resident #2. In addition, the Director of Nursing stated they had no documented evidence that they interviewed other staff for a thorough investigation and that it was the Administrator's responsibility to ensure a thorough investigation was completed. During an interview on 12/21/23 at 2:06 PM, The Administrator stated that they were made aware of the alleged allegation between Resident #1 and Resident #2 on 12/8/23. The Administrator stated the Assistant Director of Nursing and the Director of Nursing should have notified them immediately on 12/7/23 so they could have assisted with completing a thorough investigation. The Administrator stated that if they would have known immediately, they could have interviewed Resident #1 before they were sent to the hospital and they were not aware that the other unit staff were not interviewed. The Administrator stated a thorough investigation was not completed. 10 NYCRR 415.4 (b)(3)

Based on interview, and record review conducted during a Complaint investigation survey (NY00302192) started on 2/2/23 completed on 2/6/23, the facility did not ensure residents environment remained as free from accident hazards as possible for two (Resident #1 & 2) of three residents reviewed for smoking. Specifically, incidents of unsafe smoking were not investigated to determine adequate interventions to prevent recurrence, the residents did not have smoking assessments completed, and the comprehensive care plan (CCP) did not include safety measures or planned interventions to address residents smoking in their rooms. The findings are: Undated facility policy and procedure (P&P) titled Smoking Policy-Residents documented the following: -The facility shall establish and maintain a smoke free environment. -The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker and their desire to quit smoking, if a current smoker. -Residents are not permitted to give smoking articles to other residents and may not have or keep any smoking articles, including cigarettes, tobacco, etc. Undated facility P&P titled Safety and Supervision of Residents documented the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision. Undated facility P&P titled Accidents and Incidents-Investigating and Reporting documented all accidents or incidents involving residents, employees, visitors, etc., occurring on our premises shall be investigated and reported to the Administrator. The following data, as applicable, shall be included on the Report of Incident/Accident (a/i) form: -The date and time the accident or incident took place. -The nature of, circumstances surrounding, and where the a/i took place. -The name(s) of witnesses, including the involved/injured person, and their accounts of the a/i. -The time the involved person's physician was notified and his or her instructions. -The disposition of the injured/involved; any corrective action taken; follow-up information; other pertinent data as necessary or required; and the signature/title of the person completing the report. -The Nurse Supervisor/Charge Nurse and/or department director or supervisor shall complete a Report of Incident/Accident (a/i) form and submit original to the Director of Nursing (DON) within 24 hours of the a/i. -A/I reports will be reviewed by the Safety Committee for trends related to accident or safety hazards in the facility and any individual resident vulnerabilities. Undated facility P&P titled Care Plan, Comprehensive Person-Centered documented a comprehensive, person -centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The CCP will: -Incorporate identified problems areas; incorporate risk factors associated with identified problems. -Identify problem areas and their causes; and develop interventions that are targeted and meaningful to the resident. -CCP interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. -Assessments of resident are ongoing and care plans are revised as information about the resident and the resident's conditions change. 1. Resident #1 was admitted with diagnoses including chronic obstructed pulmonary disease, congestive hear failure and diabetes. The Minimum Data Set (MDS-resident assessment tool) dated 11/17/22 documented the resident was understood, able to understand others with mild cognitive impairment. They required supervision to limited assistance of one staff for activities of daily living. Current tobacco use was not assessed or answered with yes or no. Review of Smoking Screen dated 7/28/22 documented the resident utilized oxygen and no smoking was allowed. The screen lacked further additional documentation regarding resident smoking status. Review of the Baseline Care Plan (BCP) dated 7/29/22 documented the resident did not smoke. The CCP dated 7/29/22 lacked a focus area for the resident's smoking status. Review of physician Nursing Home Visit Date of Service dated 7/30/22 and 8/2/22 documented resident #1 smoking a few cigs per day. Review of the Admit/Readmit Screen effective 8/19/22 lacked documented evidence of resident #1 smoking status. Review of Nurse Report Sheets dated 11/2/22 through 11/26/22 documented the following: -11/11/22 Resident #1 suspected of smoking in their room. Claims it was not them. -11/20/22 Resident #1 smoking in room. Educated patient on danger of smoking. Patient understood. -11/21/22 Monitor resident #1 for smoking in room. Review of resident #1 Progress Notes dated August 2022 through 11/28/22 documented the following: -11/21/22 at 6:48 AM Licensed Practical Nurse (LPN) #1 documented patient admitted to smoking in their room. Tried to confiscate paraphernalia but did not recover, supervisor aware and will continue to monitor. -11/26/22 at 11:19 AM Social Worker (SW) #1 documented SW called to facility on this day as resident was found smoking in room with 02 on causing injury to resident. SW reached out to hospital and expressed despite being educated on several occasions on the dangers of smoking with 02 and that smoking is prohibited in facility, resident continued to put themselves and others at risk due to their behavior. -11/26/22 at 12:32 AM Registered Nurse Supervisor (RNS) #3 documented at 8:45 AM Resident #1 calling out for help, smoke noted in hallway outside of their room. Resident found upset, 02 nasal cannula lying on floor black with soot having burned. Resident right (R) lower lip blistered, beard of R side of face and neck singed. Fingers of R hand singed with soot. Resident upset stating I didn't do it, I'm going home. Resident sent to ER for evaluation. Medical Doctor (MD), family and DON notified. The Progress Notes dated August 2022 through 11/25/22 lacked documented evidence the facility assessed Resident #1 for smoking, provided adequate supervision to prevent smoking incidents, investigated incidents of unsafe smoking, or addressed the resident's unsafe smoking with revised care plan interventions. Review of facility investigation dated 11/26/22, signed by the former DON, documented smoke was seen in the hallway by Certified Nurse Aide (CNA) #5 who went to Resident #1 room where the smoke seemed to be coming from. No flames but a lot of smoke and a panicked resident #1 who admitted to smoking while wearing 02 via nasal cannula. The resident had black soot and singed beard, CNA #5 called for assistance. LPN #3 called the Supervisor, who then notified administration. Resident was assessed. Right lower lip appeared swollen, and beard and face had black soot on it. Nasal cannula tubing was noted to be completely melted. The floor and a towel were blackened and noted to be on the floor next to resident wheelchair. Resident sent to hospital for further evaluation. Review of written statement of Assistant Director of Nursing (ADON), dated 11/28/22, documented there have been multiple occasions upon rounding or in the hallway where teaching and reminders discussed facility is non -smoking campus, dangers and health risks associated with smoking, especially with 02. We have explained Resident #1 puts self and others at risk for injury or death. Resident verbalizes understanding but remains non- compliant. 2. Resident #2 was admitted with diagnoses including lung cancer, schizophrenia, and diabetes. The MDS dated [DATE] documented the resident was cognitively intact. They were independent to limited assistance of one staff for activities of daily living. Current tobacco use was answered no. Review of Smoking Screen dated 11/10/22 documented the resident was a current smoker and wished to continue smoking. Review of the Baseline Care Plan (BCP) dated 11/10/22 documented the resident did not smoke. Review of the Admit/Readmit Screen effective 8/19/22 lacked documented evidence of resident #1 smoking status. The CCP dated 11/14/22 lacked a focus area for the resident's smoking status. Review of medical provider/NP Progress Notes dated 11/29/22 through 1/6/23 documented resident was a heavy smoker. Review of Nurse Report Sheets dated 11/11/22 through 12/31/22 documented the following: -11/11/22 Monitor smoking in room. Lighters taken. -11/12/22 Monitor smoking in room. -11/14/22 Monitor smoking in room. -12/20/22 Monitor smoking in room. -Undated Possible smoking in room with patient on 02. Reported. Monitor. -12/29/22 Monitor smoking in room -12/30/22 Monitor smoking in room. -12/31/22 Monitor smoking in room. Review of resident #2 Progress Notes dated 11/11/22 through 2/6/22 documented the following: -11/11/22 at 3: 05 PM Resident smoking in room, lighters taken. -12/21/22 at 9:46 PM Writer was walking into another patient's room when it smelled like smoke. Writer entered patient's room where there was a heavy smell of cigarette smoke. Patient asked if they were smoking. Patient denied any smoking and stated that was the other day, not today. I don't have anything on me. Writer educated patient on seriousness of smoking inside the building especially with roommate being on 02. Writer immediately notified supervisor. The Progress Notes dated 11/11/22 through 2/5/22 lacked documented evidence the facility assessed Resident #2 for smoking, provided adequate supervision to prevent smoking incidents, investigated incidents of unsafe smoking, or addressed the resident's unsafe smoking with revised care plan interventions. During interview on 2/3/23 at 11:40, the front desk Receptionist stated there was no list of smokers and no resident's go out of the building, to smoke, that they were aware of. During interview on 2/3/23 at 11:45 AM, CNA #1 and #2, stated Resident #1 was known to smoke in their room, but was never caught red handed. The CNA's stated if they found a resident, smoking, they would notify the nurse right away and get a Supervisor. SW and nurses would do room searches if a resident was found smoking, but they kept their eyes open for smoking materials in independent resident's rooms. They stated they were not aware of Resident #2 smoking in the building. During an interview on 2/2/23 at 3:33 PM, LPN #1 stated they were working the evening and night shift of 11/20/22 when resident #1 was suspected of smoking in their room. I educated the resident. They were very apologetic. They told me they only had one cigarette. They wouldn't give me their lighter. I couldn't search them, but I told the Supervisor. I can't remember who that was. LPN # 1 stated they were also aware of Resident #2 smoking within a couple weeks of Resident #1 but Resident #2 never did it again. During telephone interview on 2/3/23 at 11:46 AM, LPN #2 stated they were familiar with Resident #1 and would find ashes in the bathroom, on the toilet seat, and cigarettes in their drawer that I would crumple up and throw in the garbage. I never actually caught Resident #1 smoking. I would tell the SW and educate and tell the resident that 02 tanks would blow up. I told the Supervisor or probably RN #2 UM, at the time. I am not sure if they put any interventions in place, the RN#2 UM and SW#1 told them they couldn't smoke in the building. During follow up interview on 2/3/23 at 3:24 PM, LPN #1 stated when resident #1 was suspected of smoking, on 11/21/22, the resident said they only had one smoke and no lighter. The room smelled like smoke. I don't remember what Supervisor was working or who I told, but they would be the one to complete an a/I not the LPN's. I was doing frequent checks on the resident, but it wasn't documented anywhere separately, looking back it probably should have been. When Resident #2 was suspected of smoking their roommate, at the time, was wearing 02. During interview, via telephone, on 2/3/23 at 10:04 AM, RNS #1 stated they remembered hearing Resident #1 had been caught smoking, but did not remember what date(s) prior to the incident on 11/26/22. If I am notified or smell smoke I will check to see if someone is smoking, search their room, but they will usually tell me they are not smoking. I do not recall if I put any measures into place for Resident #1. I would leave a note for the day shift, oncoming Supervisors, ADON, DON, or Unit Managers. During interview on 2/3/22 at 12:05 PM, SW #1 stated they were aware of Resident #1 smoking in their room on 11/21/22, prior to the incident on 11/26/22. Staff will inform me, I go speak with the resident, educate on risks and consequences. We do a room search. Notify the MD and offer the resident smoking cessation aides. We didn't find anything, I probably forgot to document all of that on Resident #1, but I should have. Additionally, SW #1 stated the CP should have been updated regarding the resident being a smoker and non-compliance with smoking rules. During interview on 2/3/23 at 1:30 PM, RNS #6 stated they had never witnessed anyone smoking in the building, but around 9:00 PM a day in December, checked Resident #2 room, where it smelled like it was coming from and didn't find anything. I searched the room and couldn't find anything. The resident stated that it was not them and they weren't smoking so I didn't notify anyone. During telephone interview on 2/6/23 at 10:58 AM, RN #2 former Second Floor UM stated they were aware of Resident #1 being suspected of smoking. The Resident always denied it. There should be a couple of progress notes written about it. There was process in place to do a room search but we never found any of their paraphernalia. The CP should have been updated, but I cannot recall if it was or not. We didn't have it documented anywhere like 15 min checks or 1:1 monitoring, but we did extra checks on Resident #1. If we could have done 24 hour, 1:1, monitoring it probably would have prevented the incident when the resident got burned. During interview on 2/3/23 at 8:05 AM, the DON stated there were no additional investigations regarding Resident #1 or #2 smoking in the facility/room prior to 11/26/22. I gave you everything we have. We caught them smoking multiple times. I would expect that it be documented, it should be. Additionally, the DON stated they would have to look to see if any additional measures or CP revisions were put in to place to prevent further smoking incidents. A lot of times we would smell smoke, they would deny it and we don't find any items. So, it's hard to say. I would have to say we put something into place. During interview on 2/6/23 at 2:45 PM, the DON stated they do not remember being notified when Resident #1 or #2 was suspected of smoking but would have been present at morning meeting when it was discussed, if it was on the 24 -hour nursing report. I don't think there was an actual sighting of the resident smoking, but I would expect progress notes to be written, at the very least, if a resident is suspected of smoking in the building. There should be a smoking focus on the CP. Resident #1 nor #2 have one. I would have expected staff to update the CP so staff could familiarize themselves with the Resident's care and history of non -compliance. During telephone interview on 2/6/23 at 12:05 PM, the Nurse Practitioner (NP) stated they were aware of Resident #1 being suspected of smoking in the facility. The NP stated the resident was educated about the danger of smoking with 02. They were offered patches and gum. It's hard to say if preventative measures were put in place, can't remember, but now that I think of it, in retrospect, probably could have done more. I don't know if Resident #1 ever got caught red handed it was more of a suspicion. During interview on 2/6/23 at 2:50 PM, the Regional QA RN stated they were not aware of Resident #1 smoking or suspicion of smoking prior to the incident on 11/26/22. Smoking or suspicion of smoking is considered an incident and they would expect an investigation so interventions could be put in place. The resident's CP should be reviewed and updated because that it what guides the resident's care. We are already working on education. 10 NYCRR 415.4(a)(2-7)

