Every finding on record at North Gate Health Care Facility

Based on observations, interviews and record reviews conducted during a survey, the facility failed to ensure that a resident with pressure ulcers (ulcers on the skin due to prolong pressure) received necessary treatment and services, consistent with professional standards of practice, to promote healing, and prevent infection for three (3) (Residents #14, #57, and #207) of eight (8) residents reviewed for pressure ulcers. Specifically, there was lack of initial staging, description and measurements of pressure ulcers upon admission (Resident #57), there was a delay in initiating treatment and lack of an assessment to determine the type of wound present upon admission (Resident #207), and lack of weekly monitoring, including a description and measurements of pressure ulcers (Resident #14). Additionally, treatments were not documented as completed (Residents #57 and #14) and there was a delay in initiating a wound consultant recommendation (Resident #14). The findings include:The facility policy and procedure titled Documentation of Pressure Ulcer and Chronic Wounds dated 6/23 documented risk factors will be identified, monitored and documented on the Skin Risk Data Collection Tool; upon admission, then quarterly or whenever there is a change in condition. An ongoing inspection and assessment of all pressure sores and chronic wounds will be conducted weekly and as needed. All pressure ulcers wound dressing will be inspected daily. The Assistant Director of Nursing (or skin nurse as designated by the Director of Nursing) will be the official baseline and subsequent reference point for all skin/wound assessments. The policy documented the Assistant Director of Nursing or designee was responsible for initiating the weekly skin status evaluation when a pressure ulcer is identified. The template contains the following: type of area, site, stage, description characteristics, treatment, debridement, exudate (drainage), pain management, teaching and additional comments. The facility policy and procedure titled Physician Orders dated 7/2025 documented the policy was to assure that medication/treatment orders are implemented accurately, timely and in accordance with the Health Code of the State of New York and Federal Government regulations. 1. Resident #57 had diagnoses including kidney transplant failure, dependence on renal dialysis and chronic kidney disease. The Minimum Data Set (a resident assessment tool) dated 05/02/2026 documented Resident #57 had moderate cognitive impairment, was understood, and understands. The assessment tool documented the resident had three (3) stage II (partial-thickness skin loss into but not deeper than the dermis) pressure ulcers that were present upon admission. The Comprehensive Care Plan revised on 05/11/2026, documented Resident #57 was at risk for impaired skin integrity related to stage II ulcers to their right and left buttock. Interventions included administering preventative treatment per medical doctor order, monitoring skin for changes daily during care; apply moisture barrier following incontinence care, turn and reposition every two (2)- (4) four hours, pressure reduction mattress and skin risk tool per policy. The care plan documented Resident #57 had impaired skin integrity related to pressure area to their buttocks. Interventions included to administer treatment per medical doctor's order, evaluate and measure skin/wound sites at least weekly and document outcome and treatment progress/changes, monitor for infection; and medical provider evaluation as needed. Review of the Nursing admission Evaluation dated 04/28/2026 at 9:32 PM, Licensed Practical Nurse #4 Unit Coordinator documented Resident #57 had open areas to the right and left buttocks- three (3) areas total. The evaluation did not include the type, the stage, measurements or descriptions of the areas. This was cosigned by Registered Nurse #2 Director of Rehab on 05/08/2026. Review of the Nursing Skin Risk Data Collection Tool dated 04/28/2026 at 9:52 PM, Licensed Practical Nurse #4 Unit Coordinator documented Resident #57 was at risk for pressure ulcers. Review of the interdisciplinary Progress Notes from 04/28/2026-05/07/2026 revealed no documented evidence of an evaluation of the type, the stage, measurement or description of Resident #57's open areas they had upon admission. Review of the Medical Visits Notes from 04/29/2026-05/07/2026 revealed no documented evidence of an evaluation of the type, the stage, measurement or description of Resident #57's open areas they had upon admission. Review of the Nursing Weekly Skin Status Documentation dated 05/08/2026 at 1:21 PM, Registered Nurse #2 Director of Subacute documented Resident #57 had a stage II pressure ulcer measuring 3 centimeters (length) x (by) 2.5 centimeters (width) x 0.1 centimeters (depth) to their sacrum (area above the tailbone on the right and left buttocks); a pressure ulcer measuring 1.5 centimeters (length) x 1.5 centimeters (width) x 0.1 centimeters (depth) to their right buttock (no stage was indicated); and a stage II pressure ulcer measuring 2.5 centimeters (length) x 2 centimeters (width) to their left buttock. Treatments included Alginate (highly absorbent dressing made of calcium and sodium) with dry clean dressing with calmoseptine (skin protectant) to surrounding intact tissue. It was documented as an addendum note for 05/04/2026. Review of the Order Summary Report dated 05/11/2026 documented Resident #57 had an order with start date of 04/28/2026 to apply calcium alginate every day shift to the three (3) open areas to their right and left buttocks after cleaning with normal saline then cover with a dry clean dressing. Resident #57 had an order to apply calmoseptine ointment to the affected area every day and evening shift. The Calmoseptine order was discontinued on 05/09/2026. Review of the Treatment Administration Record from 05/01/2026-05/10/2026 documented Resident #57's was to have:-calcium alginate every day shift to three (3) open areas to their right and left buttocks after cleaning with normal saline to then cover with a dry clean dressing. There were no initials that documented the treatment was completed from 05/01/2026 through 05/05/2026 and on 05/08/2026.-calmoseptine ointment applied to the affected area every day and evening shift started on 04/28/2026. There were no initials that documented the treatment was completed on the day shift from 05/01/2026 through 05/05/2026 and on 05/08/2026. There were no initials that documented the treatment was completed on the evening shift for 05/02/2026 and 05/04/2026. This order was discontinued on 05/09/2026. During an interview on 05/08/2026 at 1:00 PM, Resident #57 stated they had two open areas on their buttocks, and those areas were washed daily. They stated the certified nurse aides would put the cream in an orange tube on their buttocks daily, not the nurses, when the aides got them washed for the day. During a wound care observation and interview on 05/08/2026 at 3:49 PM, Licensed Practical Nurse #9, in the presence of the Director of Education, performed wound care on Resident #57 per the medical provider orders. The Director of Education stated they would describe Resident #57's sacrum/buttocks open areas as the upper area being a stage II pressure ulcer and the bottom area was closed (healed). During an interview on 05/12/2026 at 3:48 PM, Licensed Practical Nurse #4 Unit Coordinator stated they were responsible for doing an initial skin assessment on new admissions but as a licensed practical nurse they were unable to stage or measure any pressure ulcers. They stated the process for a new skin issue was they would take a picture of the wound and send it to Registered Nurse #2 Director of Subacute who then would instruct what treatments to put into place. After reviewing the electronic medical record, Licensed Practical Nurse #4 Unit Coordinator stated Resident #57's first staging and measurements of their pressure ulcers were completed on 05/08/2026 in the weekly skin notes documented by Registered Nurse #2 Director of Subacute. 2. Resident #14 had diagnoses including hypertension, heart failure and chronic kidney disease. The Minimum Data Set, dated [DATE] documented Resident #14 was cognitively intact, was understood, and understands. The assessment tool documented that the resident had two (2) deep tissue injuries (pressure-induced damage that begins in the underlying muscle, fat, or subcutaneous tissue, often near bone, while the skin may remain intact or appear discolored) that were not present upon admission. The Comprehensive Care Plan revised on 02/16/2026 documented Resident #14 was at risk for impaired skin integrity related to limited mobility. Interventions included administering preventative treatment per medical doctor order, monitoring skin for changes daily during care, updating the medical provider with skin changes, turn and reposition every two (2)- (4) four hours, use a pressure reduction mattress, skin and feet check daily, and skin risk tool per policy. The care plan documented Resident #14 had impaired skin integrity related to a right heel pressure area. Interventions included administering treatment per medical doctor's order, evaluating and measuring skin/wound sites at least weekly and documenting the outcome and treatment progress/changes, and a medical provider evaluation as needed. Review of the Nursing Weekly Skin Status Documentation form dated 02/20/2026 at 1:33 PM documented Resident #14 had a suspected deep tissue injury on the right heel measuring 3.5 centimeters (length) x 5 centimeters (width) and a suspected deep tissue injury on the left heel measuring 1 centimeter (length) x 1 centimeter (width). Treatments included applying tincture (skin protectant, adhesive enhancer, and mild antiseptic), pad and wrap daily. This note was not signed by any staff including the date the note was completed. The next Nursing Weekly Skin Status Documentation form with an effective date of 03/10/2026 at 4:38 PM was signed as completed by Registered Nurse #2 Director of Subacute on 03/15/2026 and documented Resident #14 had a suspected deep tissue injury on the right heel measuring 3.5 centimeters (length) x 3.5 centimeters (width), and a suspected deep tissue injury on the left heel measuring 0.5 centimeters (length) x 0.5 centimeters (width). Treatments included applying tincture, pad and wrap daily. There was no weekly monitoring/assessment of the suspected deep tissue injury on the heels. Review of the interdisciplinary Progress Notes from 02/20/2026-03/15/2026 revealed no documented evidence of an evaluation of the type, the stage, measurement or description of Resident #14's pressure areas on their heels. Review of the Medical Visits notes from 02/20/2026-03/15/2026 revealed no documented evidence of an evaluation of the type, the stage, measurement or description of Resident #14's pressure areas on their heels. Review of the Wound Care Assessment/Consultation note dated 04/28/2026, Nurse Practitioner #2 documented Resident #14 had a stage III (skin injury characterized by full-thickness skin loss, exposing the fatty tissue beneath) pressure ulcer measuring 2.3 centimeters (length) x 2.0 centimeters (width) x 0.1 centimeters (depth) to their right heel that they debrided (removal of dead, damage or infected tissue) the area. Nurse Practitioner #2 documented they recommended the treatment of Santyl (an ointment used to remove dead or damaged tissue) with a dry clean dressing daily to Resident #14's right heel. Review of the Order Summary Report dated 05/11/2026 documented Resident #14 had an order to apply benzoin tincture to both heels, pad and wrap with start date of 02/20/2026 that was discontinued. There was an active order dated 05/06/2026 for Santyl to the right heel, pad and wrap daily. Review of the Treatment Administration Record from 05/01/2026-05/11/2026 documented Resident #14 was to have benzoin tincture to the right heel, pad and wrap daily that was discontinued 05/06/2026 and then start Santyl to right heel, pad and wrap daily starting on 05/07/2026. The benzoin tincture treatment was documented on 05/01/2026 as 9 (other) by Licensed Practical Nurse #8 and on 05/06/2026 the treatment was blank (not signed as completed). Review of the Medication Admin Audit Report dated 05/12/2026 documented Resident #14's benzoin tincture treatment for 05/02/2026-05/05/2026 was completed by the Director of Nursing. The report documented that the Director of Nursing did not sign for those treatments as completed until 05/11/2026. During a wound care observation and interview on 05/11/2026 at 1:04 PM, Licensed Practical Nurse #5 performed wound care on Resident #14 per the medical provider orders. While the treatment was being completed, Resident #14 stated the nurse yesterday told them they needed to have their treatments to the heels completed every day because there was no dressing on their foot. During an interview on 05/12/2026 at 9:55 AM, Licensed Practical Nurse #7 stated on 05/04/2026 they believe they did not have time to complete their treatments on the E unit and if they did not sign them off in the electronic treatment administration record then they did not do them. They stated they reported to the next incoming shift they did not complete their treatments but did not recall who that staff member was. Licensed Practical Nurse #7 stated it was hard to complete treatments on the day shift on the E unit because there was a large volume of medications to be administered, then the residents were usually in dialysis, then to therapy and then visiting with their families. Licensed Practical Nurse #7 stated the importance of completing the residents' treatments was to get the residents better. During an interview on 05/12/2026 at 10:06 AM, Licensed Practical Nurse #11 stated they did not do their treatments on 05/05/2026 because they were told there was a treatment nurse that day. During a telephone interview on 05/12/2026 at 12:23 PM, Licensed Practical Nurse #8 stated that if on 05/01/2026 they did not sign off their treatments in the electronic treatment administration record then they did not do the treatment because they did not have time to do them. Licensed Practical Nurse #8 stated they were not familiar with Resident #57 but very familiar with Resident #14. They stated they have only ever completed a skin tear treatment to Resident #14's leg, not any treatments to their heels. They stated it was important to sign out treatments when completed because it documented the treatment was completed and doing treatments per medical provider's order helped the resident heal. During a telephone interview on 05/12/2026 at 12:40 PM, Registered Nurse #4 stated that if they did not sign off their treatments in the electronic treatment record then they did not do the treatment. They stated when they pick up time for the facility they only worked from 7:00 AM- 1:00 PM and usually do not have time to complete any treatments. Registered Nurse #4 stated they were not sure who replaced them on 05/03/2026 but when they leave their shift they would report to the other floor nurses what duties they could not complete. Registered Nurse #4 stated it was important to sign off treatments when completed because if you do not sign it, you did not do it, and it was important to complete treatments per medical providers order because the skin issue could get worse or lead to infection. During a telephone interview on 05/12/2026 at 11:59 AM, Nurse Practitioner #2 stated they were the wound consultant for the facility and would see residents by request of the facility. They stated they saw Resident #14 on 04/28/2026 for the first time and at the visit they performed debridement to their right heel to remove an unstable heel cap (area of hard necrotic (dead) tissue). Nurse Practitioner #2 stated they recommended changing Resident #14's treatment to Santyl and would imagine the facility would follow their recommendation at the time of the recommendation since they were asked to do a consultation. During an interview on 05/12/2026 at 3:53 PM, Registered Nurse #2 Director of Subacute stated they were responsible for measuring and staging pressure ulcers on their unit and the Assistant Director of Nursing would be their back up. They stated when there was a newly identified skin issue it should be measured and staged no later than the very next day/business day. After reviewing the admission note for Resident #57, Registered Nurse #2 Director of Subacute stated there were no measurements or staging for the pressure ulcers to their right and left buttocks until the weekly skin notes on 05/08/2026 and written on the note was an addendum that the measurements were completed on 05/04/2026. Registered Nurse #2 Director of Subacute stated the pressure ulcers should had been staged and measured by 05/01/2026 and that they missed it. After review of Resident #57's electronic treatment administration record, Registered Nurse #2 Director of Subacute stated that not all the resident's treatments were signed as completed, they did not know if Resident #57's treatments were completed daily because they were not signed off and they would expect treatments to be signed off at completion time. Registered Nurse #2 Director of Subacute stated that on 05/05/2026 they completed Resident #57's treatment themselves and did not sign them off. After review of electronic medical record for Resident #14, Registered Nurse #2 Director of Subacute stated that a weekly skin assessment was started on 02/20/2026 by Registered Nurse #3 and there was no documented evidence that the areas were being measured, staged and described weekly until 03/10/2026. They stated the importance of documenting measurements, staging and describing a wound on a weekly basis was to ensure the treatments were appropriate along with the staging. Registered Nurse #2 Director of Subacute stated that Resident #14 was seen by Nurse Practitioner #2 on 04/28/2026 and they had recommended changing the treatment to Santyl after the wound was debrided. They stated they missed changing Resident #14's order until 05/06/2026 but should have changed the treatment at the time of the recommendation. During an interview on 05/12/2026 at 4:30 PM, the Director of Nursing stated the process for when there was a new skin issue on the E unit was the Licensed Practical Nurse Unit Coordinators were to notify a Registered Nurse to determine the skin treatment. They stated that the Licensed Practical Nurses could not stage or measure any pressure ulcers and they would expect Registered Nurse #2 Director of Subacute or Registered Nurse #1 Unit Coordinator to do so within the first 48 hours of discovery of the wound. The Director of Nursing stated all skin issues were documented in the electronic medical record on the Nursing Weekly Skin Status Documentation form. The Director of Nursing stated the pressure ulcer treatments were not signed as completed every day, but they completed Resident #57's treatments on those days and failed to document them as completed. They stated they expected that there was documented staging and measurement within 48 hours of the wound being identified and then weekly after. The Director of Nursing stated they also did Resident #14's treatment on 05/02/2026-05/05/2026 but did not document them as completed until 05/11/2026 because they did not have computer access on the unit and then they got distracted. They stated they should have signed off at the time of completion, so they did not forget to sign them off, to monitor if there was any improvement, and it was a professional standard to sign off the treatments at the time they were completed. The Director of Nursing stated it was important to document skin staging, measurements and description of the pressure wounds to know if the resident came in with a wound or if it developed in the facility. They stated they expected pressure ulcer treatments that were recommended by the wound specialist to be implemented within five (5) days of the recommendation. During a telephone interview on 05/13/2026 at 11:17 AM, the Medical Director stated they expected pressure ulcers would be managed through the wound management team. They would expect the pressure ulcers documentation to include an assessment, plan and follow-up in the electronic medical record. They stated they would defer to facility protocol for documentation but the more the better and it should be completed at least weekly. The Medical Director stated they would expect all wound specialist recommendation to be followed. They stated that there should be ongoing documentation about a resident's medical status and all medications and treatments to be documented as completed when administered for continuum of care and for all to be aware of any changes with the residents. 3.Resident #207 had diagnoses including fracture of the left pubis (break of the pelvic ring on the left side), facture of right humerus (break in the upper arm bone on the right side), fracture of olecranon process (break in the bony tip of the elbow) and need for assistance with personal care. The Minimum Data Set, dated [DATE] documented Resident #207 was understood, understands others and was cognitively intact. Resident #207 was dependent on staff for bed mobility, transfers and was at risk of developing pressure ulcers/injuries. Resident #207 did not present with any skin conditions. The Kardex (a guide used by staff to direct care) dated 01/28/2026 and 02/11/2026, documented for skin integrity the resident was to go back to bed after meals as tolerated and staff were to monitor skin for changes daily during care. There was no documented evidence regarding use of barrier cream. The Comprehensive Care Plan revised on 01/30/2026 documented that the resident had impaired skin integrity related to impaired mobility, moisture/incontinence, and several fractures. They were at risk for impaired skin integrity related to anticoagulation (blood thinner) therapy, frequent injury/falls, and moisture/incontinence. Interventions included monitoring the site for signs/symptoms of infection, administer preventative treatment per doctor's order, and monitor skin for changes daily during care. On 02/16/2026 the impaired skin integrity care plan was revised related to a wound on the right inner buttocks. The Nursing admission Evaluation dated 01/28/2026 at 6:39 PM completed by Licensed Practical Nurse #4 Unit Coordinator, documented the resident had skin conditions/abnormalities noted with redness to their right groin and bilateral buttocks. Registered Nurse #1, Unit Coordinator signed on 01/30/2026 that they reviewed/approved the nursing admission evaluation. The Nursing Weekly Skin Status Documentation dated 01/28/2026 at 6:34 PM completed by Licensed Practical Nurse #4 Unit Coordinator, documented the resident had redness to the right groin and bilateral buttocks with a treatment of house cream with zinc to be applied. Interventions for impaired skin integrity related to skin injury included the resident was to go back to bed after meals as tolerated. There were no additional Nursing Weekly Skin Status Documentation forms completed after 01/28/2026 that documented the type, a description of, or measurements of the redness and/or of wounds. The Order Summary Report dated 05/08/2026, documented an order started on 02/05/2026 for Clindamycin-Tretinoin External Gel (combination antibiotic and retinoid to treat inflammatory breakouts) 1.2-0.025 percent, apply to right buttock, right hip topically two times a day for HS (Hidradenitis Suppurativa-chronic inflammatory skin condition) and an order for skin prep (topical application that toughens skin and enhances adherence of dressing) to heels at bedtime as preventative treatment. There was no documented evidence of any treatments or preventative treatments ordered for Resident #207 redness on buttocks from 01/28/2026 until 02/05/2026. The Treatment Administration Record dated January 2026 did not have any treatments documented related to the resident's buttocks. The Treatment Administration Record dated February 2026 documented a treatment for Clindamycin-Tretinoin External Gel 1.2-0.025 percent, apply to right buttock, right hip topically two times a day was started on 02/05/2026. Review of Progress Notes and Medical Visit Notes dated 01/28/2026 through 02/26/2026 documented the following: -02/11/2026 at 3:54 PM, Licensed Practical Nurse #3 documented wound care to right buttocks, and a dry clean dressing was applied. -02/15/2026 at 4:45 PM, Licensed Practical Nurse #3 documented wound care to right inner buttocks and a dry clean dressing was applied. -02/18/2026 at 12:32 PM, Nurse Practitioner #1 documented the resident had complaints of pain and bleeding from their sacral wound. A full skin exam was not completed, please see nursing documentation. -02/18/2026 at 4:08 PM, Licensed Practical Nurse #3 documented wound care to buttocks continues, dry clean dressing applied. Complaints offered about buttock discomfort. -02/19/2026 at 4:02 PM, Licensed Practical Nurse #3 documented wound care to buttocks, and a dry clean dressing was applied. -02/20/2026 at 11:00 AM, Nurse Practitioner #1 documented Resident #207 was in a chair upon examination and reported pain from their sacral wound. A full skin exam was not completed, please see nursing documentation. -02/20/2026 at 4:06 PM, Licensed Practical Nurse #3 documented wound care to sacrum. -02/23/2026 at 4:42 PM, Licensed Practical Nurse #3 documented wound care to buttocks continued. There was no documentation of weekly monitoring to include the type of wound, a description or measurements of the area on the resident's sacrum/buttocks. During a telephone interview on 05/08/2026 at 3:23 PM, Resident #207's family member stated the resident had a pressure ulcer to the middle of their butt that developed while at the facility that was red and very painful. They stated they observed this area while unknown staff were providing care to Resident #207. They stated the staff were aware of the area and they put a dressing on it. During a telephone interview on 05/08/2026 at 12:17 PM, Licensed Practical Nurse #3 stated Resident #207 had two (2) open areas, one on their sacrum and one to their right inner buttocks. They stated the areas were quite painful to Resident #207 and they medicated them for pain. They stated the right inner buttock wound was difficult to get to due to the resident's mobility. Licensed Practical Nurse #3 stated they did not recall the specific treatment but that they would have completed treatments per the treatment administration record and apply a dressing after applying the treatment to the wounds. They stated the wound assessments are completed by the unit coordinators when residents are admitted and treatments are implemented. During an interview on 05/08/2026 at 10:06 AM, Registered Nurse #1 Unit Coordinator stated any new skin breakdown, redness, or open areas are reported to Registered Nurse #2 Director of Subacute. They stated it was important to have treatments initiated for skin breakdown to prevent further breakdown and it should be