Based on observation, interview and record review conducted during an Abbreviated survey (Complaint #NY 945) started 8/2/22 and completed 8/3/22, the facility did not ensure that all alleged violations including abuse, neglect, exploitation or mistreatment including injuries of unknown source, are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury to the Administrator of the facility and other officials (including to the State Survey Agency and the Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one (Resident #1) of three residents reviewed. Specifically, the facility did not report an allegation of abuse to the New York State Department of Health (NYS DOH) as required within the two-hour time frame. The finding is: The facility's policy, revised April 2021 and titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating documented all reports of resident abuse (including injuries of unknown origin), are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. If resident abuse, neglect, exploitation, misappropriation, or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as within two hours of an allegation involving abuse or result in serious bodily injury. 1. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-a resident assessment tool) dated 6/29/22 revealed Resident #1 had moderately impaired cognition, was usually understood and usually understands. The comprehensive care plan identified as current by the Director of Nursing (DON), documented Resident #1 had impaired cognitive function related to stroke and pseudobulbar affect. Interventions included to ask yes/no questions to determine the resident's needs, face the resident when speaking and make eye contact, reduce distractions, and the resident understands simple directive sentences. Present just one thought, idea or question at a time. The Registered Nurse (RN) Unit Manager (UM) #1 Progress Note dated 7/25/22 at 5:26 PM, documented Resident #1 and boyfriend talked to the RN UM #1 regarding a bruise noted to the resident's left temple. The boyfriend insisted someone hit the resident. The resident's sister was called, and RN #1 explained the situation and was told not to listen to the boyfriend, and if they continued to upset the resident to tell the boyfriend to leave. The MD was made aware. There was no documented evidence the DON or Administrator were notified of the abuse allegation made by the visitor (boyfriend) or the bruising to the resident's temple. Additionally, there was no documented evidence the abuse allegation was reported to the DOH as required. Review of the NYS DOH Automated Complaint Tracking System (ACTS) revealed there was no report submitted by the facility of an abuse allegation for Resident #1 between 7/23/22 and 7/26/22. During an interview on 8/2/22 at 10:05 AM, Resident #1 stated a nurse hit my head and makes my head go and I'm afraid. The Resident touched their left temple area and stated it happened two months ago. The resident could not verbalize a name or description of the nurse. Observation of the resident's temple area revealed no bruising or redness. During an interview on 8/2/22 at 11:11 AM, the RN UM #1 stated Resident #1 and their boyfriend entered the RN UM's office around 5:00 PM (on 7/25/22) and reported the resident had a bruise on their head. The RN UM #1 stated they observed the area on the resident's left temple, and there was smaller than a dime size red area that was not ecchymotic and thought it looked like something fresh. When the RN asked the resident what happened, the resident looked at their boyfriend, and the boyfriend stated someone hit Resident #1 and named Licensed Practical Nurse (LPN #1). The RN UM #1 stated they did not tell the DON about the abuse allegation that was made until the next morning, and has since been educated by the DON about contacting management when there was an allegation of abuse. During an interview on 8/2/22 at 11:45 AM, the Director of Nursing (DON) stated the RN UM #1 should have let them know about the allegation that the resident was hit in order to have RN #1 further investigate as it was an allegation of abuse. The DON stated if the resident said they were hit, whether they had a dementia diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During further interview on 8/2/22 at 2:29 PM, the DON stated anybody can make an allegation of abuse, and the allegations that were supposed to be reported were the allegations that had validity. The DON stated the reason they didn't report this was because the HCP said not to go any further with it. During a telephone interview on 8/3/22 at 11:30 AM, the Administrator stated they had to report an abuse allegation right away, and if they investigate and feel it was not an abuse allegation, it still gets reported. The Administrator stated the RN UM #1 should have let someone in upper management know of any type of allegation of abuse. The Administrator stated they didn't know of this specific allegation of abuse and would have expected the DON to inform them. The Administrator stated in this case, there was an allegation and there was a bruise so they should have reported it. 415.4(b)(4)

Based on observation, interview and record review conducted during an Abbreviated survey (Complaint # NY 9945) started 8/2/22 and completed 8/3/22, the facility did not ensure that all alleged violations of abuse, neglect or mistreatment including injuries of unknown origin are thoroughly investigated for one (Resident #1) of three residents reviewed for abuse. Specifically, the facility's investigation did not include employee and resident interviews, and statements to rule out abuse after an abuse allegation (bruising to the resident's left temple) was reported by a visitor. The finding is: The facility's policy, revised April 2021 and titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating documented all reports of resident abuse (including injuries of unknown origin), are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Investigating allegations included interview of staff members (on all shifts) who have had contact with the resident during the period of the alleged incident, interviews with other residents to whom the accused employee provides care or services and documents the investigation completely and thoroughly. 1. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-a resident assessment tool) dated 6/29/22 revealed Resident #1 had moderately impaired cognition, was usually understood and usually understands. The comprehensive care plan identified as current by the Director of Nursing (DON), revealed the resident had impaired cognitive function related to stroke and pseudobulbar affect. Interventions included to ask yes/no questions to determine the resident's needs, face the resident when speaking and make eye contact, reduce distractions, present just one thought, idea or question at a time, and the resident understood simple directive sentences. The Registered Nurse (RN) Unit Manager (UM) #1 Progress Note dated 7/25/22 at 5:26 PM, documented the resident and boyfriend talked to the RN UM #1 regarding a bruise noted to the resident's left temple. The boyfriend insisted someone hit the resident. The resident's sister was called, and the RN explained the situation and was told not to listen to the boyfriend and if he continued to upset the resident to tell him to leave. The MD was made aware. There was no documentation that the DON or Administrator were notified, and that the resident or staff were interviewed about alleged abuse and the bruise. Review of an untitled facility report, identified as an incident report by the DON, dated 7/25/22 at 10:31 PM, completed by RN UM #1, revealed they were asked to look at a bruise to the resident's left temple area. A bruise was noted, less than dime size, resident places self on the floor as part of their behavior/pseudobulbar disorder and the resident was unable to give a description. The area was assessed, ice was applied, and the MD was notified. The family was notified, and the resident denied pain. The resident was alert and oriented to person, non-compliant with transfers, places self on the floor quickly, even under close supervision. No witnesses were found. There were no staff and resident statements documented or included in the report. In addition, there was no summary of how the injury occurred and that abuse was ruled out. During an interview on 8/2/22 at 10:05 AM, Resident #1 stated a nurse hit my head and makes my head go and I'm afraid. The resident started crying, touched their left temple area and stated it happened two months ago. The resident could not verbalize a name or description of the nurse. Observation of the resident's temple area revealed no bruising or redness. During an interview on 8/2/22 at 11:11 AM, the RN UM #1 stated the resident and boyfriend entered the RN UM's office around 5:00 PM (on 7/25/22) and reported the resident had a bruise on their head. The RN UM #1 stated they observed the area on the resident's left temple, and there was smaller than a dime size red area that was not ecchymotic and they thought it looked like something fresh. When the RN asked the resident what happened, the resident looked at their boyfriend, then the boyfriend stated someone hit Resident #1 and named LPN #1. The RN UM #1 stated they called the resident's health care proxy (HCP) who doubted anyone hit the resident and said if the boyfriend was upsetting the resident, that they should leave. The RN UM #1 stated they asked the LPN #1 about the allegation and the LPN #1 denied hitting or kicking the resident and didn't notice any bruising on the resident's forehead/temple. The RN UM #1 stated they asked the Certified Nurse Aides (CNAs) who were working if they noticed any bruising or saw the resident hit their head or anyone hit/be nasty toward the resident, and they all said no. The RN UM #1 stated they did not remember which staff they asked and that they didn't ensure staff wrote statements, but they should have. The RN UM #1 stated they asked the resident (without boyfriend present) if anyone hit them, and the resident said no. The RN UM #1 stated they did not tell the DON about the allegation that was made until the next day and have since been educated by the DON about contacting management when there was an allegation of abuse. Further review of the untitled facility report, identified as an incident report by the DON, dated 7/25/22 at 10:31 PM revealed the incident report did not document that an alleged perpetrator was named when the allegation of abuse was made by the visitor, and there was no evidence the accused perpetrator was removed from duty until the investigation was completed to rule out abuse. During an interview on 8/2/22 at 11:45 AM, the Director of Nursing (DON) stated the RN UM #1 should have let them know about the allegation that the resident was hit in order to have the RN further investigate as it was an allegation of abuse. The DON stated if the allegation came from the resident, then they would have gotten staff statements, but in this situation they didn't because the resident was monitored closely daily due to their behavior of placing themselves on the floor. The DON stated their investigation ruled out abuse because the RN UM #1 called the HCP who didn't think anyone hit the resident and the resident would have had a larger bruise if someone had hit them. The DON stated they did not look at camera footage for that day because they don't have access to the camera system and didn't think the footage was recorded. During a telephone interview on 8/2/22 at 1:38 PM, CNA #1 (who worked evening shift on 7/25/22) stated they knew who the resident was. The CNA stated the allegation of the resident being hit didn't sound familiar to them and that they were not asked to write a statement about it. The CNA stated they had not seen anyone hit or be nasty to the resident. During further interview on 8/2/22 at 2:29 PM, the DON stated anybody can make an allegation of abuse and any allegation that has validity gets reported. The reason they didn't report this was because the HCP said not to go any further with it. The DON stated when they found out about the allegation the next day, they told the RN UM #1 that they should have reported it to administration because any allegation of abuse or neglect should be reported. The DON stated the only thing they didn't document in a statement or in a note was that the resident said no when asked if someone hit them. The DON stated there was nothing that indicated abuse occurred and if someone had hit the resident the bruise would have been bigger. The DON stated it wasn't an injury of unknown origin because the resident places themselves on the floor all the time. During further interview at 2:38 PM, the DON stated this bruise/incident didn't go undocumented, there was a sentence or two missing but not enough evidence to say the resident was abused. During a telephone interview on 8/3/22 at 11:30 AM, the Administrator stated when there was an allegation of abuse, a nurse should do a full body assessment, usually done by the DON, then obtain statements from staff, any staff that would have been there at the time, whether CNAs or therapy. The Administrator stated even if staff were doubtful of the allegation, they should follow this procedure. Once all the statements and assessments were completed, they would put them all together and come up with a conclusion. The Administrator stated they would have expected the RN UM #1 to document all the staff and resident interviews done, and its common practice. The Administrator stated the RN UM #1 should have let someone in upper management know of any type of allegation of abuse. The Administrator stated they didn't know of this specific allegation of abuse and would have expected the DON to inform them. The Administrator stated they can see how the resident might get a bruise because of their behavior of placing themselves on the floor but the problem is they don't know (if that's how the resident got the bruise). During further interview on 8/3/22 at 3:13 PM, the Administrator stated they didn't know why staff didn't complete the investigation but maybe it was because of the resident's behaviors, and they thought it wasn't anything reportable. 415.4(b)(3)

Based on observation, interview, and record review conducted during the Standard survey started on 6/9/22 and completed on 6/16/22, the facility did not ensure that the residents' environment remains as free from accident hazards as is possible. Specifically, three (Units 2, 3, and 4) of three resident care units had issues with water temperatures exceeding 120 degrees Fahrenheit (°F) in resident rooms and care areas. The findings are: Review of the undated facility policy and procedure (P&P) titled Water Temperatures, Safety of, provided by the Maintenance Supervisor on 6/9/2022, documented tap water in the facility will be kept within a temperature range to prevent scalding of residents. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures no more than 110 °F (degrees Fahrenheit). During an observation on 6/9/22 at 10:08 AM, in Resident Room #210 the sinks hot water was checked , and the surveyor could not leave their hand under the running water because it was too hot. The resident stated that the water gets very hot, too hot. Observations on 6/9/22 between 10:21 AM and 10:59 AM, revealed the following hot water temperatures were obtained in resident rooms and care areas using a digital stem-type thermometers: Unit 2 Resident Room #200 - 122.5 °F Resident Room #210 - 124.4 °F Resident Room #209 - 125.8 °F Resident Room #212 - 123.7 °F Resident Room #224 - 121.0 °F Unit 2 Shower Room Sink - 120.4°F Unit 2 Shower Room Tub - 122.2 °F Unit 3 Resident Room #312 - 123.1 °F Resident Room #317 - 122.1 °F Resident Room #301 - 121.3 °F Unit 3 Shower Room Sink - 122.4 °F During an interview on 6/9/22 at 10:59 AM, Resident #230 stated the water gets too hot and I get out of the way. An observation of the facility boiler room on 6/9/22 at 11:01 AM, with the Maintenance Supervisor present, revealed there were three boilers, one was dedicated to the laundry and kitchen areas and was set to 158 °F. The two other boilers were dedicated for resident rooms and common areas. The boiler that was running and had a digital screen that was set to 121 °F. The other boiler was not running during the observation. The holding tank had an external digital thermometer that read 115 °F. The Maintenance Supervisor stated they monitored temperatures every day at resident room sinks and shower rooms on the resident units. The Maintenance Supervisor stated they completed the temperature check that morning, liked to see the temperatures between 115-125 °F inside the resident rooms and showers, and had no complaints from residents or staff that the water was too hot. The Maintenance Supervisor provided the water temperature audit completed that morning (6/9/22) which showed temperatures in shower rooms and resident rooms exceeded 120 °F. The Maintenance Supervisor stated the water goes from the large holding tank directly up to the resident units and didn't know why the holding tank temperature was 115 °F and that they got temperatures above 120 °F upstairs on the units. The Maintenance Supervisor stated they were told that 115-125 °F was an acceptable temperature range by the last person that inspected the boiler or their previous boss. During an interview on 6/09/22 at 11:03 AM, Certified Nurse Aide (CNA) # 5 stated the hot water can get hot, they had used the hot and cold water together. CNA #5 stated sometimes the residents say it's too hot and the CNA would report it to maintenance . Observations on 6/9/22 between 11:29 AM and 11:46 AM with the Maintenance Supervisor, revealed the following hot water temperatures were obtained using the facility's laser type thermometer: Unit 2 Resident Room #200 - 123.8 °F Resident Room #209 - 122.0 °F Resident Room #210 - 121.6 °F Resident Room #212 - 123.3 °F Unit 2 shower room sink - 121.8 °F Unit 2 shower room shower head - 121.5 °F Unit 3 Resident Room #312 - 123.4 °F Resident Room #301 120.6 °F Unit 4 Resident Room #424 - 122.2 °F Review of the Daily Maintenance Checklist dated 5/1/22-6/9/22 revealed on 27 occasions water temperatures in their sampled resident rooms and shower rooms exceeded 120 °F. During an interview on 6/9/22 at 3:12 PM, the Maintenance Supervisor stated they reviewed the facility policy and decreased the boilers to 110 °F and would check more water temperatures that evening. During further interview on 6/10/22 at 3:05 PM, the Maintenance Supervisor stated the two domestic hot water boilers were newly installed in early 2021 and they knew of no problems with the boilers, the thermometers on the boilers, or the thermometer in the holding tank. There was no mixing valve in the system, and they could not explain why hot water temperatures trended higher after leaving the holding tank but stated that was always the case. The Maintenance Supervisor stated they found out yesterday that the facility's policy and procedure indicated a maximum hot water temperature of 110 °F, and before that, they thought 115 - 120 ° F was appropriate, and up to 128 °F was acceptable, especially during winter, when residents sometimes complained the hot water was too cold. The Maintenance Supervisor further stated no one had ever complained to them that the hot water was too hot. Additionally, the Maintenance Supervisor also stated that no one had told them what the maximum hot water temperature should be or when to alert the Administrator. During an interview on 6/15/22 at 2:40 PM, the Administrator stated the facility's hot water policy and procedure indicated hot water should not exceed 110 °F, but they were not aware that the hot water boilers were set above 110 °F. The Administrator further stated the Maintenance Supervisor did not share water temperature logs, only if there was an issue, so they assumed the hot water temperatures on the resident units were below 110 °F because no issues were brought to their attention. The Administrator also stated hot water temperatures were not discussed at Quality Assurance (QA) meetings because no concerns about hot water were voiced. Additionally, the Administrator stated the boilers were newer, and they had discussed water temperatures with the Maintenance Supervisor in the past regarding Legionella prevention, and they could not explain why hot water temperatures trended higher after leaving the holding tank. During an interview on 6/15/22 at 3:22 PM, the Director of Nursing (DON) stated they were not aware of any existing issues with hot water and the maximum hot water temperature was the responsibility of the Maintenance staff. The DON stated they would only get involved personally if a resident complained and there had been no resident complaints about hot water. 415.12 (h)(1)

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY 526) completed on 6/13/17 the facility did not inform the resident's legal representative or interested family member or immediately consult with the resident's Physician when there is a significant change in the resident's physical, mental or psychological status and a need to alter treatment significantly. One (Resident #1) of three residents reviewed for family and Physician notification had issues. Specifically, nursing staff did not notify the Physician and the resident's family per the physician's orders [REDACTED]. lower blood glucose) coverage which resulted in diabetic ketoacidosis (DKA- an acute, life threatening complication of diabetes mellitus). This resulted in actual harm that is not immediate jeopardy. The finding is: 1. Resident #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS -a resident assessment tool) dated 5/18/17 revealed the resident is cognitively intact. Review of Clinical Physician order [REDACTED]. Review of the May 2017 Medication Administration Record (MAR) revealed instructions to administer insulin as follows: Humalog 100 unit/ ml - inject per sliding scale (start date 5/17/17) at 9:00 AM and 8:00 PM: - If 0-130 (blood glucose) = 0 units, less than 60 call MD (medical doctor) - 131-180 = 2 units - 181-240 = 4 units - 241-300 = 6 units - 301-350 = 8 units - 351-400 = 10 units - 401+ = 12 units Notify MD [MEDICATION NAME] 100 unit/ ml (start date 5/17/17): inject 20 units subcutaneously (SQ-beneath the skin) in the morning (9:00 AM) and 20 units SQ at bedtime (9:00 PM). Further review of the MAR revealed on 5/27/17 the resident refused the FS at 8:00 PM therefore, no sliding scale insulin was administered and refused the 9:00 PM dose of [MEDICATION NAME] 20 units. On 5/28/17 the resident refused FS at 9:00 AM and at 8:00 PM therefore, no sliding scale insulin was administered, and refused the 9:00 AM and 9:00 PM doses of [MEDICATION NAME] 20 units. In addition, the special instructions If resident refuses to have FS or to take insulin, notify the responsible party/ mother immediately was not recorded on the MAR. Review of Nursing Progress Notes revealed that there were no notes for 5/27/17 or 5/28/17. Review of a Change of Condition Nursing Progress Note dated 5/29/17 at 12:53 AM written by Registered Nurse (RN) #1 revealed the resident was noted to be less responsive than usual status. FS=HI when checked with two different glucometers. The note documents blood pressure 127/67 (normal), pulse 92 (average 80), breathing hard, lung sounds diminished, skin cool and dry, resident staring off does not respond by opening eyes, moaning. The note stated that per records the resident refused morning and bedtime FS on 5/28/17 and refused bedtime scheduled insulin. Voice message left for the MD to call. Review of a Change of Condition Nursing Progress Note dated 5/29/17 at 1:15 AM written by RN #1 revealed the Physician returned the call. The FS result and refusals were reviewed as well as symptoms and vital signs. Order received for stat (immediate) BMP (basic metabolic profile); the Physician does not want to give any insulin now. The lab (laboratory) was notified of need to draw stat lab. Review of a Laboratory Progress Note dated 5/29/17 at 3:05 AM written by RN #1 revealed that the blood was drawn for stat BMP at 2:10 AM. Review of a Laboratory Progress Note dated 5/29/17 at 4:06 AM written by RN #1 revealed the results were received from the lab for the stat BMP with results; Na (sodium) 123 (normal 136-144), K (potassium) 6.1 (normal 3.5 - 5.5), calcium 8.6 (normal 8.4 to 10.3), BUN (blood urea nitrogen) 45 (normal 8-27), CO 2 (carbon [MEDICATION NAME]) less than 5 (normal 22.0 - 32.0), Cl (chloride) 86 (normal 99-110), creatinine 2.15 (normal 0.5 to 1.6), Glucose 1,103 (normal 74-100). The note documented that the resident was sent to the hospital. Review of the 24-Hour Nursing Report Summary revealed the resident did not appear on the report on 5/27/17 and 5/29/17. On 5/29/17 the 24-Hour Nursing Report indicated the resident was at the hospital. Review of the hospital Emergency Documentation dated 5/29/17 at 5:32 AM written by the Physician revealed the resident arrived in critical condition after not receiving any insulin since 5/26/17. The resident arrived clinically in DKA, profoundly dehydrated, with Kussmaul respirations (deep labored breathing often associated with severe metabolic acidosis particularly DKA). The resident was started on intravenous insulin and admitted to the intensive care unit. Review of the History and Physical Report dated 5/29/17 written by the Physician revealed the resident's blood glucose was 1,087 on arrival to the emergency department with a severely elevated WBC (white blood count) of 42.2 (normal 4.0 - 10.5). During an interview on 6/1/17 at 1:15 PM the Director of Nursing (DON) stated that the resident is non-compliant with his diet and eats whatever he wants and sometimes refuses his insulin and/ or FS. The DON stated that if the resident refuses one time the staff can usually persuade him to take it the next time. The resident has a long history of problems with his diabetes. The DON stated that nursing staff are supposed to notify the Physician of the third consecutive refusal of insulin or medication. The Physician should have been notified on 5/28/17 after the 8:00 PM FS refusal and 9:00 PM refusal of the insulin. During a telephone interview on 6/1/17 at approximately 2:00 PM, Licensed Practical Nurse (LPN) #1 stated that she worked on 5/27/17 from 3:00 PM to 11:00 PM and on 5/28/17 worked a double shift from 7:00 AM to 11:00 PM. LPN #1 stated that the resident was very non-compliant on those days and refused to take his insulin and refused to allow her to do a FS. LPN #1 stated that she tried multiple times to do the FS but the resident waved his arms and told her to get away. LPN #1 stated that she told RN #3 Supervisor of the resident's refusal of the bedtime insulin and FS. RN #3 instructed her to re-approach the resident. LPN #1 stated that she re-approached the resident without success and notified RN #3. LPN #1 stated that she did not know if RN #3 intervened in any way. LPN #1 stated that she is not aware of a specific policy to notify the Physician after the third refusal of insulin or a medication but stated that the LPNs do not normally call the Physician, it is usually done by the RN Supervisor. LPN #1 stated that she was not aware of any instructions to call the resident's mother if the resident refuses his insulin. During a telephone interview on 6/8/17 at approximately 8:30 AM, RN #3 stated that she worked as the RN Supervisor on 5/27/17 from 7:00 AM to 11:00 PM and on 5/28/17 from 7:00 AM to 7:00 PM. RN #3 stated she was not informed by any nursing staff of the resident's refusals of insulin on 5/27/17 or 5/28/17. RN #3 stated that she is not aware of the facility's policy to notify the Physician if the resident refuses three consecutive doses of medications or insulin. During an interview on 6/1/17 at approximately 2:45 PM, RN #2 stated that she worked as the Nursing Supervisor on 5/28/17 from 7:00 PM to 11:00 PM. RN #2 stated that she does not recall being told by any nursing staff of the Resident #1's consecutive refusals of his insulin and FS. RN #2 stated that she is aware of the facility policy to call the Physician if a resident refuses three consecutive doses of medication or insulin. She stated that if a resident refuses a medication the nurses are supposed to continue to try and re-approach the resident. RN #2 stated that normally the RNs are responsible to contact the Physician but the LPNs can call if the RNs are busy. RN #2 stated that she is aware of the instructions to call the resident's mother if the resident refuses insulin but they do not call each time as they must keep trying different interventions to get the resident to take his insulin. During a telephone interview on 6/8/17 at approximately 9:30 AM, the Medical Director stated that the resident is an unstable diabetic that is non-compliant with medical interventions and diet. The Medical Director stated that he was not informed of the resident's refusal of insulin by nursing staff. The Medical Director stated that due to the resident's unstable diabetes he would expect nursing staff to notify the Physician after the first missed dose of insulin and every missed dose thereafter. The Medical Director stated that in retrospect the resident should have been given insulin prior to the resident being sent to the hospital on [DATE]. The Medical Director stated he is aware of the policy for nursing staff to notify the Physician if a resident misses three consecutive doses of medication and in most cases this is reasonable however, in a non-compliant unstable diabetic, nursing judgement must come into play. Review of a facility policy and procedure entitled Notifying MD/Responsible Party of Resident's change of condition revised 2/2016 revealed to notify the attending MD and Responsible party of any changes in resident's condition. The stated purpose of the policy is to provide Quality/Comprehensive Medical Care through updating of MD/NP (Nurse Practitioner)/Responsible Party of all new and/or changes in resident condition in a timely manner. The procedure includes the following: -Occurrence of resident change of condition must be communicated in a timely fashion to the attending MD by the Nursing supervisor and or designee. -Each unit nurse who identifies a change in condition must notify the Nursing Supervisor immediately. Change of condition may include one or more of the following - refusals to take prescribed medications for three consecutive doses. 415.3(e)(2)(ii)(c)

THIS IS A REPEAT DEFICIENCY FROM THE PARTIAL EXTENDED SURVEY COMPLETED ON [DATE] AND THE ABBREVIATED SURVEY COMPLETED [DATE]. Based on observation, interview, and record review conducted during the Standard survey completed on [DATE], the facility did not provide the necessary care and services to maintain a resident's highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Three (Residents #36, 37, 56) of thirty-one residents reviewed for quality of care had issues. Specifically, Resident #36 had a change in condition and there was a lack of a timely, comprehensive assessment by a registered nurse (RN), lack of timely physician notification, and lack of ongoing monitoring of the resident's condition. The resident expired in the facility prior to obtaining physician ordered bloodwork and a diagnostic test. This resulted in actual harm that is not immediate jeopardy for Resident #36. In addition, Resident #56 did not have a renal consult as ordered by the physician and did not receive a recommended follow-up [MEDICATION NAME] appointment after a colonoscopy. Resident #37 had an order for [REDACTED]. The findings are: 1. Resident #36 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated [DATE] revealed the resident is cognitively intact, understands, is understood, had no behaviors directed towards others, and no rejection of care. The resident requires total staff assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene. The resident did not receive scheduled or as needed (PRN) pain medication and had no pain per resident interview. Review of the current comprehensive Care Plan (CCP) revealed that the resident has a [MEDICAL CONDITION] (artificial connection of the bowel to the surface of the skin)/[MEDICAL CONDITION] (surgical creation of opening in the small intestine) with planned approaches for an ongoing assessment for abdominal distention and stool character. The CCP for Nutrition documented that the resident has the potential for altered BM (bowel movement) function with a goal to maintain normal ostomy (surgically created opening between an internal organ and the body surface) function. Additional review of the CCP revealed the problem area for Choices documented that the resident prefers the call bell to be clipped to his chest for easy accessibility. Review of the certified nurse aide (CNA) Care Guide dated [DATE] revealed the resident is to have the call bell placed on his blanket at chest level at all times for independent use. Review of an RN Assessment Documentation form dated [DATE] revealed the resident's abdomen was soft, non-tender and bowel sounds were active. A Nursing Home Follow-up Note, written by the physician, dated [DATE] documented that the resident had a [MEDICAL CONDITION] and had normoactive bowel sounds in all quadrants, soft, non-distended. Review of Nurses' Notes revealed the following: - [DATE] for the 11:00 PM to 7:00 AM shift - At 2:00 AM, a Licensed Practical Nurse (LPN #5) documented that the resident complained of abdominal pain and the right upper quadrant of the abdomen had some distention. Tylenol 650 milligrams (mg) was administered and will monitor. The LPN documented that the resident complained of nausea with no emesis (vomit). There is no documented evidence that the RN Supervisor was contacted at 2:00 AM. - [DATE] at 4:40 AM - RN #6 assessed the resident and documented that the resident had a distended, tympanic (drum like sound) abdomen, tender with palpation, right upper quadrant bowel sounds somewhat present but hypoactive, [MEDICAL CONDITION] patent with brown loose stool, bowel large and protruding through abdomen. Will monitor for continuation of signs and symptoms for possible new order from MD (medical doctor). Additional review of the Nurses' Notes dated [DATE] from 2:00 AM through 4:40 AM revealed no documented evidence that the resident's vital signs (temperature, blood pressure, pulse, respiratory rate) were assessed or that the physician was notified. Review of the Medication Administration Record [REDACTED]little relief. Additional review of the MAR indicated [REDACTED]. Review of the 24 Hour Report Summary Data dated [DATE] for the 11:00 PM to 7:00 AM shift ([DATE]) revealed at 2:00 AM, the resident complained of abdominal pain with some distention, Tylenol given, complains of nausea, no emesis. At 4:40 AM, abdomen very distended, hypoactive bowel sounds, stoma is enlarged, BM in bag. At 5:30 AM still complains of pain, Tylenol repeated. Temperature 98 (normal 98.6 degrees). No other vital signs were documented and there was no documentation that the physician was notified. Review of the facility investigation entitled Phone Conversation Notes, documented by the Acting Director of Nursing (DON) dated [DATE] revealed the RN Supervisor assessed that the resident was probably constipated and directed [MEDICATION NAME] (stool softener) to be given. The RN Supervisor told the Acting DON that at 5:30 AM, the resident's temperature was 96.4 degrees Fahrenheit (normal 98.6), pulse 100 (average 80), respirations 22 (normal 12 to 20), and no blood pressure (BP) could be taken due to the resident's shaking from [MEDICAL CONDITION]. Review of the medical record, including Nurses' Notes, the 24 Hour Report Summary Data or any other facility document provided to the survey team, revealed no documented BP reading from 2:00 AM when the resident's change of condition occurred to 7:00 AM Observation of morning activities on Unit 4 on [DATE] at 6:30 AM revealed the resident was lying in bed on his back, repeatedly calling out I need help. The observation revealed that the resident resided on the door side of the semi-private room. The resident's call light was not on, however the door was open. Continued observation for 10 minutes revealed two CNAs (#4 and #9) walked up and down the hallway arranging linens and checking rooms. During the 10 minutes, the resident intermittently called out Help, help, help or I need help for prolonged intervals, particularly when staff walked by the resident's room. Continued observation at approximately 6:40 AM revealed the resident's call light was located at the end of the bed and not within the resident's reach. The resident continued to call out I need help here, as CNA #4 passed the resident's room. CNA #4 went into other residents' rooms to wake them up and CNA #9 walked down the hall passing Resident #36's room. At 6:43 AM, CNA's #4 and #9 were two resident rooms down the hall and the resident was calling Help, I need my nurse. CNA #4 walked past the resident's room again as he was mumbling Help and CNA #4 walked down the hall and attended to another resident. The resident began to yell loudly Please help, several times. At approximately 6:46 AM, CNA #9 walked down the hall and passed the resident's room as he was calling out Help, I need help. At approximately 6:55 AM, the surveyor entered Resident #36's room and asked the resident what he needed assistance with and the resident stated his stomach was hurting and motioned towards his left lower abdomen. Interview with CNA #10 on [DATE] at approximately 6:56 AM revealed she was finishing the night shift and she was not assigned to the resident. CNA #10 stated she attended to the resident several times during the night because he was complaining of abdominal pain which was unusual for the resident. CNA #10 stated the resident usually sleeps through the night and is fairly cooperative. During an interview with the 11:00 PM to 7:00 AM shift LPN (#5) on [DATE] at approximately 6:57 AM, the surveyor informed LPN #5 of the resident's left lower abdominal pain. LPN #5 stated that the resident started complaining of abdominal pain at 2:00 AM and at 4:40 AM his abdomen became more distended. LPN #5 stated she did not notify the physician about the resident's change of condition, however she did notify the RN Supervisor who evaluated the resident, and she believed they will be ordering an abdominal flat plate. LPN #5 stated the resident did have MOLST (Medical Orders for Life-Sustaining Treatment) limitations of care. LPN #5 stated that a long time ago, the resident had similar complaints with flu-like symptoms. LPN #5 stated it was unusual for this resident to complain about abdominal pain. Review of an RN Assessment Documentation form dated [DATE] at 7:00 AM revealed the resident had a BP of ,[DATE], a pulse of 102, and respiratory rate of 26 and a temperature of 96.1. The resident had shallow breathing; a tender distended abdomen with hypoactive