documented to show awareness, acknowledgement of the skin breakdown. During an interview on 05/08/2026 at 10:11 AM, Registered Nurse #2 Director of Subacute stated if redness to buttocks is noted during an initial skin evaluation, it usually is not staged, Licensed Practical Nurses are just describing the skin and then there should be a Registered Nurse follow up on the admission skin assessment. They stated they did not follow Resident #207 but that any Registered Nurse could follow up on an admission skin assessment to determine if redness to buttocks is something or nothing. They stated it was important to determine if the area was blanchable versus non-blanchable (refers to whether skin redness temporarily turns white (blanches) when pressed), or pressure versus moisture associated skin damage. They stated they did not know if the redness to Resident #207's buttocks was blanchable or not, or if a treatment should have been initiated. They stated they did not know if the redness was pressure or moisture related. They stated they did not recall being made aware of the redness to Resident #207's buttocks and it was their responsibility to follow up on abnormal skin conditions and document it. They stated it would have been important to monitor the redness on Resident #207's buttocks to monitor for worsening, improvement, and need for further interventions. During an interview on 05/08/2026 at 11:26 AM, Registered Nurse #2 Director of Subacute stated Licensed Practical Nurse #4 Unit Coordinator can only describe wounds, they cannot assess them. They reviewed Resident #207's Nursing Weekly Skin Status Documentation dated upon their admission, 01/28/2026, in the electronic medical record and stated there should have been an order for house cream with zinc to be applied to Resident #207's bilateral buttocks as treatment of documented redness. During an interview on 05/08/2026 at 11:30 AM, Registered Nurse #1 Unit Coordinator stated they did not personally assess the redness to Resident #207 buttocks, but when redness is seen, a treatment order should be put into place to prevent further skin breakdown. They stated they are not trained in wounds and Registered Nurse #2 Director of Subacute would have determined if the redness to Resident #207 buttocks was pressure related. Registered Nurse #1 Unit Coordinator stated they could not recall if they brought Resident #207's skin condition to the attention of Registered Nurse #2 Director of Subacute. They stated Registered Nurse #2 Director of Subacute or themselves were responsible to ensure a treatment was followed through on and did not know why there was not a treatment ordered upon admission. During an interview on 05/08/2026 at 11:36 AM, Nurse Practitioner #1 stated the treatment order dated 02/05/2026 for Clindamycin-Tretinoin External Gel 1.2-0.025 percent had a typo, the treatment was for a rash, not Hidradenitis Suppurativa. They stated Resident #207 had a pimple like rash. They stated if they saw the rash they most likely only saw Resident #207's thigh area and not their buttocks. They stated if they had observed any bleeding they would have written that in their exam note for that day. Nurse Practitioner #1 stated it was important for abnormal skin findings to be brought to medical providers' attention for proper treatment to ensure there is no infection and proper treatment orders. They stated if Resident #207 had an open wound on their buttocks it should have been followed by the wound team, documented and followed up on. During a telephone interview on 05/08/2026 at 12:05 PM, Licensed Practical Nurse #4 Unit Coordinator stated upon admission residents' skin were checked and any skin concerns are documented. They stated open areas are communicated to Registered Nurse #2 Director of Subacute and they are given recommendations. They stated they are not allowed to stage pressure ulcers, that staging must be completed by a Registered Nurse. They stated if redness was observed, treatment should be implemented for protection or to prevent further progression. They stated they would not notify Registered Nurse #2 Director of Subacute of redness because they could address it themselves. During an interview on 05/13/2026 at 11:13 AM, the Director of Nursing stated they expected a complete skin assessment, full head to toe skin check, to be completed upon admission. They stated skin deterioration can happen very quickly and that areas of skin concern should be passed along to a Registered Nurse as soon as possible. They stated a house barrier cream treatment would be recommended to be applied to skin that was reddened and would be on the resident's treatment administration record. The Director of Nursing stated the treatment would be part of the residents' orders. They stated all Registered Nurses should be able to stage pressure ulcer/injury and implement interventions to prevent, treat pressure ulcers. The Director of Nursing stated they expect all wounds to be assessed with a measurement, depth, description of wound bed, signs/symptoms of infection to be completed by a Registered Nurse and to ensure a treatment is present to prevent further deterioration. 10 New York Codes, Rules, and Regulations (NYCRR) 415.12(c)(2)

Based on observation, interview, and record review conducted during the survey, the facility failed to ensure residents have the right to personal privacy including accommodations for one (1) (Resident #5) of one (1) resident reviewed. Specifically, a privacy curtain in the resident's room did not fully enclose Resident #5's bed. The findings include: The policy and procedure titled Dignity, Respect and Privacy in Treatment and Care dated 10/2023 documented the resident has a right to be treated with dignity, respect, privacy and security. Privacy is provided for Residents while being examined and treated. Curtains are drawn and people not involved in the care or treatment are not present while the Resident is being examined or treated without Resident's permission. Staff at all times provide privacy for the Resident when dressing, undressing, bathing and toileting.Resident #5 had diagnoses which included major depressive disorder, post-traumatic stress disorder and osteomyelitis (infection of the bone). The Minimum Data Set (a resident assessment tool) dated 04/26/2026 documented Resident #5 was usually understood, usually understands others and had moderate cognitive impairment.Review of the comprehensive care plan revised 06/08/2025 documented Resident #5 had an alteration in bladder function related to incontinence. Interventions included incontinent care as needed. Additionally, the comprehensive care plan documented Resident #5 was alert and oriented to their own identity, their current location, and the current time with mild cognitive impairment.On 05/08/2026 at 3:30 PM, maintenance request records were requested for Resident #5's room for the past 30 days. The facility was unable to provide any maintenance requests.During an observation and interview on 05/06/2026 at 9:44 AM, Resident #5 stated they did not feel like there was a lot of privacy in their room because their curtain needed another panel; it did not close all the way. Resident #5 stated that if their roommate were to leave their side of the room while Resident #5 was receiving care, their roommate would be able to see them. Resident #5 stated that knowing their roommate could see them receiving care at some point bothered them. When the curtain was pulled, it did not close all the way, leaving an open gap of approximately four (4) feet. Resident #5 stated they did not know when that curtain was hung or who had hung it up, but staff had commented to them that the curtain was not big enough.During an interview on 05/08/2026 at 1:21 PM Certified Nurse Aide #1 stated they noticed that Resident #5's privacy curtain did not go around their bed when they were doing care in the morning, but there was nothing they could do to fix that. They stated that if Resident #5's roommate on the window side of the room wanted to leave the room or come into the room during care, they would have to wait until Resident #5 was covered with a blanket. They stated that all the staff were aware that the curtain did not go around the bed, but everyone was too busy to fix it. Certified Nurse Aide #1 stated that the privacy curtain should have been closed completely because it was for Resident #5's privacy and dignity.During an observation and interview on 05/08/2026 at 1:27 PM, Licensed Practical Nurse #2 Unit Coordinator pulled Resident #5's privacy curtain closed and stated the curtain seemed short; it should have been longer because otherwise there was a very large gap at the end. They stated that the curtains should extend the full length of the curtain tracks on the ceiling to provide adequate privacy. They stated that Resident #5's roommate did usually leave the room around 7:00 AM and returned around 2:00 PM. They stated any staff who had noticed the curtain was not long enough for the area should have either notified them or put in a maintenance request.During an interview on 05/12/2026 at 8:34 AM, Certified Nurse Aide #2 stated they were aware of two privacy curtains on the unit that were too short and would not close all the way. They stated Resident #5's privacy curtain would not close all the way, and they were very lucky that Resident #5's roommate did not want to enter the room or leave the room when care was being done. They stated if it did happen, Resident #5's roommate would have to wait to leave or enter the room until Resident #5 was covered up. They should not have to wait to enter or leave their room. They stated maintenance was responsible for hanging up curtains and it was probably mentioned to them in the past that the curtain was too short.During an observation and interview on 05/12/2026 at 8:38 AM, Maintenance #1 stated they were one of the maintenance floor workers and they were responsible for hanging up privacy curtains in the resident rooms. When Resident #5's privacy curtain was pulled, Maintenance #1 stated there was a big gap of at least three (3) or more feet. They stated the curtains should all be wide enough to enclose Resident #5 for privacy.During an interview on 05/12/2026 at 9:52 AM, the Director of Nursing stated their expectation that staff close the privacy curtain during any treatments that would expose a resident's private area. They stated that the privacy curtains should close all the way because it would provide privacy and dignity for the residents.During an interview on 05/12/2026 at 11:26 AM, the Administrator stated Resident #5 had never voiced concerns about their privacy curtain. They stated they did not know if it would register with their staff that a privacy curtain with a three (3) foot gap in coverage would be a privacy concern. They stated that perhaps the staff member who hung the curtain should have realized that the privacy curtain was not long enough. They stated they did not know if the staff on the unit would know that the privacy curtain should fully close. Maintenance was responsible for hanging privacy curtains in rooms. Every staff member was responsible for providing privacy to residents.10 New York Codes, Rules, and Regulations 415.3(e)

Based on interview and record review conducted during the survey, the facility failed to ensure that comprehensive care plans included to the extent practicable, the participation of the resident and the resident's representative(s); an explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan for one (1) (Resident #112) of one (1) reviewed for care plan participation. Specifically, Resident #112 was not invited to participate in their care plan meetings. The findings include: The facility policy and procedure titled Interdisciplinary Care Planning revised 9/2025, documented each resident and their family members and/or legal representative will be encouraged to participate in the development of the resident's comprehensive care plan. The Interdisciplinary Team will review the Care Plan as scheduled and the patient and/or family member(s) are invited to attend this review meeting. Revised May 2023 Job Title/Job Code titled Social Services Assistant, documented position assists in the planning, organizing and implementation of the Social Services Department; to assure that the medically related, emotional and social needs of the resident were met/maintained on an individual basis. Essential Duties and Responsibilities included to develop and maintain a good rapport with professional departments involved with the care plan to ensure that a team effort was achieved in the development of the comprehensive plan of care; types and mails all Team Care letters. Resident #112 had diagnoses including chronic obstructive pulmonary disease (lung disease), osteoarthritis (degenerative joint disease), and major depressive disorder. The Minimum Data Set (a resident assessment tool) dated 03/14/2026 documented Resident #112 was cognitively intact, understands and was understood by others. The Comprehensive Care Plan Report last reviewed 03/17/2026 documented Resident #112 had no alteration in psychosocial well-being and was independent with decision making skills. Interventions included: to remain involved in daily decisions/care; provide information to make safe/independent decisions, respect choices; invite to attend Comprehensive Care Plan Meetings; and invite responsible party to attend Comprehensive Care Plan Meetings. During an interview on 05/07/2026 at 9:03 AM, Resident #112 stated they have never been invited to attend a care