bowel sounds and the [MEDICAL CONDITION] stoma was bright red. The RN documented that the resident's abdomen was tender with palpation and the resident had emesis x 1 brown. Observation on [DATE] at 7:37 AM revealed that CNA #8 entered the resident's room to answer the call light, the resident told CNA #4 that his abdomen hurts, and CNA #8 told the resident that staff were getting help for him. Review of Physician's Telephone Orders dated [DATE] at 8:30 AM revealed orders for a Stat (immediate) abdominal flat plate (X-ray of the abdomen), a CBC (complete blood count (CBC - blood test to determine the components of cells in the blood) with differential, BMP - (basic metabolic profile - blood test including basic chemistry studies of the blood), a Chest x-ray, and to provide a clear liquid diet for 24 hours. Review of a Nurses' Note dated [DATE] at 10:45 AM revealed at 9:30 AM the resident had no pulse and no respirations. Additional review of Nurses' Notes and the 24 Hour Report Summary Data report dated [DATE] revealed no documented evidence that the resident was monitored, including vital signs and a comprehensive assessment of the resident including an examination of the resident's abdomen, pain, and nausea, from 7:15 AM to 9:30 AM when the resident expired. Interview with the Acting DON on [DATE] at 9:47 AM revealed at approximately 6:40 AM the night RN Supervisor reported to her that the resident had a change of condition with abdominal distention and the resident's vital signs were stable. The RN Supervisor stated during an interview on [DATE] at approximately 12:35 PM, that he went to assess the resident after the night charge LPN informed him of her concern regarding the resident's abdomen. The RN Supervisor stated that the resident's abdomen was tympanic, hard and more distended than normal as he documented in his note at 4:40 AM on [DATE]. The RN Supervisor stated he told the DON that we may want to get an abdominal flat plate and stated he did not notify the Physician because he did not know what the resident's baseline abdominal assessment was like. The RN Supervisor stated that the resident had hypoactive bowels sounds, everything else was normal, and the plan was to continue to monitor the resident. Regarding physician notification, the RN Supervisor stated since it was late in the shift he notified the oncoming supervisor. The RN Supervisor stated that he should have been informed at 2:00 AM when the change first occurred. Further interview with the Acting DON on [DATE] at approximately 12:50 PM revealed that when the RN Supervisor gave her report at approximately 5:30 AM and she (the DON) did not know whether the physician was notified; she left the night RN Supervisor to handle the issue. When questioned about the delay in LPN #5 notifying the RN Supervisor about the resident's change of condition at 2:00 AM, the DON stated that LPN #5 should have contacted the RN Supervisor immediately, and physician notification for a change of condition should happen right away. Interview with CNA #8 on [DATE] at 11:25 AM revealed she and CNA #9 were in the resident's room ,[DATE] times during the day shift on [DATE] and the resident stated his stomach was real uncomfortable. CNA #8 stated that the floor nurse and the charge nurse knew about the resident's pain/ discomfort and the doctor had been called. CNA #8 stated she responded to the resident's cries for help an emergent situation happened at approximately 9:15 AM because the resident was saying Help me, help me and when she entered the room, the resident was real congested. CNA #8 stated she immediately went to get the RN Coordinator and when they arrived the resident was throwing up a lot and they got the suction equipment and suctioned the resident. Interview with the Nurse Practitioner (NP) on [DATE] at approximately 1:37 PM revealed the RN Coordinator called her and informed her that the resident's [MEDICAL CONDITION] was not putting out stool and the resident's belly was distended. The NP stated she ordered Stat diagnostic and labs (laboratory tests). The NP did not know at the time of the interview that the resident's problems started at 2:00 AM; she thought the change of condition had just occurred at the time of the call this morning at 8:30 AM. The NP stated that the providers should have been notified immediately; there is on-call service ,[DATE]. The NP stated the resident had recently signed his own DNR order with no hospitalization ; however, she was familiar with the resident and stated he still wanted medical treatment and he could make his own decisions and people change their minds all the time. And he may have opted for treatment. The flat plate most likely would have showed a need for emergent treatment for [REDACTED]. Interview with the resident's physician on [DATE] at approximately 8:00 AM, in the presence of the Acting DON, revealed that the physician provided medical care for the resident for years; the resident had a [MEDICAL CONDITION] for chronic constipation and severe skin issues. The DON stated that the nurse suctioned fecal material from the resident yesterday morning when the emergent situation occurred around 9:15 AM. The attending MD stated the cause of the resident's death was probably bowel obstruction or perforation. When the MD was informed that the resident was alert until the final event, the MD stated that although the resident recently made himself a DNR with no hospitalization s, the resident could (and frequently did) change his mind and medical staff would honor his decision in that situation, he might have opted for treatment. Review of the facility policy entitled Notifying MD/ Responsible Party of Residents change of condition revised on ,[DATE] documented an occurrence of resident change of condition must be communicated in a timely manner to the attending MD by the nursing supervisor. Each Unit Nurse who identifies a change of condition must notify the Nursing supervisor immediately. 2. Resident #56 had [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed that the resident has moderate cognitive impairment, understands, is understood, and is frequently incontinent of bowel and bladder. Review of an Acute Visit Note, written by the NP, dated [DATE] revealed that the resident was admitted to the facility for short term rehabilitation. The NP documented a plan to refer the resident to a [MEDICATION NAME] (a physician specially trained in the management of diseases of the gastrointestinal tract and liver) due to positive stool for occult blood (blood in the stool that is not visible). Review of a hospital Discharge Summary dated [DATE] revealed the resident had a [DIAGNOSES REDACTED]. The Discharge Summary documented that the resident should be followed by a nephrologist and it will be up to the primary care Physician to arrange this. Review of an Acute Visit Note, written by the NP, dated [DATE] revealed the resident is to be referred to nephrology (a kidney specialist) due to his Stage IV [MEDICAL CONDITION]. The NP documented that the resident had [MEDICAL CONDITION]/ positive stool for occult blood and he is to follow-up with [MEDICATION NAME] after discharge from short-term rehabilitation services. Review of Physician's Orders dated [DATE] revealed an order to obtain a Nephrology consult. Additional review of Acute Visit Notes, written by the NP, revealed the following: - [DATE] - The resident was evaluated for rectal bleeding/diarrhea with plans to change the GI (gastrointestinal) appointment to next week. - [DATE] - The resident was evaluated again for rectal bleeding/diarrhea with plans for a [MEDICATION NAME] appointment for [DATE]. - [DATE] - The resident was evaluated again for rectal bleeding/diarrhea. The resident was not seen by the [MEDICATION NAME] due to a mix-up with transportation and the appointment was rescheduled or [DATE]. The NP documented that the resident continues with rectal bleeding with some diarrhea. - [DATE] - The resident was seen for hematochezia (passage of bloody stools) and diarrhea. The NP documented that the resident was seen by the [MEDICATION NAME] on [DATE], who recommended a colonoscopy. The resident continues with loose stools on a frequent basis. - [DATE] - The resident was evaluated status [REDACTED]. Review of a [MEDICATION NAME] Colonoscopy Preliminary Report/ Communication Form dated [DATE] revealed a biopsy was taken and a polyp was removed. A sticky note was attached to the top of the form directing to make a follow-up appointment with the [MEDICATION NAME]. Review of the entire medical record on [DATE] revealed there was no documented evidence of a follow-up appointment with the [MEDICATION NAME] and there was no Nephrology consult completed for Resident #56. During an interview on [DATE] at approximately 10:00 AM, the NP stated that she could not identify whether the resident had a Nephrology consult performed after the [DATE] order. The Registered Nurse (RN) Coordinator stated during an interview on [DATE] at approximately 8:20 AM that as of [DATE] there was no follow-up appointment made with the [MEDICATION NAME] and the colonoscopy report was not in the medical record. The RN Coordinator was not aware that the Nephrology consult was not completed. 3. Resident #37 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed that the resident is cognitively intact, understands, and is understood. Review of a Psychological Services Progress Note dated [DATE] revealed the resident is in good spirits, denied AH (auditiry hallucination) ameable to supportive Rx (treatment). Plan: Supportive Rx to increase reality orientation. Review of Nursing Progress Notes dated from [DATE] through [DATE] revealed no documentation of behaviors. Review of the Comprehensive Care Plan (CCP) dated [DATE] revealed that problem areas include antipsychotic drug use, potential for behaviors related to a [DIAGNOSES REDACTED]. Review of a Physician's Order dated [DATE] revealed an order to refer for psych (psychiatric) medication evaluation and possible gradual dose reduction (GDR) for psychiatric medications. Review of an Acute Care Visit note, written by the NP, dated [DATE], revealed A referral has been placed for psychiatric evaluation of medication usage and possible GDR. Review of the chronological medical record revealed no documented evidence that the resident was seen by the Psychiatrist or the psychiatric NP in [DATE], [DATE], or [DATE]. Interview with the Unit Clerk on [DATE] at approximately 11:00 AM revealed there was no documentation to be filed for Resident #37 related to a psychiatric visit. During an interview on [DATE] at approximately 11:11 AM, the Social Worker stated that the resident was not scheduled to be seen by the Psychiatrist and the last time the resident saw the Psychiatrist was last May (2015). Review of a list of residents to be seen by the psychiatric NP or the Psychiatrist, dated [DATE] to [DATE], revealed that Resident #37 was not on the list. Interview with the Director of Social Work on [DATE] at approximately 11:12 AM revealed that a resident is put on a list to be seen by the psychiatric NP or by the Psychiatrist after the residents are discussed during morning report. The Director stated that she will put the resident on the list to be seen [DATE]. Review of a facility policy and procedure entitled [MEDICAL CONDITION] Medications and BMARC (Behavioral Management Review Committee) Team dated [DATE] revealed Nursing/ Social Work will report to the facility interdisciplinary team changes in medication, behavioral response, and intervention recommendations during morning report and during quarterly care plan meetings. 415.12

Based on interview and record review conducted during a Partial Extended survey (Complaint #NY 084) completed on 8/13/15, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status. Six (Residents #4,5,8,13,16, 22) of 25 residents reviewed for physician notification had issues involving the lack of timely physician notification when intravenous antibiotics and a subcutaneous (below the skin) fluid infusion (Clysis) were not administered as ordered; lack of physician notification of a change in a resident's condition; lack of physician notification when a resident's peripherally inserted internal catheter (PICC) was dislodged; and lack of physician notification when a wound culture result revealed the infectious organism was not sensitive to the antibiotic that was ordered. This resulted in a pattern of IMMEDIATE JEOPARDY that is actual harm. The IMMEDIATE JEOPARDY was removed on 8/17/15, following the survey exit. The findings include but are not limited to: 1. Resident # 8 has [DIAGNOSES REDACTED]. Review of a Report of Consultation, completed and signed by a Wound Specialist Physician, dated 7/10/15 revealed the resident had a Stage 4 infected, foul smelling, sacral (area above the tailbone on the right and left buttocks) decubitus (localized injury to the skin that is a result of pressure) ulcer. The physician documented that a culture of the wound was obtained and recommended [MEDICATION NAME] (antiseptic solution containing iodine) wound packing, Clysis (an infusion of fluid, under the skin, for hydration) with 0.45 NS (normal saline) at 50 cubic centimeters (cc) per hour for 10 days, and intravenous (IV) [MEDICATION NAME] (antibiotic) 500 milligrams (mg) every 12 hours. Review of three separate Physician's Telephone Orders dated 7/10/15 revealed the following: - Clysis 0.45 NS at 50 cc per hour for 10 days for hydration related to the sacral wound - [MEDICATION NAME] 500 mg IV every 12 hours - Obtain PICC line, per the Physician Wound Specialist, for IV antibiotics. Send to hospital on Tuesday 7/14/15 at 9:30 AM for PICC insertion Review of a nursing progress note dated 7/11/15 at 1:00 AM revealed the Clysis infusion was started per the physician's orders [REDACTED]. Review of a nursing progress note dated 7/14/15 for the 7:00 AM to 3:00 PM shift revealed that the resident returned to the facility at 1:15 PM after having the PICC line inserted. The note documented that the (sacral) wound culture results were obtained and the wound was positive for [MEDICAL CONDITION] resistant staphylococcus aureas (MRSA - antibiotic resistant bacteria). Additional review of the 7/2015 MAR indicated [REDACTED]. Review of an untimed nursing progress note, signed by the Registered Nurse (RN #1) Supervisor, dated 7/14/15 revealed that the resident's temperature (T) was 99.6 degrees (normal 98.6 - no baseline temperature noted for Resident #8), pulse (P) was 108 (average 80), blood pressure (BP) 104/60 (normal), oxygen saturation level (amount of oxygen in the blood) was 81 % (percent) (normal 90 to 100 %) and the resident was shaky. The RN Supervisor documented that oxygen at 2 liters per minute was applied and the resident's oxygen saturation level increased to 93%. The physician was notified and ordered [MEDICATION NAME] (antibiotic) 1 gram (gm) IV daily for 10 days. Review of a nursing progress note, written by RN #2, dated 7/15/15 at 1:00 AM, revealed that the PICC line was in the right jugular vein (major blood vessel located on both sides of the neck) and the right side of the resident's face and neck were swollen and firm. The RN documented that the resident had difficulty swallowing, the right side of the neck was tender to touch, the resident's temperature was 102.4 degrees, and APAP (Acetominophen) was given. Additional review of the Nursing Progress Noted revealed that the resident's BP was 104/40, P was 130, respirations (R) were 28 (normal 12 to 20) and the oxygen saturation level was 94%. while wearing oxygen. The RN documented that the Physician was notified and orders were received to send the resident to the emergency room . A nursing progress note dated 7/15/15 at 4:40 AM documented that the resident was admitted to the hospital with [REDACTED]. Additional review of the Medication Administration Record [REDACTED]. Review of the hospital General Admission H&P (History and Physical) dated 7/15/15 revealed the resident's [DIAGNOSES REDACTED]. The General Admission H&P documented that the resident's white blood cell count (indicates presence of infection) upon admission was 30.0 (normal 4.0 to 10.5). The Physical Exam section of the H&P documented that the resident had a Stage 4 sacral decub (decubitus) with a central opening that was approximately 4 cm in diameter and had surrounding [DIAGNOSES REDACTED]. The H&P also documented that the sacral decubitus had a foul smell, exposed sacral bone, and minimal pus. Interview with the Acting Director of Nursing (DON) on 8/4/15 at 11:30 AM revealed that a PICC line insertion must be a scheduled procedure at the hospital. The Acting DON stated that the resident's PICC was ordered on [DATE] (Friday) and 7/14/15 (Tuesday) was the first day available to have the PICC line inserted. The Acting DON stated that the facility does not give IV [MEDICATION NAME] through a peripheral (arms, hands, legs, or feet) IV because [MEDICAL CONDITION] vein. During a telephone interview on 8/4/15 at 1:00 PM, the Physician Wound Specialist stated that he assessed the resident on 7/10/15 and found that the resident had an infected, foul smelling Stage 4 sacral decubitus ulcer. The Physician Wound Specialist stated that he recommended IV [MEDICATION NAME] on 7/10/15 to treat the resident's infected sacral ulcer and that his expectation was that the IV [MEDICATION NAME] would be started on 7/10/15. The Physician Wound Specialist stated that nursing staff did not call him and inform him that there would be a four day delay starting the IV antibiotics due to the delay in PICC line insertion and he was not aware of the 7/10/15 order to send the resident to the hospital for the PICC line insertion on 7/14/15. The Physician Wound Specialist stated that nursing staff should have called him to inform him of the situation so that alternate plans for the IV antibiotic therapy could have been made, possibly infusing the antibiotic through a peripheral IV or sending the resident to the hospital to begin the antibiotics. The Physician Wound Specialist stated that he was not aware of the plan to send the resident to the hospital for the PICC line insertion on 7/14/15 and he did not authorize waiting four days to start the IV antibiotic. The Physician Wound Specialist stated that the delay in starting the IV antibiotics very likely caused the resident's condition to worsen. He stated that the wound was already very infected when he saw it on 7/10/15. In summary, there was an approximate four day delay starting IV antibiotics for a resident with an infected Stage 4 decubitus ulcer. The resident did not receive the IV antibiotics at the facility as ordered. The resident was transferred to the hospital on [DATE], admitted with a [DIAGNOSES REDACTED]. 