plan meeting. They stated no one has ever asked them to attend, and they have never received an invitation/letter to attend their care plan meeting. During an interview on 05/12/2026 at 10:46 AM, Social Worker #2 stated the front desk receptionist sends letters to designated resident representatives and/or residents when their scheduled care review meetings were due. They stated if a family member wishes to attend, they contact the social worker to schedule a meeting. They stated they do not specifically invite residents to attend their care plan meeting. They stated if a resident was their own responsible party, then they should receive a letter regarding their care plan meeting. During an interview on 05/12/2026 at 3:01 PM, Receptionist #1stated they were emailed a list of care plan reviews due, by the Medical Records Manager. They utilize that list to send letters out to the responsible party notifying them of the care plan meeting date and name of social worker. They stated they go by the indicated responsible party in the resident electronic medical record to determine who the letter is sent to. They stated if a resident is their own responsible party, the letter is given to the activities department to deliver to the resident, otherwise the letter is mailed out to the responsible party. Receptionist #1 reviewed Resident #112's contact information in the electronic medical record and stated Resident #112's care plan meeting letters were mailed to their responsible party, indicating a family member, not Resident #112. They stated they did not know why Resident #112 was not their own responsible party. Review of Resident Contacts dated 05/12/2026 at 3:04 PM, revealed there was documented contact type assigned to Resident #112. During an interview on 05/12/2026 at 3:16 PM, the Quality Compliance Registered Nurse stated Resident #112 should have been informed and invited to their care plan meetings because they were an active part of their care and should be involved. During an interview on 05/12/2026 at 3:38 PM, Resident #112 stated it would be important to them to be invited to attend their care plan meetings, as it would enlighten them on what was going on with their care. During an interview on 05/13/2026 at 10:31 AM, Social Worker #2 stated they were not aware that Resident #112 was not being invited to attend their care planning meeting and that they specifically did not ask Resident #112 to attend. They stated they did not believe that Resident #112 had attended their care plan meeting in a while. They stated Resident #112 should have been invited to attend the meetings because they were their own decision maker. During an interview on 05/13/2026 at 11:23 AM, the Administrator stated the social workers were responsible for inviting residents to their care plan meeting. They stated it was important for residents to be invited to their care meeting to uphold their rights and for residents to know their own plan of care. New York Code Rules Regulations 415.11 (c)(2)(ii)

Based on observation, interview, and record review conducted during the survey, the facility failed to ensure that each resident received proper treatment and assistive devices to maintain vision; and if necessary, must assist the resident in making appointments for one (1) (Resident #99) of one (1) resident reviewed. Specifically, Resident #99's glasses were reported missing on 03/04/2026 to facility staff and the resident was not seen by an eye doctor until it was arranged by the family 05/05/2026. Resident #99 complained that they were unable to see well without their glasses and were unable to read without their glasses. The findings include: The facility policy titled Consultants revised 2/2023 documented the facility used outside resources to furnish specific services provided by the facility. The facility arranges for qualified professional personnel to furnish specific services to residents and the facility. Consultant services were utilized in the following area: Optometrist. The facility policy titled Resident Rights and Responsibilities revised 1/13/2025 documented the facility functions on the premise that the service it renders should demonstrate its belief in the dignity and worth of every individual. The objective was to provide the Resident with optimal nursing and psychosocial care. Every effort was made by the Staff to meet the Resident's individual needs and requirements. Resident #99 had diagnoses including cerebral infarction (stroke), congestive heart failure (heart muscle unable to pump blood efficiently) and major depressive disorder. The Minimum Data Set (a resident assessment tool) dated 04/18/2026 documented Resident #99 had moderate cognitive impairments, understands and was understood by others. Ability to see in adequate light (with glasses or other visual appliances) was adequate and Resident #99 utilized corrective lenses. The Minimum Data Set, dated [DATE] documented it was very important for Resident #99 to have books, newspapers and magazines to read. The comprehensive care plan last reviewed 04/21/2026 documented Resident #99's vision was adequate with glasses. Interventions included glasses cleaned/applied daily by resident, glasses worn at own discretion, optometry and ophthalmology consult per order. Goal documented Resident #99 will not have signs/symptoms of decreased vision as evidence by ability to continue to read/recognize family/staff through next review. Kardex Report (guide used by staff to provide care) as of 05/10/2026 documented glasses cleaned/applied daily by resident, glasses worn at own discretion, and monitor for vision changes. Leisure Time Activities: interests include reading large print books, reading magazines. Review of progress notes dated 03/04/2026 through 04/29/2026, revealed there was no documented evidence that Resident #99 had missing glasses. A document provided by the facility titled Schedule of residents to be seen by Optometrist dated 04/03/2026 documented thirty-three residents for visits. Resident #99's name and purpose of visit was documented as missing glasses. A line was drawn through Resident #99's name and n/a noted in remarks. An email provided by the facility date sent 04/06/2026 at 12:45 PM from Social Worker #2 to the Medical Records Manager documented that Resident #99's family was eagerly waiting for the appointment (eye doctor on 04/03/2026). Social Worker #2 documented that they were not aware of Resident #99 being 'unavailable'. They documented the family would be upset to wait another month. An email provided by the facility dated 04/06/2026 at 1:03 PM from the Medical Records Manager to Social Worker #2 documented there were many people scheduled for a day, the doctor moves on quickly if someone seems unavailable to them. They stated they did not know for sure, but that Medical Records Clerk was sending the Optometrist service an email to see if there was anything they could do. A progress noted written by the Medical Records Clerk dated 04/30/2026 at 2:21 PM documented an appointment was scheduled on 05/05/26 with an eyecare center at 1:00 PM and that Resident #99's family member was taking them. During an observation and interview on 05/06/2026 at 9:21 AM, Resident #99 was sitting in their wheelchair in their room with a family member. Resident #99 stated they were missing their glasses and needed them for reading and crocheting. Resident #99's family member stated the glasses had been missing for over six weeks and the only thing they were told by the facility was that there was an optometrist. They stated they waited for Resident #99 to be seen but they never were. The family member stated they got tired of waiting, so they made Resident #99 an appointment at an eye doctor outside the facility and took the resident themself on 05/05/2026. During an interview on 05/11/2026 at 11:50 PM, Resident #99 stated they enjoy reading and have not been able to read without their glasses. They stated it bothered them not having their glasses, makes it harder for them to see and causes their eyes to hurt. Resident #99's family member stated they did not know if a lost/missing report was completed but that Registered Nurse Unit Coordinator #3, and Social Worker #2 were aware of Resident 99's eyeglasses missing. They stated they had never received any follow-up from the facility related to Resident 99's missing glasses. During an interview on 05/11/2026 at 12:43 PM, Social Worker #2 stated they were aware that Resident #99's glasses were missing and believed a lost/missing report was completed. They stated that the glasses had been missing since the end of March. Social Woker #2 stated that they had spoken to Resident #99's family member once about the missing glasses and about Resident #99 having an appointment to see the in-house eye doctor to get new glasses. Social Worker #2 stated there were email correspondences between Medical Records and them after Resident #99 was not seen by the in-house eye doctor on 04/03/2026. Social Worker #2 stated that Resident #99's quality of life could be affected by not having their glasses. During an interview on 05/11/2026 at 1:38 PM, the Medical Records Clerk stated they were notified on 03/04/2026, through email from Registered Nurse Unit Coordinator #3, that Resident #99's glasses were missing. They stated Resident #99 was added to the in-house eye doctors visit list for 04/03/2026 and they were not seen. The Medical Records Clerk stated they did not know why Resident #99 was not seen on 04/03/2026, just that the visit list indicated, not available. They stated they reached out to the eye doctor via email on 04/06/2026 to inquire about getting glasses for Resident #99 and they never heard back. The Medical Records Clerk stated there was no further follow- up with the eye doctor because they were waiting for a response from them. During a telephone interview on 05/11/2026 at 2:53 PM, Resident #99's family member stated they were not happy that Resident #99 had been without their glasses for two (2) months. They stated prior to today there was no follow up from the facility regarding their missing glasses. They stated they had just spoken with Social Worker #2 about forty-five minutes ago and were asked to bring in a receipt to see what could be done regarding reimbursement. They stated the facility did not offer to arrange any outside appointments for Resident #99 to have their glasses replaced, and that was why they arranged the appointment and took Resident #99 themself. During an interview on 05/11/2026 at 3:47 PM, the Administrator stated they were notified of Resident #99's missing glasses mid to late March and that staff were working with the family to get Resident #99 on list to see in-house eye doctor. They stated Resident #99 was on the eye doctor's list but was not seen. The Administrator stated they did not know why Resident #99 was not seen but that they would have then been placed on the list for the next month. They stated the family did not want to wait for the next eye doctor's visit. They stated the Social Worker followed up with the family today regarding the missing glasses because Resident #99 was just seen by an eye doctor last week. During an interview on 05/12/2025 at 1:08 PM, the Director of Nursing stated every resident should be provided with their assistive devices including glasses. They stated at times glasses can break or go missing, and they would have the resident placed on list to be seen by the Optometrist. They stated an appointment should be made as soon as possible to have glasses replaced for quality of life. They stated they did not believe it should take two (2) months for glasses to be replaced. The Director of Nursing stated they were not aware until last week when Resident #99 went out on the appointment, that their glasses were missing. They stated they were not notified of the circumstances as to why Resident #99's family member took them to see an eye doctor outside of the facility. During an interview on 05/12/2025 at 1:34 PM, Licensed Practical Nurse #7 stated that Resident #99's glasses had been missing for a while. They stated Resident #99 wore them all day and they were their main source for vision. They stated they have not seen Resident #99 reading or crocheting since their eyeglasses went missing. They further stated by Resident #99 not having their glasses limited their ability to do things they enjoy. During an interview on 05/13/2026 at 10:49 AM, Resident #99 stated, I hope the next time I see you I have my glasses so I can see you better. During an interview on 05/13/2026 at 11:33 AM, the Chief Nursing Officer stated they had no policy and procedures specific to vision or eye care. New York Code Rules Regulations 415.11(c)(3)(i)