2. Resident #22 has [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS - a resident assessment tool) dated 7/16/15 revealed the resident is cognitively intact, understands, and is understood. Review of a Report of Consultation dated 7/25/15 revealed a Physician Wound Specialist evaluated the resident at the facility. The Consultation documented that the resident had an advanced diabetic ulcer on the right great (big toe) toe which was infected. The Physician Wound Specialist debrided (removed dead tissue or foreign matter in the wound) necrotic (dead tissue) tissue down to the bone. Additional review of the Consultation revealed the Physician Wound Specialist ordered the IV [MEDICATION NAME] 1 gram daily for 10 days, a culture (took a swab sample to test for bacteria) of the wound was obtained, and the physician requested to be notified of the culture results. The Physician Wound Specialist documented that the resident must be on bedrest and needs a PICC line. Review of a Physician's Telephone Order dated 7/25/15 revealed orders to administer IV Vanco ([MEDICATION NAME]) 1 gram daily for 10 days and to update the Wound Specialist with the culture results. Review of a subsequent Physician's Telephone Order dated 7/25/15 revealed orders to hold Vanco until the PICC line is inserted and to administer Bactrim (antibiotic) DS (double strength) one tab by mouth twice a day for 10 days. Review of the Medication Administration Record [REDACTED]. An undated Continuous IV Therapy Flow Sheet documented Vanco 1 gram IV upon insertion. Review of a Physician's Telephone Order dated 7/30/15 revealed an order to schedule patient for PICC line ASAP (as soon as possible) . Review of Nurses' Notes and 24 Hour Report Sheets dated 7/26/15 to 8/5/15 revealed there was no documented follow-up regarding the wound culture obtained by the Wound Specialist on 7/25/15. Review of a repeat Report of Consultation dated 8/1/15 revealed the Wound Specialist again cultured the wound and requested follow up on the culture done on 7/25/15. Interview with the Physician Wound Specialist on 8/6/15 at approximately 1:10 PM revealed he was following the resident for treatment of [REDACTED]. The Physician Wound Specialist stated that he cultures all residents' wounds at each visit. The wound culture done on 7/25/15 was not reported to him despite two requests. The Physician Wound Specialist stated that he was just informed today that both of the cultures (7/25/15 and 8/1/15) revealed that the identified organisms (the infections) were not sensitive (shown to be effective to eliminate the infection) to the IV antibiotic that the resident was on so it will require a change in treatment. The Physician Wound Specialist stated he felt that the facility was too late in calling him and that they do not have enough nursing staff to care for the residents properly. Review of a Physician's Telephone Order dated 8/6/15 revealed orders to discontinue IV [MEDICATION NAME] and start [MEDICATION NAME] (antibiotic) after contacting the pharmacy. Interview with the Acting DON on 8/6/15 at approximately 1:00 PM revealed the unit coordinator is responsible for following through on all aspects of the residents' care needs. The RN should have called the lab to follow up on the lab results a few days after completion of the wound culture and after each consult that requests follow-up. Interview with the Second Floor RN UC on 8/6/15 at approximately 2:40 PM revealed the RN UC did not call the lab or follow up on the culture reports until today (8/6/15). The RN UC stated that the organisms identified in the culture showed that the antibiotic treatment that the resident was receiving was not effective in treating the infection. 3. Resident #5 has [DIAGNOSES REDACTED]. Review of an undated Comprehensive Care Plan revealed the resident has altered communication due to a language barrier and an altered mental status. Review of Admission physician's orders [REDACTED]. Review of the medical record, including nursing progress notes and PICC Line Therapy Flow sheets, revealed the following: - 6/24/15 at 10:45 PM - LPN #5 documented that the resident had a large amount of foul smelling drainage noted from the PEG tube ([DEVICE]) site. There was no documentation that the Physician was notified. - 6/26/15 - LPN #5 documented there was green drainage coming from the PEG tube site. The LPN documented that a culture (laboratory test to determine if an infection is present) was obtained. - 6/27/15 and 6/28/15 - LPN #6 documented there was a moderate amount of drainage from the PEG tube site. There was no documentation that the Physician was notified. - 7/1/15 and 7/3/15 - The PICC Line Therapy Flow Sheets documented that the PICC migrated (movement/change in position), was pulled out partially, and was taped in place to the resident's arm. There was no documentation that the physician was informed. - 7/4/15 - LPN #6 documented that the resident had emesis (vomiting) twice and that the supervisor was informed. There was no documented evidence of an RN assessment or that the physician was notified. - 7/7/15 at 7:00 PM - Physician notified of increased secretions and nonproductive cough, pulse of 110 (average 80), and blood pressure of 100/60. New orders were obtained for [MEDICATION NAME] (combination inhalant medication to open the airway) every four hours for congestion and [MEDICATION NAME] (cough medicine) 15 cc (cubic centimeters) as needed for cough. - 7/8/15 at 5:15 AM - The nursing progress note documented that the resident was more congested, less responsive, and had a temperature of 101.5. The physician was updated and an order was obtained to send the resident to the ER (emergency room ). - 7/8/15 at 7:00 AM - The ER called the facility after resident evaluation and stated that the resident was diagnosed with [REDACTED]. Review of the hospital General Admission H&P dated 7/8/15 revealed the resident was admitted with a high WBC count of 23.7 and a high suspicion of bacteremia (bacteria in the bloodstream) due to the PICC line being displaced and exposed. The resident's admitting [DIAGNOSES REDACTED]. Review of an abdominal CT (computerized tomography - a diagnostic test that provides detailed images) Report dated 7/10/15 revealed an addendum dated 7/12/15 documented that the resident had an abscess in the left abdominal wall. There was a small tract from the PEG tube channel to the abscess. Interviews with facility staff on 8/5/15 at approximately 1:50 PM revealed the following: - The second floor RN Unit Coordinator stated that when an LPN finds a change in status in a resident such as drainage from a peg tube site, an open wound or vomiting, the RN Supervisor is to be notified. The RN is to assess the resident and contact the physician and responsible party as needed. When the PICC was found advanced out, the physician should have been contacted at that time or the following morning. - The Acting DON reviewed the resident's medical record and stated that when the PICC line was found partially out, the line should have been measured and the physician notified. 4. Resident #4 has [DIAGNOSES REDACTED]. Review of the comprehensive Care Plan dated 6/17/15 revealed the resident always understands and is always understood. Review of an Admission history and physical examination [REDACTED]. Review of a nursing progress note, written by a Licensed Practical Nurse (LPN #1), dated 7/12/15 at 8:00 AM revealed the resident had a temperature of 100.6 degrees (98.6 normal - no baseline temperature noted for Resident #4). The LPN documented that the resident requested to remain in bed, and ate and drank poorly despite encouragement. Review of nursing progress notes, written by LPNs #2 and #3, dated 7/12/15 for the 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shifts revealed there was no documentation regarding the resident's oral intake or temperature. Additional review of the nursing progress notes and 24 Hour Reports dated 7/12/15 revealed no documented evidence that the resident's temperature was monitored, that an RN assessed the resident or that the physician was notified. Review of a nursing progress note, written by a registered nurse (RN #3), dated 7/13/15 at 9:30 AM revealed the RN was called to the physical therapy room to assess the resident. The RN documented that the resident was shaking; the resident stated that his upper (arms) and lower extremities (his legs) were numb; breathing was rapid with an oxygen saturation level of 85 % (percent) (normal 90 to 100 %); and the pulse was 120 (average 80). The resident was returned to the unit for further assessment, which revealed a blood pressure of 88/64 (low blood pressure), respirations were 32 (normal 14 to 30) and labored, pulse ranged from 109 to 132 and oxygen was applied. The Nurse Practitioner (NP) was notified and new orders were obtained to send the resident to the hospital for evaluation. Review of the hospital Discharge Summary dated 7/29/15 revealed the resident had an abscess (a collection of pus under the skin) in the spinal column and [MEDICAL CONDITION] ([MEDICAL CONDITION] - contagious, antibiotic resistant bacteria) infection in the sacral decubitus. The Discharge Summary documented that the resident underwent [REDACTED]. Interviews with nursing staff on 8/5/15 revealed the following: - At approximately 12:00 PM, the 3rd floor LPN (#4) stated that all changes in resident status noted by an LPN need to be reported to the RN Supervisor. If vital signs (temperature, pulse, respirations, blood pressure) are found to be abnormal, the resident is to be monitored for 24 hours, an RN is to assess the resident, and the Physician or Nurse Practitioner are to be notified of the change in status. - At approximately 1:55 PM, the acting DON stated that LPN #1 should have notified the RN Supervisor and an assessment should have been completed by an RN. The staff should have continued to monitor the resident's vital signs and the physician should have been contacted regarding the change in status. Review of a facility policy and procedure (P&P) entitled Notifying MD/ Responsible Party of Change dated 2/2015 revealed it is the policy of the facility to notify the attending MD and responsible party of any changes in the resident's condition. Each nurse who identifies a change in condition must notify the Nursing Supervisor immediately. Change in condition may include an increased temperature, unstable vital signs and change in diet or fluids. 5. Resident #13 has [DIAGNOSES REDACTED]. Review of A Nursing Admission assessment dated [DATE] revealed the resident is alert to person, has impaired judgement, and is confused at times regarding time and place. Review of nursing progress notes dated 6/30/15 to 7/2/15 revealed the following: - 6/30/15 at 12:30 PM - The resident arrived at the facility from the hospital via ambulance. The nursing progress note documented that the resident had no IV access and nursing staff were unable to establish peripheral IV access despite two attempts - 6/30/15 at 4:30 PM - A physician order [REDACTED]. - 7/2/15 - PICC line in place Review of a PICC Line Therapy Flow Sheet dated 7/2015 revealed the first doses of Meropenum (antibiotic) 1 gram IV were administered on 7/3/15 at 8:00 AM and 4:00 PM and [MEDICATION NAME] (antibiotic) 100 mg IV on 7/3/15 at 9:00 AM and 9:00 PM. There was no documentation that IV Meropenum was administered on 7/4/15 at 12:00 AM, 8:00 AM, and 4:00 PM or that IV [MEDICATION NAME] was given on 7/4/15 at 9:00 AM or 9:00 PM. Review of a nursing progress note dated 7/4/15 at 12:00 PM revealed the resident was found on the floor with her [MEDICAL CONDITION] (surgical creation of an opening in the airway to assist breathing) out and she was transferred to the emergency room for [MEDICAL CONDITION] replacement. An untimed nursing progress note dated 7/4/15 documented that the the hospital gave a verbal report to the nursing facility, prior to transferring the resident back to the facility, that the resident pulled out the PICC line while in the hospital. Additional review of the PICC Line Therapy Flow Sheet dated 7/2015 revealed there was no documentation that the resident received IV Meropenum or IV [MEDICATION NAME] from 7/5/15 to 7/7/15 as ordered by the physician. Review of nursing progress notes and 24 Hour Report Sheets dated 7/5/15 to 7/7/15 revealed no documented evidence that the physician was notified that the PICC line was out and that the IV antibiotics were not being administered as ordered. Review of a nursing progress note dated 7/7/15 at 11:00 AM revealed the physician's office was contacted and there was no need for additional antibiotics. Review of Physician's Telephone Orders dated 7/7/15 revealed orders to discontinue the IV [MEDICATION NAME] and Meropenum Interview with the Acting DON on 8/5/15 at approximately 1:50 PM revealed the physician is to be called if an IV med is unable to be given due to malfunctioning IV access. The DON stated if staff are unable to reinsert the line, the physician may want to have the antibiotic given via another route such as oral or by injection. 6. Resident #16 has [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS - a resident assessment tool) dated 5/6/15 revealed the resident is severely cognitively impaired with long and short term memory problems. Review of physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of a nursing progress note dated 7/4/15 for the 3:00 PM to 11:00 PM shift revealed that the resident had a temperature of 99 degrees F (normal 98.6 - no baseline temperature noted for Resident #16), was diaphoretic (sweating), and cool compresses were applied. There was no documentation that the physician or nursing supervisor were notified of the low grade fever or diaphoresis. Review of a nursing progress note dated 7/5/15 for the 11:00 PM to 7:00 AM shift revealed that at 2:00 AM the resident had a temperature of 101 degrees F, a fluid filled blister was noted on the right arm near the elbow, and cool compresses were applied. A recheck revealed the temperature was 99 degrees F and the resident was diaphoretic (sweating). There was no documentation that the physician or nursing supervisor were notified of the fever or blister on the right arm. Review of the Medication Administration Record [REDACTED]. No other administration of Tylenol was noted on the MAR for 7/5/15. Review of a Nursing Progress Note dated 7/5/15 at 1:25 PM revealed that the resident had elevated temperatures on and off since 7/4/15 and the resident was currently receiving [MEDICATION NAME] 7.5/325 mg four times a day, however not controlling temp. Cool compresses to armpits and groin applied without results. Temp retaken at 12:50 PM, results 102.5 degrees F. Physician notified. Review of a Hospital Transfer Form dated 7/5/15 revealed that the physician was notified of the resident's condition at approximately 1:00 PM. Review of a Physician's Telephone Order dated 7/5/15 at 1:15 PM revealed an order to send the resident to the emergency department for evaluation and treatment if needed. During an interview on 8/6/15 at approximately 12:33 PM, the Administrator was asked when a physician should be contacted for a change in condition. The Administrator stated that's too long of a time to wait to call the Physician about the temperature. During the interview the Chief Nursing Officer (CNO) was asked if [MEDICATION NAME] is an appropriate intervention for fever. The CNO stated That isn't an appropriate intervention for a fever especially if they have Tylenol ordered for fever. Review of a facility policy and procedure (P&P) entitled Notifying MD/ Responsible Party of Resident's Change of Condition dated 2/2015 revealed that each unit nurse who identifies a change of condition must notify the nursing supervisor immediately. The P&P documented that change of condition may include one or more of the following: increased temperature, symptoms of warmth, swelling, redness of any limb or body part, or symptoms of infectious process. 415.3(e)(2)(ii)(b)(c)