Based on observation, interview and record review conducted during a Complaint (#NY00338861) investigation completed on 1/30/25 the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (Resident #2) of three resident reviewed. Specifically, Resident #2 did not receive weekly and comprehensive wound assessments and received applied dressings without a physician's order for a chronic left lower leg vascular ulcer (a chronic skin wound that develops due to poor blood circulation). In addition, the Minimum Date Set (MDS, resident assessment tool) was inaccurately assessed for the chronic left lower leg vascular ulcer. The finding is: Review of the facility's policy entitled Documentation of Pressure Ulcers and Chronic Wounds revised in June 2023 revealed weekly skin assessments are documented to include type of area (Pressure Ulcer, Stasis Ulcer, venous wound, arterial or diabetic), site, stage for pressure/stasis Ulcer, only, length, with and depth measurements, description/characteristics, treatment, debridement, exudate, pain management, and progress toward healing. Resident # 2 diagnoses included diabetes mellitus (condition where the body's blood glucose (blood sugar) levels are higher than normal), schizophrenia and a past medical history significant for a right above the knee leg amputation (a surgical procedure where a part of the body, usually a limb, is removed). Review of the Minimum Data Set, dated dated dated [DATE] revealed the resident is cognitively intact and understands and is understood. Indicates the resident has one unstageable pressure ulcer and no other ulcers, wounds, or skin problems. During an observation on 1/14/25 at 9:45 AM Resident #2 was lying in bed with a white gauze dressing secured with paper tape that encircled the left lower leg in the calf region and was approximately 8 inches in height; the dressing was not dated or signed. During the observation Resident #2 stated they had the left lower leg wound for quite a while, staff performed dressing changes on the wound daily, and said the surveyor could observe the treatment later. An additional observation on 1/14/2025 at 11:55 AM revealed Resident #2 refused the left lower leg dressing change when the nurse approached them for the procedure and the left lower leg dressing remained in place. During an observation on 1/15/25 at 10:00 AM Resident #2 was in lying bed and a left lower leg dressing was visible and in place. The resident stated the surveyor could watch the treatment; however, they later refused the observation of the wound treatment. Review of a hospital discharge summary dated 9/5/24 revealed discharge diagnosis of a chronic non-healing wound of the left lower extremity with recommendations for the resident to return to the facility's wound care regimen that was in place prior to the hospital admission. Review of a Nursing Admission Assessment, performed by Registered Nurse #1 dated 9/5/24 revealed when the resident re-entered the facility after a hospital stay Resident #2 had a vascular skin abnormality on the left lower leg without any other assessment characteristics noted. Review of the 9/10/24 History and Physical performed by the Medical Doctor revealed Resident #2 was a long-term resident with a previous right above the knee amputation and a full skin examination was not completed and to refer to nursing documentation for the skin assessment. Review of the Comprehensive Care Plan revealed a problem of impaired skin integrity related to venous ulcers of the left lower extremity initiated on 7/31/24 and revised on 1/13/25 with plans to evaluate and measure skin/wound site(s) at least weekly, document outcome and treatment progress/changes, and administer treatment per physician's orders. Review of the Physician Orders dated 1/2/25 revealed check the skin/wound every shift for visible redness, swelling or saturation and follow up and document accordingly. Mupirocin External Ointment 2 % (Mupirocin- topical antibiotic) application to the left lower extremity topically each day shift for a venous ulcer. Review of the Nursing Weekly Skin Status Documentation revealed on 7/30/24 the re-emergence of an old vascular ulcer of the left lower extremity. The assessments documented on 7/30/24 describe the left vascular wound as diffuse open areas with surrounding redness to the anterior of the left lower extremity without providing any measurements or any other characteristics of the wound. In addition, documentation from 7/30/24 to 1/13/25 documented the resident had a left lower front vascular wound with diffuse open areas with surrounding redness to the anterior left lower extremity without providing any measurements and complete characteristics of the wound. Documentation on 8/13/24, 9/30/24, 10/14/24, 11/25/24, 12/9/24 documented improvement of the wound. During a telephone interview on 1/24/25 at 11:45 AM Licensed Practical Nurse #1 stated they have provided many wound treatments for Resident #2's left lower leg vascular ulcer which Resident #2 has had for a long time. During the interview Licensed Practical Nurse #1 while referring to Resident #2's medical record, stated there was no specific order for the daily wound dressings because the nurses know to put it on with the treatment. In addition, Licensed Practical Nurse #1 stated that the vascular wound is open at times, other times it is scabbed with some redness, and sometimes there is drainage on the bandage when it is removed. The wound nurses document the wounds weekly, so the floor nurses typically don't document on the wound other than signing the resident's treatment records. During an interview on 1/16/25 at 8:55 AM Registered Nurse #1, Unit Manager stated they provide the weekly wound assessment for the left lower leg wound and stated sometimes the left lower leg wound is scabbed and other times it's open. Registered Nurse #1, Unit Manager stated Resident #2 has had the wound for quite a while, it's chronic and has been there over two years. During the interview the Registered Nurse #1, Unit Manager referred to their 12/30/24 documentation of the left lower leg and stated the documentation of the wound with a foul odor with purulent (consisting of, containing, or discharging pus) drainage was not correct, it was an error, and no wound culture of the vascular wound was obtained. In addition, the Registered Nurse #1, Unit Manager stated the left lower leg diffuse area was approximately 5-7 centimeters, but it wasn't all open and stated they did not document the size because they were taught not to by wound specialists when the affected area is diffuse. During an additional telephone interview on 1/27/25 at 2:21 PM the Registered Nurse #1, Unit Manager stated they performed the 9/10/24 skin assessment on Resident #2 upon re-entry into the facility post hospitalization . Once a treatment order is placed in the electronic medical record, the computerized system automatically populates an order to check the wound. When asked why the location of the wound was not indicated on the wound check entry in the treatment administration record, the Registered Nurse #1, Unit Manager stated they didn't know. During the interview the Registered Nurse #1, Unit Manger stated there was not a current order for the leg dressings although there is a treatment order and stated the nurses have worked with it so long, they know when to put a dressing on the wound which is usually done when the wound is open. When asked if the wound dressing required a physician's order the Registered Nurse #1, Unit Manager did not answer the question. During the interview the Registered Nurse #1, Unit Manager stated it is the responsibility of the floor nurses and the Unit Manger to check order for accuracy and completeness. During an interview on 1/22/25 at 4:06 PM, the Adult Nurse Practitioner stated they serve as a wound consultant for the facility and evaluates wounds upon request by nursing staff and had not received a request to evaluate the left lower leg vascular wound for Resident #2. The Adult Nurse Practitioner stated since October 2024 they have been evaluating a wound on the buttocks and was not even aware that the resident had a vascular wound on the left lower extremity. The wound consultant stated that vascular wounds, require weekly assessments with the same detail of a pressure ulcer; however, they are not usually stated; this would include length, width, depth, color, odor, and area of the surrounding skin. During a telephone interview on 1/22/25 at 5:45 PM the Medical Doctor stated that the wound team is responsible to assess all wounds weekly and should include the type of wound, size, depth, treatment, and signs of infection. During the interview the physician read Resident #2's documented wound notes and stated staff should never document a wound is improving without providing all the required wound characteristics; the measurements should be documented. The Medical Doctor stated each treatment including dressings require an order from the provider in the medical record. During a telephone interview on 1/29/25 at 4:16 PM the Director of Nursing stated that after they checked with corporate staff, they determined that open vascular wounds require measurements and that dressings require physician's orders. 10 NYCRR 415.12

Based on interview and record review conducted during an Abbreviated survey (complaint #NY00322899) completed on 5/30/24 the facility did not ensure that residents who had an indwelling (foley) catheter (tube inserted into the bladder to drain urine) received the appropriate care and services to manage catheters for one (Resident #1) of three residents reviewed. Specifically, there was lack of a provider order for the indwelling catheter (tube placed in bladder to drain urine), lack of documented urine outputs, and catheter care provided. The finding is: The policy titled Clinical Records revised 4/01 documented the medical record would be complete and accurately documented. The medical record would contain information pertinent to resident care and planning. The policy titled Catheter Drainage Bag Care revised 5/13, documented urinary drainage bag care was performed appropriately to prevent complications caused by the presence of an indwelling urethral catheter. Output was to be recorded every shift. Resident #1 had diagnoses including post laminectomy syndrome (chronic back pain following surgery), depression, and colitis (inflammation of the colon). The Minimum Data Set (a resident assessment tool) dated 8/16/23 documented Resident #1 was cognitively intact, did not have a foley catheter, and was occasionally incontinent of urine. The Nursing Admission Evaluation dated 8/9/23, completed by Licensed Practical Nurse Unit Manager #1, documented Resident #1 did not have a foley catheter. Review of the Kardex (guide used by staff to direct care) dated 8/9/23 and 8/10/23 documented to monitor bowel movements each shift and the resident used a bed pan for toileting with total assistance. There was no documentation the resident had an indwelling catheter or that staff were to provide catheter care. Review of provider orders dated 8/9/23-8/17/23 revealed there were no orders to address use of or discontinuation of the foley catheter. Review of Medical Visit Notes dated 8/10/23 to 8/14/23 revealed no evidence the resident had a foley catheter. Review of the OT (occupational therapy) Evaluation dated 8/10/23, completed by Occupational Therapist #1, documented Resident #1 had a foley catheter. Review of nursing Progress Notes dated 8/9/23 to 8/14/23 revealed the following: -On 8/11/23 at 2:11 AM, the resident's foley was intact -On 8/13/23 at 4:51 AM, the resident's foley was intact There was no documentation of urine outputs, urine characteristics, or any catheter care was provided. Review of the 24-hour Nursing Services Supervisor Report dated 8/9/23 to 8/14/23 revealed the following: -On 8/10/23 11:00 PM-7:00 AM shift documented the resident was confused and had a foley -On 8/13/23 the 7:00 AM-3:00 PM shift, documented the foley output was 850 cc (cubic centimeters-unit of measurement) and the 3:00 PM-11:00 PM shift documented the resident had a foley, no output was documented -On 8/14/23 the 7:00 AM-3:00 PM shift documented the resident's foley was discontinued and a urine sample was obtained and sent Review of the Treatment Administration Record dated 8/1/23-8/31/23 revealed no documentation the resident's urinary output was measured from their admission on 8/9/23 until the catheter was documented as discontinued on 8/14/23. Review of the Lab Results Report dated 8/16/23 documented a urine culture (urine test done to detect bacteria) was collected on 8/14/23 at 1:30 PM and was positive for Escherichia coli (bacteria commonly found in the lower intestine). The facility was unable to provide certified nurse aide task documentation related to urine output or catheter care. Review of the hospital History and Physical dated 8/17/23 at 3:30 PM, revealed the resident was admitted with sepsis as evidenced by leukocytosis (increased number of white cells in the blood, especially during an infection), tachycardia (rapid heart rate), and hypotension (low blood pressure) secondary to a urinary tract infection. During a telephone interview on 5/28/24 at 12:59 PM, Licensed Practical Nurse #2 stated if they documented a resident had a foley catheter on 24-hour report, it meant the resident had a catheter. Licensed Practical Nurse #2 stated that sometimes they emptied the foley catheter drainage bags and would document the output, but sometimes rehab people emptied them and didn't report the output to them. During an interview on 5/29/24 at 3:19 PM, Licensed Practical Nurse Unit Manager #1 stated they didn't know if the resident had a foley catheter and could only refer to their note. The Licensed Practical Nurse #1 stated they didn't know why other staff members documented the resident had a foley and if a resident did have a foley on admission, they usually automatically wrote orders for it, then a provider would figure out of the resident needed to keep it or discontinue it. During an interview on 5/29/24 at 9:25 AM, the Occupational Therapist #1 stated they didn't remember the resident. They reviewed the Occupation Therapy Evaluation dated 8/10/23 and stated they assume at the time they wrote the note that the resident had a foley catheter because it was documented. During an interview on 5/29/24 at 12:16 PM, the Registered Nurse Unit Manager #1 stated if someone was admitted with a foley, they would do a set of admission orders and would be up to the providers to decide if the foley was discontinued. The Registered Nurse Unit Manager #1 reviewed the record and stated they saw where some staff have documented the resident had a foley and others didn't. The Registered Nurse Unit Manager #1 stated there should be an order for the foley catheter and catheter care every shift should have gone onto the care plan and Kardex. They stated resident's with foley catheters were at risk for urinary tract infections. During an interview on 5/29/24 at 1:59 PM, the Director of Nursing stated they could not say whether the resident had a foley catheter or not based on the medical record. They also stated they could not determine if catheter care was provided. The Director of Nursing stated they should have been able to determine all of that that from the medical record. The Director of Nursing stated it was possible the foley was missed by nursing upon admission. 10 NYCRR 415.12(d)(1)(2)