Based on observation, record review and staff interview conducted during a Partial Extended survey (Complaint #NY 084) completed on 8/13/15, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Fourteen residents (Resident's #1,4,5, 6, 8, 9,10,13,14,16,18, 22, 23, 24) of 25 residents reviewed for quality of care had issues involving delays obtaining intravenous (IV) access to administer IV antibiotics; delay starting a continuous fluid infusion; lack of physician's orders [REDACTED]. verbal physician's orders [REDACTED]. This resulted in a pattern of IMMEDIATE JEOPARDY and SUBSTANDARD QUALITY OF CARE TO RESIDENT HEALTH AND SAFETY that is actual harm. The IMMEDIATE JEOPARDY was removed on 8/17/15, following the survey exit. The findings include but are not limited to: 1. Resident # 8 has [DIAGNOSES REDACTED]. Review of a Report of Consultation, completed and signed by a Wound Specialist Physician, dated 7/10/15 revealed the resident had a Stage 4 infected, foul smelling, sacral (area above the tailbone on the right and left buttocks) decubitus (localized injury to the skin that is a result of pressure) ulcer. The physician documented that a culture of the wound was obtained and recommended [MEDICATION NAME] (antiseptic solution containing iodine) wound packing, Clysis (an infusion of fluid, under the skin, for hydration) with 0.45 NS (normal saline) at 50 cubic centimeters (cc) per hour for 10 days, and intravenous (IV) [MEDICATION NAME] (antibiotic) 500 milligrams (mg) every 12 hours. Review of three separate Physician's Telephone Orders dated 7/10/15 revealed the following: - Clysis 0.45 NS at 50 cc per hour for 10 days for hydration related to the sacral wound - [MEDICATION NAME] 500 mg IV every 12 hours - Obtain PICC line, per the Physician Wound Specialist, for IV antibiotics. Send to hospital on Tuesday 7/14/15 at 9:30 AM for PICC insertion Review of a nursing progress note dated 7/11/15 at 1:00 AM revealed the Clysis infusion was started per the physician's orders [REDACTED]. Review of a nursing progress note dated 7/14/15 for the 7:00 AM to 3:00 PM shift revealed that the resident returned to the facility at 1:15 PM after having the PICC line inserted. The note documented that the (sacral) wound culture results were obtained and the wound was positive for [MEDICAL CONDITION] resistant staphylococcus aureas (MRSA - antibiotic resistant bacteria). Review of an untimed nursing progress note, signed by the Registered Nurse (RN #1) Supervisor, dated 7/14/15 revealed that the resident's temperature (T) was 99.6 degrees (normal 98.6 - no baseline temperature noted for Resident #8), pulse (P) was 108 (average 80), blood pressure (BP) 104/60 (normal), oxygen saturation level (amount of oxygen in the blood) was 81 % (percent) (normal 90 to 100 %) and the resident was shaky. The RN Supervisor documented that oxygen at 2 liters per minute was applied and the resident's oxygen saturation level increased to 93%. The physician was notified and ordered [MEDICATION NAME] (antibiotic) 1 gram (gm) IV daily for 10 days. Review of a nursing progress note, written RN #2, dated 7/15/15 at 1:00 AM, revealed that the PICC line was in the right jugular vein (major blood vessel located on both sides of the neck) and the right side of the resident's face and neck were swollen and firm. The RN documented that the resident had difficulty swallowing, the right side of the neck was tender to touch, the resident's temperature was 102.4 degrees, and APAP ([MEDICATION NAME]) was given. Additional review of the Nursing Progress Noted revealed that the resident's BP was 104/40, P was 130, respirations (R) were 28 (normal 12 to 20) and the oxygen saturation level was 94% while wearing oxygen. The RN documented that the Physician was notified and orders were received to send the resident to the emergency room . A nursing progress note dated 7/15/15 at 4:40 AM documented that the resident was admitted to the hospital with [REDACTED]. Additional review of the Medication Administration Record [REDACTED]. Review of the hospital General Admission H&P (History and Physical) dated 7/15/15 revealed the resident's admission [DIAGNOSES REDACTED]. The General Admission H&P documented that the resident's white blood cell count (indicates presence of infection) upon admission was 30.0 (normal 4.0 to 10.5). The Physical Exam section of the H&P documented that the resident had a Stage 4 sacral decub (decubitus) with a central opening that was approximately 4 cm in diameter and had surrounding [DIAGNOSES REDACTED]. The H&P also documented that the sacral decubitus had a foul smell, exposed sacral bone, and minimal pus. Interview with the Acting Director of Nursing (DON) on 8/4/15 at 11:30 AM revealed that a PICC line insertion must be a scheduled procedure at the hospital. The Acting DON stated that the resident's PICC was ordered on [DATE] (Friday) and 7/14/15 (Tuesday) was the first day available to have the PICC line inserted. The Acting DON stated that the facility does not give IV [MEDICATION NAME] through a peripheral (arms, hands, legs, or feet) IV because [MEDICAL CONDITION] vein. During a telephone interview on 8/4/15 at 1:00 PM, the Physician Wound Specialist stated that he assessed the resident on 7/10/15 and found that the resident had an infected, foul smelling Stage 4 sacral decubitus ulcer. The Physician Wound Specialist stated that he recommended IV [MEDICATION NAME] on 7/10/15 to treat the resident's infected sacral ulcer and that his expectation was that the IV [MEDICATION NAME] would be started on 7/10/15. The Physician Wound Specialist stated that nursing staff did not call him and inform him that there would be a four day delay starting the IV antibiotics due to the delay in PICC line insertion and he was not aware of the 7/10/15 order to send the resident to the hospital for the PICC line insertion on 7/14/15. ThePhysician Wound Specialist stated that nursing staff should have called him to inform him of the situation so that alternate plans for the IV antibiotic therapy could have been made, possibly infusing the antibiotic through a peripheral IV or sending the resident to the hospital to begin the antibiotics. The Physician Wound Specialist stated the he was not aware of the plan to send the resident to the hospital for the PICC insertion on 7/14/15. The Physician Wound Specialist stated that the delay in starting the IV antibiotics very likely caused the resident's condition to worsen. He stated that the wound was already very infected when he saw it on 7/10/15. In summary, there was an approximate four day delay obtaining intravenous access (PICC) for starting IV antibiotic administration for a resident with an infected Stage 4 decubitus ulcer. In addition, there was an approximate ten hour delay starting the Clysis infusion. The resident was transferred to the hospital on [DATE], admitted with a [DIAGNOSES REDACTED]. 2. Resident #10 was readmitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. a.) Review of the facility's PICC Line Therapy Flow Sheet revealed instruction for the following: - Measure external PICC line length with each dressing change from insertion site, observe for migration (movement/change in position) - Sterile dressing change within 24 hours for new insertion then sterile dressing change every week and PRN (as needed). Change end cap with each dressing change (Label dressing with date/time/initials) - Site Status: check for redness, swelling, pain, or leaking at site - Flush PICC per SASH (saline, administer medication, saline, [MEDICATION NAME]) ([MEDICATION NAME] - blood thinning medication) - Maintenance of PICC flush every 24 hours and PRN - IV tubing change every 24 hours, document exact time Additional review of the PICC Line Therapy Flow Sheet revealed instructions for the following: - Sterile dressing change within 24 hours for new insertion then sterile dressing change every week and PRN (as necessary) using. Change end cap with each dressing change (Label dressing with date/ time/ initials. - Measure external PICC length with each dressing change from insertion site, observe for migration (movement/change in position). Review of a PICC Line Therapy Flow Sheet dated June 2015 revealed the resident had a PICC line and received [MEDICATION NAME] 500 IV daily at 9:00 PM. Further review of the PICC Line Therapy Flow Sheet dated June 2015 revealed that the sterile dressing change and external catheter measurement were documented as completed 6/1/15 and 6/8/15. The dressing change and catheter measurement scheduled for 6/15/15 and 6/22/15 were not documented as done. Review of a Transfer Form dated 6/23/15 revealed the resident's PICC line was dislodged and the resident was transferred to the hospital on [DATE]. Review of Nurses' Notes and 24 Hour Report Sheets dated 6/15/15 through 6/22/15 revealed no documented evidence that the PICC line dressing changes or catheter measurements were done. During an interview on 8/5/15 at 2:00 PM, the RN UC stated there was no documentation that the PICC line dressing changes or catheter measurements were done 6/15/15 and 6/22/15. The RN UC stated that she did not recall doing the dressing changes. b.) Review of a hospital Discharge Summary sheet dated 7/28/15 revealed orders for the resident to receive Meropenum (antibiotic) IV every eight hours with a stop date of August 1 (2015). Review of a Nurse's Note, written by RN #5, dated 7/29/15 at 4:00 PM revealed the RN was unable to establish IV access despite three attempts. The RN documented that a new order was obtained from the Nurse Practitioner (NP) to insert a PICC line for IV antibiotics due to the inability to establish peripheral IV access. The NP ordered that once the PICC line is inserted, give one gram of Meropenum IV every eight hours for three days. Review of a Nurse's Note, written by RN #5, dated 7/30/15 for the 3:00 PM to 11:00 PM revealed the resident was awaiting PICC line insertion for IV antibiotics; Attempted x 2 this shift to The RN further documented that an appointment was made to have the PICC line inserted on 8/6/15 which was the soonest appointment available. Review of a Nurse's Note, written by the Acting DON, dated 7/31/15 at 11:00 PM revealed that a #20 (size of intravenous catheter) angio (IV) was inserted into the resident's right hand for IV antibiotic Meropenum every eight hours for three days. Review of an Intermittent IV Therapy Flow sheet dated August 2015 revealed the resident received IV Meropenum three times a day for three days and the first dose was started on 8/1/15 at 6:00 AM. During an interview on 8/5/15 at 2:00 PM, the Fourth Floor RN UC stated that her attempts to insert a peripheral IV were unsuccessful on 7/29/15 and 7/30/15. The RN UC stated that the Acting DON was able to insert a peripheral IV on 7/31/15 and the IV antibiotics were started on 8/1/15 at 6:00 AM. In summary, PICC line site care was not provided and arm circumference was not monitored as planned. In addition, the resident returned from the hospital on [DATE] with discharge [DIAGNOSES REDACTED]. Orders included IV antibiotics to be administered three times a day through 8/1/15. There was an approximate three day delay in starting the IV antibiotics upon the resident's return to the facility from the hospital due to the lack of IV access. 3. Resident #23 was admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. Review of a hospital Discharge Summary dated 7/21/15 revealed that [MEDICATION NAME] is to be given intravenously and goal is to keep the trough (blood samples collected to determine the level of an antibiotic, usually collected 30 minutes prior to a dose) between 15 and 20. The Discharge Summary documented that the pharmacy is to dose the [MEDICATION NAME] and that the [MEDICATION NAME] needed to be continued until 8/7/15. Review of a Physician's Telephone Order dated 7/21/15 revealed an order for [REDACTED]. Review of a Nurse's Note dated 7/22/15 revealed that the resident's CVP line (central venous pressure - an intravenous catheter inserted into a large vein and passing into the heart) pulled out. The Nurse's Note documented that the NP (nurse practitioner) was notified and that a new order was obtained to change [MEDICATION NAME] IV to 1.5 grams daily per the pharmacy recommendations. The Note documented a plan to re-insert the CVP line at the hospital on [DATE] and to restart IV antibiotics on 7/24/15 at 10:00 AM. Review of a Physician's Telephone Order dated 7/22/15 revealed an order to change IV [MEDICATION NAME] to 1.5 gm IV every day and to re-insert the triple lumen catheter (three separate lumens attached to one intravenous catheter) CVP on 7/23/15. Review of a Nurses' Notes dated 7/23/15 revealed there was no documentation that the CVP line was re-inserted or why the resident did not have the CVP line inserted on that day. Review of a PICC Line Therapy Flow Sheet dated July 2015 revealed the resident had a Hohn (type of central venous catheter) inserted on 7/24/15. Additional review of the PICC Line Therapy Flow Sheet for July 2015 revealed the resident did not receive the 9:00 PM dose of IV [MEDICATION NAME] on 7/21/15 as ordered by the physician. Further review of the PICC Line Therapy Flow Sheet revealed the resident received one dose of IV [MEDICATION NAME] on 7/22/15 at 9:00 AM. The Flow Sheet indicated that the IV [MEDICATION NAME] was restarted on 7/24/15 at 2:00 PM and continued through 8/7/15 at 2:00 PM. Review of physician's orders [REDACTED]. The DON stated during an interview on 8/12/15 at 2:00 PM that there was a delay obtaining IV access until 7/24/15 which resulted in a delay in IV antibiotic treatment. 4. Resident #14 has [DIAGNOSES REDACTED]. Review of Nurses' Notes dated 7/7/15 to 8/3/15 revealed the resident is alert with some confusion and is able to make needs known. Review of a Nurse's Note dated 7/9/15 at 7:15 PM revealed the resident was readmitted from the hospital and new orders included [MEDICATION NAME] ([MEDICAL CONDITION] medication) 500 mg 2 tabs po (by mouth) BID (twice a day) for 2 days only, [MEDICATION NAME] (antibiotic) 875/125 mg PO every 12 hours, [MEDICATION NAME] 10 mg (2 tabs) PO BID times 3 days, [MEDICATION NAME] 10 mg BID for 3 days with meals, and [MEDICATION NAME] 10 mg PO daily for 3 days then stop. There was no documentation of an order for [REDACTED].>Review of Physician order [REDACTED]. Review of Unit Four's Inter Shift MD/ NP Orders Checklist dated 7/9/15 revealed the resident's new orders were checked by three nurses. Under medication changes, it stated that the resident is to be given medication when it arrives from the pharmacy. There was no notation about the blood work to be done in one week. Review of the resident's chronological medical chart revealed there were no laboratory reports from 7/16/15 or 7/17/15. Review of the Unit Four Lab (laboratory) Requisition Book revealed there were no lab requisition for 7/9/15, 7/16/15 or 7/17/15 for Resident #14. During an interview on 8/5/15 at approximately 2:54 PM, the RN UC stated there were no lab results in the resident's medical chart. The RN UC stated sometimes she refuses. We will note that either in the chart or on the slip. Review of Nurses' Notes dated 7/16/15 to 8/3/15 revealed there was no documentation that the resident refused to have bloodwork drawn. During an interview on 8/6/15 at approximately 9:05 AM, the RN UC called the lab where the blood specimens are sent. The RN UC stated that the lab did not have a record of Resident #14's bloodwork being drawn on 7/16/15. The RN UC also stated that the lab slip should have been written on 7/9/15 and hung up (on the nurse's station counter) for people to see that lab work was needed. Review of a facility policy and procedure entitled Laboratory Specimens/ Diagnostic Testing/ Transcribing/ Obtaining/ Filing dated 2/2015 revealed When the MD/ NP orders a laboratory specimen to be obtained by the lab, the nurse transcribes this on the logbook (located on each unit) and completes the laboratory requisition form. 5. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Nursing New/ Re-Admission assessment dated [DATE] revealed the resident was admitted with a Foley catheter (tube inserted into the bladder to drain urine). a.) Review of a Physician's Telephone Order dated 6/18/15 revealed an order to obtain a urine C&S (culture and sensitivity) today. Review of a Nurse's Note dated 6/24/15 at 8:30 AM revealed the resident's Foley catheter was draining bloody urine during the night. A Nurse's Note dated 6/26/15 at 12:00 documented that the resident had a temperature of 101.3 degrees Fahrenheit (normal 98.6 degrees - no baseline temperature noted for Resident #6)). Tylenol was administered and the temperature was rechecked at 100.2 degrees. The Nurse's Note documented that the resident was transferred to the hospital. Review of 24 Hour Report Sheets dated 6/18/15 to 6/26/15 revealed no documented evidence that the urine specimen for culture and sensitivity was collected for analysis. Review of Laboratory data for the same time period revealed there was no urine culture report. Interview with the Registered Nurse (RN) Unit Coordinator (UC) on 8/5/15 at 2:00 PM revealed the order for the urine C&S never made it to the unit laboratory book for collection. The RN UC stated that when the physician or nurse practitioner orders laboratory work to be collected, the order is transcribed to the laboratory requisition book. The RN UC stated the order for the urine culture was not transcribed as ordered and was not obtained. Interview with the Inservice Education RN on 8/5/15 at 2:15 PM revealed the laboratory was called and they did not receive a urine specimen for the urine culture Review of the hospital Discharge Summary dated 7/1/15 revealed the resident was diagnosed with [REDACTED]. During an interview on 8/5/15 at 12:15 PM, the NP who ordered the urine C&S on 6/18/15 stated she ordered the urine C&S because the resident was a new admit with a history of UTI's and had a Foley catheter. The NP stated she wanted to make sure the resident was infection free. The NP stated she was not aware that the urine C&S was not done. b.) Review of the hospital Discharge Summary dated 7/1/15 revealed discharge medications included Ertapenem Sodium (antibiotic) 1 gram daily for five days to be administered through the PICC line and then the PICC line and the antibiotic were to be discontinued. Review of the Readmission assessment dated [DATE] revealed the resident had a PICC line in the left upper arm. Additional review of the Assessment revealed there was no documentation of measurements of the PICC line catheter or of the left arm circumference. Review of the Admission physician's orders [REDACTED]. Review of a PICC Line Therapy Flow Sheet dated July 2015 revealed the order for Ertapenam Sodium IV was documented on the sheet with a notation to administer the antibiotic for 5 days and then d/c (discontinue) PICC line after the antibiotic was finished. The Flow Sheet documented that the last dose of Ertapenem was 7/5/15. Additional review of the July 2015 PICC Line Therapy Flow Sheet revealed the following: - There was no documentation of the type or location of the PICC line - There were no measurements of the external length of the PICC line or the upper arm circumference - The Flow Sheet documented that the PICC site was checked for redness on four of the 14 days the line was intact. - Four of the 14 days had documentation that the PICC line was flushed with [MEDICATION NAME], however the Flow Sheet included direction to flush the PICC every 24 hours - The sections for IV tubing change every 24 hours, Document exact time and Sterile dressing change were not signed as being done. Review of a Nurse's Note dated 7/3/15 at 10:00 AM revealed the resident was transferred to the hospital via ambulance for evaluation of left upper extremity/PICC line [DIAGNOSES REDACTED] (redness). Additional review of the PICC Line Therapy Flow Sheet dated July 2015 and Nurses' Notes dated 7/5/15 to 7/13 15 revealed no documented evidence that the PICC was discontinued after completion of the IV antibiotics. Review of a Physician's Telephone Order dated 7/14/15 revealed a verbal order to discontinue the PICC line. Review of a Nurse's Note dated 7/14/15 at 6:00 PM revealed the PICC line was removed from the resident's left arm Interview with the NP on 8/6/15 at approximately 2:00 PM revealed she did not realize there were no orders written for the care of the PICC line. 6. Resident #24 has [DIAGNOSES REDACTED]. Review of an IV Order form dated 8/6/15 revealed the resident had a PICC line ordered on [DATE] in the left brachial (vein that runs between the shoulder and the elbow) vein for antibiotic administration. Review of the PICC Line Therapy Flow Sheets dated July 2012 through 8/6/15 revealed there were no measurements of the length of the external portion of the PICC line or of the circumference of the left upper arm. Additional review revealed no documented evidence that the sterile dressing was changed, the PICC was flushed, or that the IV tubing was changed every 24 hours. Interview with the RN UC on 8/6/15 at 2:00 PM revealed that each resident who has a PICC line also has a maintenance kit with their name on it for dressing changes and overall maintenance. The RN UC stated there are also house kits in case they run out of individual resident's kits that can be used. She stated that everything needed is in the kit. The RN UM stated that all care should be documented on the PICC Flow Sheet and that the night shift is usually responsible for the maintenance flushes. 