Based on interview and record review conducted during a Complaint investigation (Complaint #NY00304973) completed during the Standard survey on 3/13/24, the facility did not ensure the resident's right to be free from verbal abuse for one (Resident #12) of five residents reviewed. Specifically, on 11/3/22 Licensed Practical Nurse #12 was witnessed using vulgar language towards Resident #12. The finding is: The policy and procedure titled Abuse Reporting and facility Incident Reporting revised 10/24/22, defined verbal abuse as any use of oral, written, or gestured language that includes disparaging and derogatory terms to residents, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability. Resident #12 had diagnoses including vascular dementia, chronic obstructive pulmonary disease, and cerebral atherosclerosis (a disease where the arteries in the brain become hard and narrow). The Minimum Data Set (a resident assessment tool) dated 9/3/22 documented Resident #12 had moderate cognitive impairment, was usually understood, and usually understands. Review of Facility Reported Incidents Initial Report completed by the Administrator, documented alleged verbal abuse occurred on 11/3/22 at 9:30 PM in the hallway by Licensed Practical Nurse #12 towards Resident #12. Witnesses, Registered Nurse #2 Supervisor and Licensed Practical Nurse #11, reported hearing Licensed Practical Nurse #12 state I am not dealing with these mother f .ers, referring to the residents. The Administrator concluded they verified the allegation by evidence collected during the investigation and the evidence was strongly in favor that there was verbal abuse directed at Resident #12. Review of a forwarded email provided by the Director of Nursing dated 11/4/22 at 11:10 AM from Licensed Practical Nurse #12, documented they went to take Resident #12 their medications and Resident #12 started complaining and yelling at them about their meds being late. Licensed Practical Nurse #12 documented they told Resident #12 they were alone and doing the best they could. Licensed Practical Nurse #12 documented they then called Registered Nurse #2 Supervisor and told them to come get the f .ing keys and finish the med pass cause I'm sick of the f .ing residents talking to me and yelling at me any kind of way. During an interview on 3/8/24 at 12:26 PM, Resident #12 stated they recalled the interaction with Licensed Practical Nurse #12 on 11/3/22. Resident #12 stated they had asked Licensed Practical Nurse #12 for something to help them go the bathroom around 4 PM and Licensed Practical Nurse #12 did not come until 9:30 PM with their medication. Resident #12 stated Licensed Practical Nurse #12 called them names and put both their middle fingers in their face. Resident #12 stated they told Licensed Practical Nurse #12 they were going to report them, and the nurse stated, Go ahead, I don't give a damn about you. Resident #12 stated that Licensed Practical Nurse #12 was abusive, and it made them feel disrespected and mad. During a telephone interview on 3/12/24 at 8:49 AM, Licensed Practical Nurse #12 stated they remembered Resident #12 going off swearing and being verbally aggressive towards them about some bowel medication. Licensed Practical Nurse #12 stated they were angry and frustrated being short staffed, the only nurse on the unit for 38-40 residents. Licensed Practical Nurse #12 stated that swearing and giving offensive gestures, middle finger, to a resident would be considered verbal abuse. Licensed Practical Nurse #12 denied using the F word and giving offensive gestures in front of or at Resident #12. Licensed Practical Nurse #12 stated they may have written the email dated 11/4/22. During a telephone interview on 3/12/24 at 9:17 AM, former Registered Nurse #2 Supervisor stated they recalled the incident between Resident #12 and Licensed Practical Nurse #12 on 11/3/22. Registered Nurse #2 Supervisor stated Licensed Practical Nurse #12 was yelling, using the F word, and acting unprofessional, getting into Resident #12's face in front of Resident #12's room. Registered Nurse #2 Supervisor stated that Licensed Practical Nurse #12 was verbally abusive towards Resident #12. Additionally, Registered Nurse #2 Supervisor stated they notified the Director of Nursing over the phone about the verbal abuse within the hour it occurred. During a telephone interview on 3/12/24 at 1:58 PM, Licensed Practical Nurse #11 stated they recalled the incident from 11/3/22. Licensed Practical Nurse #11 stated when they arrived on the unit, Licensed Practical Nurse #12 was yelling profanities, using the F word at Resident #12 and that Resident #12 was upset, yelling at Licensed Practical Nurse #12. Licensed Practical Nurse #11 stated Licensed Practical Nurse #12's language towards Resident #12 was verbal abuse. Licensed Practical Nurse #11 stated that Resident #12 was upset and mad over the way Licensed Practical Nurse #12 spoke to them. During an interview on 3/13/24 at 11:42 AM, the Director of Nursing stated the language that Licensed Practical Nurse #12 used was inappropriate and could potentially cause emotional harm to a resident. Director of Nursing, upon reviewing investigation report, stated the facility concluded the evidence was strongly in favor that there was verbal abuse directed at Resident #12 by Licensed Practical Nurse #12. The Director of Nursing stated verbal abuse should not be occurring, as this is the residents' home and residents need empathy and compassion. During an interview on 3/13/24 at 12:38 PM, Administrator stated Resident #12 ultimately didn't feel it was abuse, they saw it as a spat and Licensed Practical Nurse #12 was terminated for bad customer service. The Administrator stated they did not expect staff to argue back and forth with residents using vulgarities, and/or giving gestures to residents as it was not respectful. 10 NYCRR 415.4 (b)(1)(i)

Based on observations, interviews, and record review conducted during the Standard survey completed on 3/13/2024 the facility did not ensure that all residents care plans were implemented as planned, consistent with the resident rights and meet their preferences, goals and medical, physical, and psychosocial needs that are identified in the comprehensive assessment for one (Resident #14) of two reviewed. Specifically, Resident #14 was not care planned for the use of a positioning wedge. The resident was observed on multiple occasion lying in bed with the wedge positioned between the mattress and the bedframe. The finding is: The policy and procedure titled Interdisciplinary Care Planning last revised 1/22/2024 documented the care plan is developed based on information obtained from but not limited to assessments/observations, diagnostics, and interviews with the resident/responsible party. The Comprehensive Care Plan and Kardex must be current and accurately reflect the resident's status. The Care Plan/Kardex must always be reviewed by staff prior to initiating care to the resident. Resident #14 had diagnosis including unspecified psychosis, anxiety disorder and frontotemporal neurocognitive disorder (disorder of the brain). The Minimum Data Set (a resident assessment tool) dated 2/3/24 documented Resident #14 had severe cognitive impairment, rarely/never understood, and rarely/never understands. The comprehensive care plan last reviewed 2/6/24 documented Resident #14 was at risk for falls related to cognition, medication, and mobility. Interventions included border definer to left side of bed initiated 6/9/23; low bed initiated 2/23/23; gym mat on floor: left side initiated 6/1/23. The comprehensive care plan did not include the use of a positioning bed wedge between the bed frame and mattress. Review of the closet care plan (guide used by staff to provide care) dated 3/6/2024 documented under Safety: Big Boy bed, border definers to left side of bed, gym mat on floor-left side, low bed; Bed Mobility: Border definer to left side of bed, positioning devices for bed-pool noodle attached to left edge of bed. The closet care plan did not include the use of a positioning wedge between the bed frame and mattress. Review of facility Nursing Falls Risk Data Collection Tool dated 11/10/23 and 2/2/24 completed by Register Nurse #1 Unit Manager, indicated Resident #14 was at risk for falls due to confusion, poor safety awareness, forgets to ask for assistance, incontinent, use of medications, agitation, and behavior issues. Applicable interventions: low bed, gym mat on floor: left side, non-skid shoes/slippers, monitor for medication side effects, and pharmacy medication review. During observations on 3/6/24 at 10:13 AM and 4:28 PM; 3/8/24 at 10:09 AM; and 3/11/24 at 9:55 AM and 10:37 AM, Resident #14 was in a low bed with right side of bed against wall, gym mat on floor- left side, gym mat secured to wall on right side, left side of mattress with border definer (pool noodles) and a thick dark pink foam positioning bed wedge was wedged in the center of the bed under the left side of the mattress and bedframe. During an interview on 3/11/24 at 10:45 AM, Certified Nursing Assistant #7 stated the use of safety, positioning devices for residents is on their closet care plan. Certified Nursing Assistant #7 stated that Resident #14 used a wedge, winged mattress, and mats (one on left side of bed and one on wall). Certified Nursing Assistant stated the positioning wedge was used all the time while Resident #14 was in bed and removed for care and at meals. Certified Nursing Assistant #7 stated aides place the wedge under the mattress (between the bedframe and mattress) to make the mattress higher so Resident #14 can't roll out of bed. Certified Nursing Assistant stated that Resident #14 can move in bed very well and the positioning wedge does not impact their ability to do care on Resident #14. During an interview on 3/11/24 at 11:00 AM, Licensed Practical Nurse #13 stated Resident #14 moves and positions themself in bed and prefers to be in bed. Licensed Practical Nurse #13 stated a positioning bed wedge was used for Resident #14 to keep them in place in bed, so they don't fall out. Licensed Practical Nurse #13 stated usually the aides place the positioning bed wedges and the nurses were responsible to oversee the aides. Licensed Practical Nurse #13 stated the use of pool noodles, and a positioning bed wedge keeps Resident #14 in place, gives us a chance to get down the hall if Resident #14 is yelling or if they are attempting to try to get out of bed. During an interview and observation on 3/11/24 at 11:13 AM to 11:23 AM, Registered Nurse #1 Unit Manager stated Resident #14 has had several falls in the past and pool noodles were used as a border definer on the mattress, so Resident #14 knows where the edge of the bed was. Registered Nurse #1 Unit Manager stated positioning bed wedges were usually used for positioning on top of the mattress, to help keep residents centered in bed, and keep them off the edge of the bed. Registered Nurse #1 Unit Manager stated the use of a positioning bed wedge between the bedframe and mattress wasn't a practice they were familiar with and should not be positioned there. Registered Nurse #1 Unit Manager observed the placement of the bed wedge and then removed the bed wedge from between the bedframe and mattress. Registered Nurse #1 stated staff should not have placed the positioning wedge between the mattress and bed frame. During an interview on 3/12/24 at 10:16 AM, Assistant Director of Rehab Services stated they wouldn't use positioning wedges under a mattress, they would achieve goals better if positioning wedge was next to, under the resident. Assistant Director of Rehab Services stated they wouldn't use a positioning wedge under the mattress as it could be a restrictive device, restricting a resident's movement which was not legal. During an interview on 3/13/24 at 11:58 AM, the Director of Nursing stated the use of a positioning bed wedge between the bed frame and mattress was not permittable or the purpose of their use. 10NYCRR 415.11