7. Resident #4 has [DIAGNOSES REDACTED]. Review of the comprehensive Care Plan dated 6/17/15 revealed the resident always understands and is always understood. Review of a nursing progress note, written by a Licensed Practical Nurse (LPN #1), dated 7/12/15 at 8:00 AM revealed the resident had a temperature of 100.6 degrees (98.6 normal - no baseline temperature noted for Resident #4). The LPN documented that the resident requested to remain in bed, and ate and drank poorly despite encouragement. Review of nursing progress notes, written by LPNs #2 and #3, dated 7/12/15 for the 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shifts revealed there was no documentation regarding the resident's oral intake or temperature. Additional review of the nursing progress notes and 24 Hour Report Sheets dated 7/12/15 revealed no documented evidence that the resident's temperature was monitored, that an RN assessed the resident or that the physician was notified. Review of a nursing progress note, written by a registered nurse (RN #3), dated 7/13/15 at 9:30 AM revealed the RN was called to the physical therapy room to assess the resident. The RN documented that the resident was shaking; the resident stated that his upper (arms) and lower extremities (his legs) were numb; breathing was rapid with an oxygen saturation level of 85 % (percent) (normal 90 to 100 %); and the pulse was 120 (average 80). The resident was returned to the unit for further assessment, which revealed a blood pressure of 88/64 (low blood pressure), respirations were 32 (normal 14 to 30) and labored, pulse ranged from 109 to 132 and oxygen was applied. The Nurse Practitioner (NP) was notified and new orders were obtained to send the resident to the hospital for evaluation. Review of the hospital Discharge Summary dated 7/29/15 revealed the resident had an abscess (a collection of pus under the skin) in the spinal column and [MEDICAL CONDITION] ([MEDICAL CONDITION] - contagious, antibiotic resistant bacteria) infection in the sacral decubitus. The Discharge Summary documented that the resident underwent [REDACTED]. Interviews with nursing staff on 8/5/15 revealed the following: - At approximately 12:00 PM, the 3rd floor LPN (#4) stated that all changes in resident status noted by an LPN need to be reported to the RN Supervisor. If vital signs (temperature, pulse, respirations, blood pressure) are found to be abnormal, the resident is to be monitored for 24 hours, an RN is to assess the resident, and the Physician or Nurse Practitioner are to be notified of the change in status. - At approximately 1:55 PM, the acting DON stated that LPN #1 should have notified the RN Supervisor, an assessment should have been completed by an RN, and staff should have continued to monitor the resident's vital signs. Review of a facility policy and procedure (P&P) entitled Notifying MD/ Responsible Party of Change dated 2/2015 revealed each nurse who identifies a change in condition must notify the Nursing Supervisor immediately. Change in condition may include an increased temperature, unstable vital signs and change in diet or fluids. 8. Resident #22 has [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS - a resident assessment tool) dated 7/16/15 revealed the resident is cognitively intact, understands, and is understood. Review of a Report of Consultation dated 7/25/15 revealed a Physician Wound Specialist evaluated the resident at the facility. The Consultation documented that the resident had an advanced diabetic ulcer on the right great (big toe) toe which was infected. The Physician Wound Specialist debrided (removed dead tissue or foreign matter in the wound) necrotic (dead tissue) tissue down to the bone. Additional review of the Consultation revealed thePhysician Wound Specialist ordered the IV [MEDICATION NAME] 1 gram daily for 10 days, a culture (took a swab sample to test for bacteria) of the wound was obtained, and the physician requested to be notified of the culture results. The Physician Wound Specialist documented that the resident must be on bedrest and needs a PICC line, Review of a Physician's Telephone Order dated 7/25/15 revealed orders to administer IV Vanco ([MEDICATION NAME]) 1 gram daily for 10 days and to update the Wound Specialist with the culture results. Review of a subsequent Physician's Telephone Order dated 7/25/15 revealed orders to hold Vanco until the PICC line is inserted and to administer Bactrim (antibiotic) DS (double strength) one tab by mouth twice a day for 10 days. Review of the Medication Administration Record [REDACTED]. An undated Continuous IV Therapy Flow Sheet documented Vanco 1 gram IV upon insertion. Review of a Physician's Telephone Order dated 7/20/15 revealed an order to schedule patient for PICC line ASAP (as soon as possible). Review of Nurses' Notes revealed the following: - 7/30/15 at 3:00 PM - PICC line placement scheduled at the hospital for 7/31/15. - 7/31/15 at 12:45 PM - PICC line placed. - 7/31/15 at 8:00 PM - orders written to start [MEDICATION NAME] 1 gram every day for 10 days after PICC line inserted original order 7/25/15. Review of Nurses' Notes and 24 Hour Report Sheets dated 7/26/15 to 8/5/15 revealed there was no documented follow-up regarding the wound culture obtained by the Wound Specialist on 7/25/15. Review of a repeat Report of Consultation dated 8/1/15 revealed the Wound Specialist again cultured the wound and requested follow up on the culture done on 7/25/15. b.) Review of an undated PICC Line Therapy Flow Sheet, located in the resident's medical record revealed there was no documentation regarding site assessment of the PICC line every shift, dressing change of the PICC site 24 hours after insertion, measuring of the upper arm circumference or length of the external PICC line, or flushes as per physician's orders [REDACTED]. Observation of the resident's room on 8/6/15 at approximately 10:40 AM revealed an IV pump (a machine to program delivery of a medication over a set period of time) contained an empty intravenous medication bag connected to undated tubing. Interview with the Second Floor RN UC on 8/6/15 at approximately 10:45 AM revealed IV tubing is to be dated and signed every day. The RN stated that the nurse who changes the PICC site dressing is to assess the insertion site for redness and the other shifts do not sign for assessing the site every shift. Interview with the Acting DON on 8/6/15 at approximately 11:00 AM revealed the facility policy is for an RN on each shift to monitor the PICC line sites and initial it was done (on the PICC Line Therapy Flow Sheet). The PICC site dressing is to be changed 24 hours after the insertion of the PICC and then weekly. At those changes, it is the policy of the facility for the PICC line to be measured for length and the upper arm measured for circumference. The IV tubing is to be changed, dated and initialed as done on the IV flow sheet every day. The Acting DON stated that the facility had done recent inservice training to the nursing staff on IV and PICC line protocols and she did not know that the staff was not completing PICC line care as per policy. Interview with the Physician Wound Speci

Based on observation, interview, and record review conducted during a Partial Extended survey (Complaint #NY 084) completed on 8/13/15, the facility failed to ensure that residents are free from any significant medication errors. Six (Residents # 8, 9, 10, 13, 22, 23) of 25 residents reviewed for medications had issues involving the failure of the facility to provide intravenous (IV) antibiotics as ordered by the physician. There were delays starting IV antibiotics as ordered by the physician and/or discontinuing IV antibiotics as recommended. This resulted in a pattern of IMMEDIATE JEOPARDY and SUBSTANDARD QUALITY OF CARE TO RESIDENT HEALTH AND SAFETY that is actual harm. The IMMEDIATE JEOPARDY was removed on 8/17/15, following the survey exit. The findings are: 1. Resident # 8 has [DIAGNOSES REDACTED]. Review of a Report of Consultation, completed and signed by a Physician Wound Specialist Physician, dated 7/10/15 revealed the resident had a Stage 4 infected, foul smelling, sacral (area above the tailbone on the right and left buttocks) decubitus (localized injury to the skin that is a result of pressure) ulcer. The Physician Wound Consultant documented that a culture of the wound was obtained and recommended [MEDICATION NAME] (antiseptic solution containing iodine) wound packing, Clysis (an infusion of fluid, under the skin, for hydration) with 0.45 NS (normal saline) at 50 cubic centimeters (cc) per hour for 10 days, and intravenous (IV) [MEDICATION NAME] (antibiotic) 500 milligrams (mg) every 12 hours. Review of three separate Physician's Telephone Orders dated 7/10/15 revealed the following: - Clysis 0.45 NS at 50 cc per hour for 10 days for hydration related to the sacral wound - [MEDICATION NAME] 500 mg IV every 12 hours - Obtain PICC line, per the Physician Wound Specialist, for IV antibiotics. Send to hospital on Tuesday 7/14/15 at 9:30 AM for PICC insertion Review of the Medication Administration Record [REDACTED]. Review of a nursing progress note dated 7/14/15 for the 7:00 AM to 3:00 PM shift revealed that the resident returned to the facility at 1:15 PM after having the PICC line inserted. The note documented that the (sacral) wound culture results were obtained and the wound was positive for [MEDICAL CONDITION] resistant staphylococcus aureas (MRSA - antibiotic resistant bacteria). Additional review of the 7/2015 MAR indicated [REDACTED]. Review of an untimed nursing progress note, signed by the Registered Nurse (RN #1) Supervisor, dated 7/14/15 revealed that the resident's temperature (T) was 99.6 degrees (normal 98.6 - no baseline temperature noted for Resident #8), pulse (P) was 108 (average 80), blood pressure (BP) 104/60 (normal), oxygen saturation level (amount of oxygen in the blood) was 81 % (percent) (normal 90 to 100 %) and the resident was shaky. The RN Supervisor documented that oxygen at 2 liters per minute was applied and the resident's oxygen saturation level increased to 93%. The physician was notified and ordered [MEDICATION NAME] (antibiotic) 1 gram (gm) IV daily for 10 days. Review of a nursing progress note, written by RN #2, dated 7/15/15 at 1:00 AM, revealed that the PICC line was in the right jugular vein (major blood vessel located on both sides of the neck) and the right side of the resident's face and neck were swollen and firm. The RN documented that the resident had difficulty swallowing, the right side of the neck was tender to touch, the resident's temperature was 102.4 degrees, and APAP ([MEDICATION NAME]) was given. Additional review of the Nursing Progress Noted revealed that the resident's BP was 104/40, P was 130, respirations (R) were 28 (normal 12 to 20) and the oxygen saturation level was 94% while wearing oxygen. The RN documented that the Physician was notified and orders were received to send the resident to the emergency room . A nursing progress note dated 7/15/15 at 4:40 AM documented that the resident was admitted to the hospital with [REDACTED]. Additional review of the Medication Administration Record [REDACTED]. Review of the hospital General Admission H&P (History and Physical) dated 7/15/15 revealed the resident's [DIAGNOSES REDACTED]. The General Admission H&P documented that the resident's white blood cell count (indicates presence of infection) upon admission was 30.0 (normal 4.0 to 10.5). The Physical Exam section of the H&P documented that the resident had a Stage 4 sacral decub (decubitus) with a central opening that was approximately 4 cm in diameter and had surrounding [DIAGNOSES REDACTED]. The H&P also documented that the sacral decubitus had a foul smell, exposed sacral bone, and minimal pus. Interview with the Acting Director of Nursing (DON) on 8/4/15 at 11:30 AM revealed that a PICC line insertion must be a scheduled procedure at the hospital. The Acting DON stated that the resident's PICC was ordered on [DATE] (Friday) and 7/14/15 (Tuesday) was the first day available to have the PICC line inserted. The Acting DON stated that the facility does not give IV [MEDICATION NAME] through a peripheral (arms, hands, legs, or feet) IV because [MEDICAL CONDITION] vein. During a telephone interview on 8/4/15 at 1:00 PM, the Physician Wound Specialist stated that he assessed the resident on 7/10/15 and found that the resident had an infected, foul smelling Stage 4 sacral decubitus ulcer. The Physician Wound Specialist stated that he recommende IV [MEDICATION NAME] on 7/10/15 to treat the resident's infected sacral ulcer and that his expectation was that the IV [MEDICATION NAME] would be started on 7/10/15. The Physician Wound Specialist stated that nursing staff did not call him and inform him that there would be a four day delay starting the IV antibiotics due to the delay in PICC line insertion and he was not aware of the 7/10/15 order to send the resident to the hospital for PICC insertion on 7/14/15 . The Physician Wound Specialist stated that nursing staff should have called him to inform him of the situation so that alternate plans for the IV antibiotic therapy could have been made, possibly infusing the antibiotic through a peripheral IV or sending the resident to the hospital to begin the antibiotics. The Physician Wound Specialist stated that he was not aware of the plan to send the resident to the hospital for the PICC line insertion on 7/14/15 and he did not authorize waiting four days to start the IV antibiotic. The Physician Wound Specialist stated that the delay in starting the IV antibiotics very likely caused the resident's condition to worsen. He stated that the wound was already very infected when he saw it on 7/10/15. In summary, there was an approximate four day delay starting IV antibiotics for a resident with an infected Stage 4 decubitus ulcer. The resident did not receive the IV antibiotics at the facility as ordered. The resident was transferred to the hospital on [DATE], admitted with a [DIAGNOSES REDACTED]. 2. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital Discharge Summary dated 6/19/15 revealed discharge medications included [MEDICATION NAME] (antibiotic) 2 gm IV every eight hours with an end date of 7/17/15. Review of Physician's Orders, signed by the Nurse Practitioner (NP), dated 6/22/15 revealed orders for [MEDICATION NAME] 2 grams/50 ml (milliliter) intravenous solution q (every) eight hours for bacteremia. The Physician's Order did not include an end date for the [MEDICATION NAME]. Review of a PICC Line Therapy Flow Sheet dated 7/2015 revealed documentation that the resident received the IV [MEDICATION NAME] every eight hours from 7/1/15 through the 6:00 AM dose on 7/27/15. Review of a Nurse's Note, written by a registered nurse (RN #4), dated 7/27/15 at 2:46 PM revealed the resident's (right) PICC line was partially removed. The RN documented that a Radiology Report was obtained for length, a NP (nurse practitioner) order was obtained to remove the (right) PICC line, and the resident was scheduled for a (left) PICC line on Thursday (7/30/15). Review of Physician's Telephone Orders dated 7/27/15 at 2:02 PM and 2:15 PM respectively revealed orders for the following: - May remove the right PICC, partially removed already with radiography report of length. Apply pressure dressing. - Extend antibiotic therapy the length of the lapse. Hold IV therapy until PICC reinsertion. Review of a Nurse's Note, written by a license practical nurse (LPN #7) dated 7/29/15 for 7:00 AM to 9:00 PM revealed the resident went out on pass (out of the building) at 1:00 PM for PICC line reinsertion and returned at 2:00 PM. Review of a Consultant Pharmacist's monthly Medication Regime Review dated July 2015 revealed that Resident #9's monthly medication review was completed on 7/29/15 and no irregularities noted. Review of a Physician's Telephone Order dated 7/31/15 at 9:00 AM revealed a clarification order from the NP for IV to end per d/c (discharge) summary 7/17/15, stop IV antibiotic therapy. During an interview on 8/5/15 at 1:00 PM, the Second Floor RN Unit Coordinator (UC) stated that the resident received an extra 10 days of IV antibiotic therapy. The RN UC stated that she did not transcribe the admission orders [REDACTED]. The RN UC stated that usually pharmacy is on top of end dates for IV medications. During an interview on 8/5/15 at 1:45 PM, the 3:00 PM to 11:00 PM RN Supervisor stated that she transcribed the resident's admission orders [REDACTED]. The RN Supervisor stated that she reviewed the hospital Patient Discharge Instructions sheet for medication transcription which did not include an end date for the IV antibiotic. During a telephone interview on 8/13/15 at 3:30 PM, the Pharmacy Consultant stated that he completed the monthly Medication Regimen Review for Resident #9 on 7/29/15 and noted that there were no irregularities in the resident's medication regimen. The Consultant Pharmacist stated that he did not review the hospital Discharge Summary and he had no knowledge that the resident received an additional 10 days of IV antibiotic therapy. In summary, the resident received an additional 10 days of IV antibiotic therapy beyond the stated end date of the medication per the hospital discharge summary. 3. Resident #10 was readmitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Review of a hospital Discharge Summary sheet dated 7/28/15 revealed orders for the resident to receive Meropenum (antibiotic) IV every eight hours with a stop date of August 1 (2015). Review of a Nurse's Note, written by RN #5, dated 7/29/15 at 4:00 PM revealed the RN was unable to establish IV access despite three attempts. The RN documented that a new order was obtained from the Nurse Practitioner (NP) to insert a PICC line for IV antibiotics due to the inability to establish peripheral IV access. The NP ordered that once the PICC line is inserted, give one gram of Meropenum IV every eight hours for three days. Review of a Nurse's Note, written by RN #5, dated 7/30/15 for the 3:00 PM to 11:00 PM revealed the resident was awaiting PICC line insertion for IV antibiotics; Attempted x 2 this shift to The RN further documented that an appointment was made to have the PICC line inserted on 8/6/15 which was the soonest appointment available. Review of a Nurse's Note, written by the Acting DON, dated 7/31/15 at 11:00 PM revealed that a #20 (size of intravenous catheter) angio (IV) was inserted into the resident's right hand for IV antibiotic Meropenum every eight hours for three days. Review of an Intermittent IV Therapy Flow sheet dated August 2015 revealed the resident received IV Meropenum three times a day for three days and the first dose was started on 8/1/15 at 6:00 AM. During an interview on 8/5/15 at 2:00 PM, the Fourth Floor RN UC stated that her attempts to insert a peripheral IV were unsuccessful on 7/29/15 and 7/30/15. The RN UC stated that the Acting DON was able to insert a peripheral IV on 7/31/15 and the IV antibiotics were started on 8/1/15 at 6:00 AM. In summary, the resident returned from the hospital on [DATE] with discharge [DIAGNOSES REDACTED]. Orders included IV antibiotics to be administered three times a day through 8/1/15. There was an approximate three day delay in starting the IV antibiotics upon the resident's return to the facility from the hospital due to the lack of IV access. 4. Resident #23 was admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. Review of a hospital Discharge Summary dated 7/21/15 revealed that [MEDICATION NAME] is to be given intravenously and goal is to keep the trough (blood samples collected to determine the level of an antibiotic, usually collected 30 minutes prior to a dose) between 15 and 20. The Discharge Summary documented that the pharmacy is to dose the [MEDICATION NAME] and that the [MEDICATION NAME] needed to be continued until 8/7/15. Review of a Physician's Telephone Order dated 7/21/15 revealed an order for [REDACTED]. Review of a Nurse's Note dated 7/22/15 revealed that the resident's CVP line (central venous pressure - an intravenous catheter inserted into a large vein and passing into the heart) pulled out. The Nurse's Note documented that the NP (nurse practitioner) was notified and that a new order was obtained to change [MEDICATION NAME] IV to 1.5 grams daily per the pharmacy recommendations. The Note documented a plan to re-insert the CVP line at the hospital on [DATE] and to restart IV antibiotics on 7/24/15 at 10:00 AM. Review of a Physician's Telephone Order dated 7/22/15 revealed an order to change IV [MEDICATION NAME] to 1.5 gm IV every day and to re-insert the triple lumen catheter (three separate lumens attached to one intravenous catheter) CVP on 7/23/15. Review of a Nurses' Notes dated 7/23/15 revealed there was no documentation that the CVP line was re-inserted or why the resident did not have the CVP line inserted on that day. Review of a PICC Line Therapy Flow Sheet dated July 2015 revealed the resident had a Hohn (type of central venous catheter) inserted on 7/24/15. Additional review of the PICC Line Therapy Flow Sheet for July 2015 revealed the resident did not receive the 9:00 PM dose of IV [MEDICATION NAME] on 7/21/15 as ordered by the physician. Further review of the PICC Line Therapy Flow Sheet revealed the resident received one dose of IV [MEDICATION NAME] on 7/22/15 at 9:00 AM. The Flow Sheet indicated that the IV [MEDICATION NAME] was restarted on 7/24/15 at 2:00 PM and continued through 8/7/15 at 2:00 PM. The DON stated during an interview on 8/12/15 at 2:00 PM that the resident should have received a dose of IV [MEDICATION NAME] on 7/21/15 at 9:00 PM. He further stated that there was a delay obtaining IV access until 7/24/15 which resulted in a delay in IV antibiotic treatment. 5. Resident #22 has [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS - a resident assessment tool) dated 7/16/15 revealed the resident is cognitively intact, understands, and is understood. Review of a Report of Consultation dated 7/25/15 revealed a Physician Wound Specialist evaluated the resident at the facility. The Consultation documented that the resident had an advanced diabetic ulcer on the right great (big toe) toe which was infected. The Physician Wound Specialist debrided (removed dead tissue or foreign matter in the wound) necrotic (dead tissue) tissue down to the bone. Additional review of the Consultation revealed the Physican Wound Specialist ordered the IV [MEDICATION NAME] 1 gram daily for 10 days, a culture (took a swab sample to test for bacteria) of the wound was obtained, and the physician requested to be notified of the culture results. The Physician Wound Specialist documented that the resident must be on bedrest and needed a PICC line. Review of a Physician's Telephone Order dated 7/25/15 revealed orders to administer IV Vanco ([MEDICATION NAME]) 1 gram daily for 10 days and to update the Wound Specialist with the culture results. Review of a subsequent Physician's Telephone Order dated 7/25/15 revealed orders to hold Vanco until the PICC line is inserted and to administer Bactrim (antibiotic) DS (double strength) one tab by mouth twice a day for 10 days. Review of the Medication Administration Record [REDACTED]. An undated Continuous IV Therapy Flow Sheet documented Vanco 1 gram IV upon insertion. Review of a Physician's Telephone Order dated 7/30/15 revealed an order to schedule patient for PICC line ASAP (as soon as possible). Review of Nurses' Notes and 24 Hour Report Sheets dated 7/26/15 to 8/5/15 revealed there was no documented follow-up regarding the wound culture obtained by the Physician Wound Specialist on 7/25/15. The PICC line insertion was not addressed until 7/30/15 with placement scheduled for 7/31/15. Interview with the Physician Wound Specialist on 8/6/15 at approximately 1:10 PM revealed he was following the resident for treatment of [REDACTED]. The Physician Wound Specialist stated the plan is to improve the infection in the resident's toe and then he planned to schedule the resident for amputation of the toe. Interview with the Acting DON on 8/6/15 at approximately 1:00 PM revealed the unit coordinator is responsible for following through on all aspects of the residents' care needs. The RN should have called to set up the PICC line placement if peripheral access was not possible. Interview with the Second Floor RN UC on 8/6/15 at approximately 2:40 PM revealed the RN UC did not call to set up the PICC line insertion until 7/30/15. It was an oversight and when found, a phone order was written and the PICC placement was scheduled. 6. Resident #13 has [DIAGNOSES REDACTED]. Review of A Nursing Admission assessment dated [DATE] revealed the resident is alert to person, has impaired judgement, and is confused at times regarding time and place. Review of nursing progress notes dated 6/30/15 to 7/2/15 revealed the following: - 6/30/15 at 12:30 PM - The resident arrived at the facility from the hospital via ambulance. The nursing progress note documented that the resident had no IV access and nursing staff were unable to establish peripheral IV access despite two attempts - 6/30/15 at 4:30 PM - A physician order was obtained to hold antibiotics until a PICC line inserted and that the PICC line insertion will be scheduled for 7/1/15 by the unit clerk. - 7/2/15 - PICC line in place Review of a PICC Line Therapy Flow Sheet dated 7/2015 revealed the first doses of Meropenum (antibiotic) 1 gram IV were administered on 7/3/15 at 8:00 AM and 4:00 PM and [MEDICATION NAME] (antibiotic) 100 mg IV on 7/3/15 at 9:00 AM and 9:00 PM. There was no documentation that IV Meropenum was administered on 7/4/15 at 12:00 AM, 8:00 AM, and 4:00 PM or that IV [MEDICATION NAME] was given on 7/4/15 at 9:00 AM or 9:00 PM. Review of a nursing progress note dated 7/4/15 at 12:00 PM revealed the resident was found on the floor with her [MEDICAL CONDITION] (surgical creation of an opening in the airway to assist breathing) out and she was transferred to the emergency room for [MEDICAL CONDITION] replacement. An untimed nursing progress note dated 7/4/15 documented that the hospital gave a verbal report to the nursing facility, prior to transferring the resident back to the facility, that the resident pulled out the PICC line while in the hospital. Additional review of the PICC Line Therapy Flow Sheet dated 7/2015 revealed there was no documentation that the resident received IV Meropenum or IV [MEDICATION NAME] from 7/5/15 to 7/7/15 as ordered by the physician. Interview with the Acting DON on 8/5/15 at approximately 1:50 PM revealed the physician is to be called if an IV med is unable to be given due to malfunctioning IV access. The DON stated if staff are unable to reinsert the line, the physician may want to have the antibiotic given via another route such as oral or by injection. 415.12(m)(2)

Based on interview and record review conducted during an Abbreviated survey (complaint #NY 4772) completed on 10/9/13, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, one (Resident #1) of three residents reviewed for accidents, lacked care plan development for fall prevention and lack of adequate supervision and implementation of interventions for a resident who experienced repeated falls. The resident fell three times on 8/17/13 and consequently sustained a traumatic intracranial hemorrhage (bleeding within the brain tissue) after the third fall. This resulted in actual harm that is not immediate jeopardy. The findings are: 1. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - an assessment tool) dated 7/27/13 revealed the resident had severe cognitive impairment and severe vision impairment. Review of the New Admission Assessment, dated 7/9/13, revealed that the resident had dementia, was blind, deaf, anxious, agitated and restless. Review of Fall Risk Assessments dated 7/10/13 and 7/25/13 revealed that the resident was at high risk for falls. Review of the Care Plan (comprehensive care plan) for impaired functional mobility, dated 7/12/13, revealed that the resident had difficulty with ambulation. The approaches included that the resident was independent with a wheeled walker for transfers and ambulation. Review of the Care Plan for behavior, dated 7/17/13, revealed that the resident had wandering behaviors. Further review of the entire Care Plan revealed that there was no comprehensive care plan for the resident's risk for falls. Review of an Accident/ Incident Report dated 8/1/13 revealed that at 4:30 PM the resident was found on the floor in front of the nurse's station after he was looking for something to eat. The report included that the resident had no injuries and that an afternoon snack was added. Review of an Accident/ Incident Report dated 8/13/13 revealed that at 7:15 PM the resident was found on the floor in the Main Dining Room with a 2 centimeter (cm) "goose egg" (swelling) on the right side of his head that was bleeding. The report included that the physician and family were notified, ice was applied to the injury and neurological checks were initiated. The report included a plan for a Physical Therapy (PT) referral "for a decline in ability to be safe". Review of the entire medical record revealed no documented evidence of a PT referral or evaluation following the resident's fall on 8/13/13. Review of an Accident/Incident Report dated 8/17/13 revealed that at 7:35 AM the resident was found on the floor in his room with his back and head almost under the bed. The report included that there was no injury and a plan was documented for non-skid socks at all times, a low bed, one assist for transfers and ambulation, neurological checks every 15 minutes and a PT referral. Review of the 24 Hour Report dated 8/17/13 for the 7 AM to 3 PM shift revealed notations of "bed low to floor", "neuro checks" and "15 minute checks". Review of a Nurse's Note dated 8/17/13 9:30 AM revealed that the resident was placed at the nurse's station in his wheelchair for safety and that the resident was found on the floor in Room 431. Review of the corresponding Accident/ Incident Report revealed that on 8/17/13 at 9:30 AM a CNA reported that she heard the resident yell out and that she went into Room 431 and found the resident on the floor (2nd fall that morning). The report included that the resident wheeled himself into Room 431, attempted to ambulate unassisted and fell . The report documented that the resident did not hit his head and there was no apparent injury. A plan was documented for the resident to be placed at the nurse's station for close observation in the wheelchair and "PT to re-evaluate". Review of an Accident/ Incident Report dated 8/17/13 revealed that at 6:15 PM the resident was found on the floor in the Day Room after he got out of the wheelchair, attempted to ambulate without assistance and fell backwards. The resident's CNA documented on the report that she placed the resident at the dining table and left to care for other residents. The report included that the resident sustained [REDACTED]. Further review of the report revealed that the resident was sent to the hospital and admitted with a cranial bleed (bleeding within the skull). Review of the Neurological Observation Flowsheet dated "8/17" revealed an undated, untitled policy that following an accident with head trauma, neurological signs are monitored and recorded every 30 minutes for two hours, then every four hours for 22 hours, then every eight hours for 48 hours for a total of 72 hours. Further review of the Flowsheet revealed that neuro checks were done at 7:45 AM, 8:15 AM, 8:45 AM, 9:15 AM, 11:30 AM and 1:30 PM. There were no further neuro checks documented on the Flowsheet after 1:30 PM. Review of the entire medical record and 24 Hour Reports revealed no documented evidence that neuro checks were done every 30 minutes or that they were done at all after 1:30 PM on 8/17/13. Additionally, there was no documented evidence of a PT referral or evaluation after the falls on 8/17/13 at 7:35 AM and 9:30 AM. Review of the current Care Plan, dated 8/8/13, revealed no comprehensive care plan with approaches for the resident's risk for falls. Review of the current Care Guide, dated 8/17/13, revealed instructions for a low bed and one assist for transfers and ambulation and a "wheelchair for safety until PT evaluation". Further review of the Care Guide revealed that it did not indicate that the resident was at risk for falls and it did not include instructions to seat the resident near the Nurse's Station or provide non-skid socks. Review of the untitled hospital emergency room (ER) progress notes dated 8/17/13 revealed that the resident was diagnosed with [REDACTED]. The ER physician documented that the resident needed "trauma specialty" and was transferred to another acute care hospital. Review of the ED (emergency department) MD (physician) Note dated 8/18/13 revealed that the resident was transferred from another hospital for further evaluation of a traumatic intracranial hemorrhage (bleeding within the brain tissue caused by trauma). The ED MD documented that the resident was admitted to the ICU (intensive care unit) and a neurosurgery consult was ordered. During an interview on 8/30/13 at 12:45 PM, the Registered Occupational Therapist (OTR) Director of Rehabilitation said that he could not produce documented evidence of PT evaluations after the 8/13/13 and 8/17/13 falls. The OTR said that the resident's care plan was not revised to include safety interventions after the falls on 8/13/13 or 8/17/13.. During an interview on 8/30/13 at 10:30 AM the Registered Nurse (RN) Unit Coordinator said she worked from 7:30 AM to 11:30 AM on 8/17/13. The RN said that after the resident's fall at 7:35 AM that morning, she and the RN Supervisor decided to take away the resident's walker and place him in his wheelchair at the Nurse's Station after breakfast in order to monitor the resident. The RN said that the resident had safety checks throughout the day on 8/17/13 at 15 minute intervals and that she thought this was documented. The RN said that while the resident was at the Nurse's Station staff must have been busy and did not notice the resident wheeling himself into Room #431. The RN said that Room #431 is approximately 50-60 feet away from the Nurse's Station. The RN also said that they decided to refer the resident to Physical Therapy for an assessment. The RN said she did not know if the resident had PT evaluations after the falls on 8/13/13 and 8/17/13. During an interview on 9/19/13 at 2:50 PM, the RN Supervisor said she worked from 7:00 AM to 11:00 PM on 8/17/13 and was involved with the resident's falls that day. The RN Supervisor stated that she and the RN Unit Coordinator changed the resident's transfer and ambulation status to assist of one, placed him near the Nurse's Station for monitoring and planned to get a physical therapy assessment. The RN Supervisor stated she can't recall if other staff were informed that the resident was to have increased supervision. During an interview on 9/19/13 at 12:50 PM the CNA who was assigned to the resident on 8/17/13 for the 3:00 PM - 11:00 PM shift said that when she arrived for work that day the resident was seated at the Nurse's Station. The CNA stated that the nurses informed her that the resident was at the Nurse's Station because he was trying to get out of his wheelchair earlier that day and had a couple of falls. The CNA stated that she was not instructed to provide any special monitoring or supervision of the resident and said that the Care Guide did not include any instructions to provide increased monitoring or supervision of the resident. During an interview on 9/20/13 at 10:50 AM, the RN Unit Coordinator said that after the resident experienced the first fall on 8/17/13 at 7:35 AM, the resident was placed on every 15 minute safety checks that were to be done for 72 hours by the staff nurses. The RN said that after the resident fell at 9:30 AM that day he was started on "1:1 intervention" which means that a staff nurse was to visually supervise the resident at all times. The RN stated that before she left for the day, she instructed the floor nurses to keep the resident in his wheelchair and to monitor him. During an interview on 10/9/13 at 11:45 AM the resident's attending physician revealed that he was aware of the resident's history of falls and that the resident experienced three falls on 8/17/13. The physician stated that he would expect the nursing staff to provide monitoring on a 1:1 basis with at least a visual supervision after the resident fell , including in the Day Room and that other staff needed to know that the resident required 1:1 supervision to prevent additional falls. 415.12(h)(2)