Based on observation, interview, and record review conducted during a Standard survey completed on 3/13/24, the facility did not ensure that services being provided met professional standards of quality for two (Resident #166 and #477) of four reviewed. Specifically, a medication transcription error led to Resident #166 receiving the wrong medications, causing a decrease in the resident's blood pressure which resulted in a transfer to the hospital for evaluation. Additionally, during a medication pass observation Licensed Practical Nurse #7 documented medications administered to Resident #477 using Licensed Practical Nurse #8 Unit Coordinators' employee identifier. The finding is: Review of the policy and procedure titled Medication/Treatment Discrepancy/Error dated 3/2011 documented that to assure proper medication/treatment administration, compliance with the legal requirements of medication administration, and to report all errors in medication administration and documentation. Further review of the policy and procedure documented that the significance of the medication errors is determined by the patient's condition and drug category. Review of the policy and procedure titled Computerized Physician's Orders, Prescriber eSigning, and Medication Administration dated 5/2023 documented that all physicians' orders and nursing interventions are transcribed into the computerized order entry software. Review of the policy and procedure titled Physician Orders dated 10/2022 documented that all medication/treatment orders are written on the physician order form or on the telephone order form and/or entered into the electronic health record. 1. Resident #166 was admitted to the facility with end stage kidney disease and Type 2 diabetes. Review of the Minimum Data Set (a resident assessment tool) dated 2/2/24 documented that the resident was cognitively intact, understands others, and is understood by others. Further review of the Minimum Data Set documented that the resident did not have a diagnosis of hypertension (high blood pressure). Review of the comprehensive care plan dated 1/30/24 documented that Resident #166 was care planned for impaired cardiac functions related to coronary artery disease (a condition where there is plaque build up in a patient's arteries). Further review of the comprehensive care plan documented that the resident was to have their vital signs, including blood pressure and pulse, monitored. Review of the Physician Telephone/Verbal Orders Admission/Readmission Orders Form A dated 1/26/24 documented the following medications ordered for the resident: -Humalog insulin, sliding scale for diabetes -Aspirin to prevent blood clots -Atorvastatin for high cholesterol -Cyclosporine for dry eyes -Pioglitazone for diabetes -Vancomycin antibiotic for infections Review of the January 2024 Medication Administration Record documented those vital signs including blood pressure (normal 120/80), heart rate (60 to 100 beats per minute), temperature (98.6 Fahrenheit), respirations (12 to 20 per minute), and oxygen saturation levels (92% or greater on room air) are to be taken once a shift for two weeks. Resident 166's blood pressure measurements were: 1/22/24 11PM to 7AM shift - blood pressure 124/57. 1/23/24 7AM to 3PM shift - blood pressure 126/62. 1/23/24 3PM to 11PM shift - blood pressure 130/80. 1/23/24 11PM to 7AM shift - blood pressure 124/57. 1/24/24 7AM to 3PM shift - blood pressure 123/66. 1/24/24 3PM to 11PM shift - blood pressure 91/54. 1/24/24 11PM to 3PM shift - blood pressure 107/57. 1/25/24 7AM to 3PM shift - blood pressure 106/58. 1/25/24 3PM to 11PM shift - no blood pressure recorded. 1/25/24 11PM to 7AM shift - no blood pressure recorded. 1/26/24 7AM to 3PM shift - no blood pressure recorded. 1/26/24 3PM to 11PM shift - no blood pressure recorded. 1/26/24 11PM to 7AM shift - blood pressure 106/58. 1/27/24 7AM to 3PM shift - blood pressure 111/62. 1/27/24 3PM to 11PM shift - blood pressure 108/61. 1/27/24 11PM to 7AM shift - no blood pressure recorded. 1/28/24 7AM to 3PM shift - blood pressure 106/60. 1/28/24 3PM to 11PM shift - no blood pressure recorded. 1/28/24 11PM to 7AM shift - blood pressure 145/62. 1/29/24 7AM to 3PM shift - blood pressure 90/48. Review of the Dialysis Hand Off Communication Sheet dated 1/29/24 documented that Resident #166 was given the wrong medication during the weekend and their blood pressure was 76/46 at dialysis. The Dialysis Hand Off Communication Sheet also documented the resident was hypotensive (low blood pressure under 90/60), complained of dizziness, and per the nephrologist (a doctor who specializes in kidney diseases) was to be sent to the emergency room for observation. Review of the Clinical Physicians Orders with a print date of 3/12/2024 revealed orders for Metoprolol Succinate ER 100 milligrams with a revision dated of 1/26/2024 and a start date of 1/27/2024 and an end date of 1/28/2024. Additionally, Amlodipine Besylate 10 milligrams with a revision dated of 1/26/2024 and a start date of 1/27/2024 and an end date of 1/28/2024. Further review of the January 2024 Medication Administration Record documented Resident #166 received one dose of Amlodipine Besylate 10 milligrams (a medication that lowers blood pressure) on 1/27/24 and 1/28/24; Resident #166 also received one dose of Metoprolol Succinate extended release 24 hour 100 milligrams (a medication that lowers blood pressure) on 1/28/24. Review of the Medication/Treatment Variance Report dated 1/29/2024 documented that License Practical Nurse Facilitator #5 put incorrect medications into the electronic medical record of Resident #166. The medications belonged to a new admission resident at another facility. Further review of the report documented that Licensed Practical Nurse Facilitator #5 entered into Resident #166's electronic medical record the wrong medication, the wrong dose, the wrong resident and that there were transcription errors. The Medication/Treatment Variance Report documented that the medications involved were Amlodipine and Metoprolol. During an interview on 3/6/24 at 12:39 PM, Resident #166, stated that they had received the wrong medication and went to the hospital with a low blood pressure. During a telephone interview on 3/12/24 at 9:59 AM with Licensed Practical Nurse #4, they stated that blood pressure parameters weren't on the order that they could remember. They stated that if they thought the resident's blood pressure was low, they would hold the medication and call their supervisor. They stated they thought that one of the medications wasn't available or they thought the blood pressure was too low to give it. They stated that they don't remember calling the supervisor about the medication order. During a telephone interview on 3/12/24 at 10:07 AM, Licensed Practical Nurse #5 Facilitator stated that they entered the wrong medications in the wrong resident's chart. Licensed Practical Nurse #5 Facilitator stated that there used to be a policy that if a resident's blood pressure was less than 90 systolic (the first number in blood pressure) or less than 60 diastolic (the second number in blood pressure), they held high blood pressure medications. They stated that they didn't know if that was still in effect. During a telephone interview on 3/12/24 at 10:57 AM, Nurse Practitioner #2, stated Resident #166 became hypotensive at dialysis and could not complete dialysis that day (1/29). Nurse Practitioner #2 stated Resident #166 complained of being dizzy and lightheaded. The nephrologist wanted the resident to be sent to the hospital to be monitored. Nurse Practitioner #2 stated this was a significant medication error because Resident #166 was not supposed to be administered the high blood pressure medications as they were not ordered for them; they became dizzy and hypotensive. Nurse Practitioner #2 stated that Resident #166's did not need high blood pressure medications. During a telephone interview on 3/12/24 at 11:39 AM, Nurse Practitioner #1 stated they put in telephone orders for Resident #166 on 1/26/24 but there were no orders for high blood pressure medications. They stated that a resident with normal or low normal blood pressures could become hypotensive or bradycardic (low heart rate below 60 beats per minute) if they received high blood pressure medications. During an interview on 3/13/24 at 8:43 AM, the Director of Nursing stated they expected nursing staff to check the orders for accuracy. The Director of Nursing stated that Licensed Practical Nurse #6 Facilitator Manager found the error and alerted them. During a telephone interview on 3/13/24 at 9:36 AM, Licensed Practical Nurse #6 Facilitator Manager stated when any order comes in from a provider, they process the order. After an order was processed, the order goes to pharmacy to be filled. Licensed Practical Nurse #6 Facilitator Manager stated that they spoke with the provider who wanted the resident to be monitored for vital signs. They stated that vital signs were to be taken once a shift for two weeks for newly admitted residents. They stated that if the nurse thought a blood pressure seemed low, they should contact the provider about holding the medication. During an interview on 3/13/24 at 9:58 AM, the Administrator stated that they expected their staff to call the providers if there were concerns about a resident's vital signs. They also stated that they expected their staff to enter orders under the correct resident's name with the correct medications into the electronic medical record. During a telephone interview on 3/13/24 at 11:06 AM, the Pharmacist Consultant stated Resident #166 should not have received the high blood pressure medications if they have a normal or low normal blood pressure. They stated the resident could have hypotension or other symptoms of hypotension like dizziness or lightheadedness. 2. Resident #477 had diagnoses of unspecified condyle fracture of lower end of left femur (a break in the ball shaped bone located at the end of the thighbone), transient ischemic attack (a brief blockage of blood flow to the brain) and cerebral infarction (a disrupted blood flow in the blood vessels that supply blood to the brain). The Minimum Data Set (a resident assessment tool) dated 3/8/24 documented Resident #477 was cognitively intact, was understood and understands. The comprehensive care plan revised on 3/1/24 documented, Resident #477's medication should be administered per the physicians' orders. During an observation on 3/11/24 at 9:28 AM, Licensed Practical Nurse #7 administered/applied the following medications to Resident #477: Benazepril (used to treat high blood pressure) 10 milligrams. Cetirizine (used to treat allergies) 10 milligrams. Metformin (used to treat diabetes) 500 milligrams. Metoprolol (used to treat high blood pressure) extended release 50 milligrams. Fluticasone (used to treat nasal congestions) 1 spray in each nostril. Nystatin topical powder (antifungal) applied to folds of the skin. Vitamin C (supplement) 500 milligrams. Vitamin D3 (supplement) 25 micrograms. Review of the medication administration record dated 3/1/2024 - 3/31/2024 revealed that on 3/11/24 the above morning medications were documented as being administered by Licensed Practical Nurse #8 Unit Coordinator. During an interview and record review on 3/11/24 at 3:31 PM, Licensed Practical Nurse #8 Unit Coordinator reviewed Resident #477's medication administration record and stated that they did not administer the morning medications for Resident #477. They stated they must have forgotten to log out of the computer system. Licensed Practical Nurse #8 stated it was important to log out of the computer system, so that no one inadvertently documented patient care under the wrong employee identifier. Licensed Practical Nurse #8 Unit Coordinator stated if the patient care or medication administration was done improperly that they would get blamed for it. During an interview on 3/12/24 at 3:40 PM, Licensed Practical Nurse #7 stated they had administered Resident #477 morning medications on 3/11/24. Licensed Practical Nurse #7 stated it was important to verify that they were logged into the system before documentation because if they were ever to make a medication error the other nurse would be the one the facility would have to investigate. Licensed Practical Nurse #7 stated this was something that happened frequently. During an interview on 3/13/24 at 12:10 PM, the Director of Nursing stated the nurses needed to ensure the previous nurse was completely logged out of the electronic health record prior to documenting their medication entries. The Director of Nursing stated this was important because the wrong person would get blamed if a medication error had occurred, and to prevent falsification of documentation. The Director of Nursing stated that diversion was a possibility if a nurse signed out a narcotic medication under the wrong log in identifier. The Director of Nursing stated they did not have a specific policy and procedure the facility utilized to ensure nurses used the correct log in identifier when administering and documenting medications. During an interview on 3/13/24 at 12:16 PM, the Administrator stated it was important for the medication administration records to be properly documented because if they had to investigate a medication error, they would need to know the actual nurse who administered the medication. 10 NYCRR 415.11(c)(3)(i)

Based on observation, interview and record review conducted during a Complaint investigation (Complaint #NY00328436) during a Standard survey completed on 3/13/24, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living received the necessary assistance to maintain grooming and personal hygiene for one (Resident #120) of six residents reviewed. Specifically, Resident #120 was not offered toileting or provided incontinent care as planned. The finding is: The policy and procedure titled Activities of Daily Living dated 11/16 documented each resident will receive and the facility will provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and care plan. The policy and procedure titled Toileting-Continence dated 1/1/20 documented toileting needs of each resident were identified and interventions were applied to promote and maintain continence. Residents requiring assistance for toileting were on a scheduled toileting program (every 2,3 or 4 hours during the day). Resident specific needs in relation to toileting/incontinence care were identified on the Comprehensive Care Plan. Resident #120 had diagnoses including chronic kidney disease (kidney damage), depression and hypertension. The Minimum Data Set (a resident assessment tool) dated 1/20/24, documented Resident #120 had severely impaired cognition, was totally dependent on staff for toileting, and was occasionally incontinent of bowel and bladder. Review of Resident #120's undated comprehensive care plan identified as current by the Director of Nursing, documented Resident #120 had alterations in bowel and bladder function and was frequently incontinent of bowel and bladder. Interventions included the use of incontinence products (brief), offer toileting before every 4 hours, and incontinent care every 4 hours and as needed. Toilet transfers required maximal assistance of two staff members with a gait belt (used by staff to help support an unsteady/weak person) using the manual sit to stand lift (assistive device). Review of the Visual/Bedside Kardex Report (a guide used by staff to provide care) dated 3/12/24 documented staff were to provide incontinent care every 4 hours and as needed and were to offer toileting before every 4 hours and as needed. Review of Resident #120's nursing Progress Notes dated 3/4/24 through 3/12/24 revealed there was no documented evidence the resident refused incontinence care or toileting. During a continuous observation on 3/12/24 from 8:19 AM to 1:39 PM, Resident #120 sat in their wheelchair at a table in the Unit B dining room. The resident was not toileted during this timeframe. During an interview on 3/12/24 at 1:39 PM, Certified Nurse Aide #2 (assigned to care for Resident #120) stated Resident #120 was not toileted or provided with incontinent care since 8:00 AM when they got out of bed because Resident #120 didn't ask to be changed and they didn't have time to change them. Certified Nurse Aide #2 stated the care plan said that Resident #120 was to be toileted before every 4 hours. Certified Nurse Aide #2 stated Resident #120 should have been toileted before 12:00 PM and was not. During an observation on 3/12/24 at 2:07 PM, Licensed Practical Nurse #10 and the Associate Director of Quality and Education transferred Resident #120 from their wheelchair to the toilet using the sit to stand lift. When Resident #120 stood up to a standing position the back of their pants were visibly wet. The Associate Director of Quality and Education removed Resident #120's pants and brief and Resident #120 was lowered onto the toilet. The resident's brief and gel cushion in the wheelchair were saturated and soiled with a foul wet liquid substance. The 12 inch by 12-inch blue dycem (non-slip, self-adhesive mat) on top of the wheelchair cushion contained an 8-inch puddle of yellow odorous liquid substance. The Associate Director of Quality and Education stated the yellow liquid was urine, the puddle of urine was unacceptable, and the wheelchair cushion with dycem needed to be disinfected. During an interview on 3/12/24 at 2:11 PM, Licensed Practical Nurse #10 stated Certified Nurse Aide #2 should have toileted Resident #120 before lunch. There was no way this resident was toileted. Toilet schedules were every 2-4 hours and as needed per the care plan and prevented skin break down. Licensed Practical Nurse #10 stated they were not informed the care was not provided and had not assisted Certified Nurse Aide #2 with Resident #120 for any care needs on 3/12/24. During an interview on 3/13/24 at 9:15 AM, the Associate Director of Quality and Education stated Resident #120 was not cared for more than six and a half hours on 3/12/24 and this was unacceptable. Certified Nurse Aide #2 should have checked on the resident before the resident ate lunch. During an interview on 3/13/24 at 10:30 AM, Certified Nurse Aide #3 stated they did not assist with toileting or incontinent care for Resident #120 on 3/12/24. Resident #120 wouldn't ask to use the toilet, we would just take them. During an interview on 3/13/24 at 10:37 AM, Certified Nurse Aide #4 stated Resident #120's care plan documented to offer toileting before every 4 hours, incontinent care every 4 hours and as needed. Resident #120 should have been changed before lunch. Incontinent care reduced skin breakdown and impacted one's dignity. Certified Nurse Aide #4 did not provide care for resident on 3/12/24. During a telephone interview on 3/13/24 at 11:20 AM, Certified Nurse Aide #5 stated they knew when Resident #120 would say they were cold they knew they had to be changed or toileted. Resident #120 should have been toileted prior to lunch. Certified Nurse Aide #5 did not provide care or assisted with toileting needs for Resident #120 on 3/12/24. During an interview on 3/13/24 at 10:54 AM, Registered Nurse #1, Unit Manager stated Resident #120 was totally dependent on staff for toileting needs and should have been toileted before lunch. Staff nurses were responsible to ensure the certified nurse aides followed the care plan and residents were toileted timely. They were responsible to ensure all staff followed the care plan for all residents. During an interview on 3/13/24 at 12:32 PM, the Director of Nursing stated Certified Nurse Aide #2 should have informed Licensed Practical Nurse #10 that care wasn't provided. If they still can't meet the expectation then Registered Nurse #1, Unit Manager should have been informed and determined why the task couldn't be performed per the plan of care. A resident should never be sitting in a puddle of urine. Resident #120 was not toileted therefore the care plan was not followed. During an interview on 3/14/24 at 1:26PM, the Administrator stated if Resident #120 had incontinent care at 8:00 AM, then they should be toileted no later than 12:00 PM or more frequently based what's stated on the plan of care. Urinary incontinence led to skin breakdown and caused emotional and physical discomfort. 10 NYCRR 415.12 (a)(3)

Based on interview and record review during a Standard survey completed on 3/13/24, the facility did not ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for one of three employees reviewed for licensure and certification. Specifically, the Associate Director of Quality and Education did not have the required license or certification and was observed providing hands on care for a resident on 3/12/24. Refer to F 677 D The finding is: Review of facility's undated Job Title: Associate Director for Quality and Education, documented they plan, organize, and directs all staff development programs and Continuous Quality Improvement Programs throughout the facility and in accordance with applicable federal, state, local and facility guidelines/regulations to ensure that the highest degree of quality is maintained at all times. Review of facility's Job Title: Licensed Practical Nurse reviewed August 2023 documented, provides nursing care in accordance with resident care policies and procedures and ensures the safety and well-being of the residents is maintained, maintains and updates New York State licensure in compliance with New York State regulations and qualifications include valid New York State Licensed Practical Nursing License. Review of the Associate Director for Quality and Education's personnel file showed that it contained the following: A document titled The University of the State of New York dated January 9, 2024, documented that the determination and recommendation of the Regents Review Committee in this violation of probation proceeding be accepted as follows: That respondent's license to practice as a licensed practical nurse in the State of New York be suspended indefinitely, for no less than sixty (60) days, and until respondent successfully completes coursework in Nursing Ethics and Documentation, along with two (2) years of concurrent probation. In addition, it is documented, that this order shall take effect as of the date of the personal services of this order upon the respondent or five days after mailing by certified mail. A document titled, Associate Director for Quality and Education License Practical Nurse Suspension as of 1/19/24 documented, may continue to work in a capacity as follows: -Non-direct patient care duties, General Orientation, Quality Assurance and Performance Improvement Safety Committee, Workers Compensation Coordinator, Continuous ongoing education with staff, Nurse Orientation, Inservice referral, Staff Mentoring, monitoring of staff education files, clerical keeping of staff health records. During an interview on 3/6/24 at 9:28 AM, the Administrator stated the Associate Director for Quality and Education was the Infection Preventionist for the facility but at this time their Licensed Practical Nurse license was suspended, therefore they were not able to perform any nursing duties. During an interview on 3/13/24 at 9:15 AM, the Associate Director for Quality and Education stated they knew their Licensed Practical Nurse license was suspended in January 2024 and was directed by the Director of Nursing and the Administrator not to provide any hands-on care to the residents until their license was reinstated. The Associate Director for Quality and Education stated they should have directed a Certified Nurse Assistant or another Nurse to assist with providing incontinent care on 3/12/24 at 2:07 PM to Resident #120 and stated they provided care because the resident needed care and it was a reaction to assist. During an interview on 3/13/24 at 12:18 PM, the Director of Nursing stated when the Associate Director for Quality and Education informed them their license was suspended in January 2024 they met with the Administrator, duties were developed to continue their employment and had reviewed what they were allowed and not allowed to do. They were not to provide any hands-on care to any resident because they were not licensed or certified. The Director of Nursing stated when they were informed yesterday that the Associate Director for Quality and Education provided hands on care, they suspended them for the remainder of the day and would have expected them to direct a Certified Nursing Assistant or a Nurse to provide the care. During an interview on 3/13/24 at 1:09 PM, the Administrator stated when they were informed the Associate Director for Quality and Education's license was suspended January 2024 they met with the [NAME] President of the facility's corporation to discuss what duties they were going to allow them to do and met with the Associate Director for Quality and Education with the Director of Nursing, and reviewed all the duties they were allowed to perform and informed them they were not to provide any hands on care to any resident because their license was suspended. The Administrator stated they would have expected the Associate Director for Quality and Education to direct a Certified Nursing Assistant or Nurse to provide care for the resident on 3/12/24. 10NYCRR 415.26(c)

Based on observation, interview, and record review completed during the Standard survey conducted from 5/11/22 through 5/17/22, the facility did not ensure that a resident with an indwelling catheter (Foley-tube inserted into the bladder to drain urine), received the appropriate care and services to prevent urinary tract infections ([CONDITION(S)]) to the extent possible. Specifically, two (Resident's # 25, 157) of three residents reviewed for urinary catheters lacked proper infection control measures for residents with a history of [CONDITION(S)]. The finding is: The facility policy and procedure (P&P) titled Catheter Drainage Bag Care revised 5/13 documented all nursing personnel care for urinary drainage bags. The catheter and tubing must remain patent, with the drainage bag kept below the level of the bladder. Care should be taken to make sure the tubing does not touch or drag on the floor. 1. Resident # 25 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-a resident assessment tool) dated 5/7/22 documented Resident #25 had moderate cognitive impairments and an indwelling catheter. During intermittent observations on 5/12/22 at 10:48AM, the Foley catheter tubing contained yellow urine was lying directly under Resident #25's wheelchair touching the floor. At 11:01 AM, Resident #25 self-propelled their wheelchair 75 feet down the Unit E long hall. Ten inches of the Foley catheter tubing was dragging on the floor. Nursing staff passed Resident #25 and didn't acknowledge the Foley catheter tubing dragging on the floor. During an observation on 5/17/22 at 10:47AM, the Rehab Aide transferred Resident #25 into the wheelchair, secured the Foley drainage appliance into the privacy bag under the wheelchair with the tubing lying directly on the floor. At 10:49AM, Registered Nurse (RN) Unit Coordinator #2 verified that Resident #25 self-propelled 20 feet with ten inches of the Foley tubing dragging across the floor. Review of the undated Comprehensive Care Plan (CCP), identified as current by RN Unit Coordinator #2, documented Resident #25 had a urinary catheter. Interventions included to monitor for signs and symptoms of a urinary tract infection. Review of the undated Visual/Bedside Kardex Report (a guide used by staff to perform care) documented to provide urinary catheter care every shift. Review of the Order Summary Report dated 4/9/22 documented to obtain a urine sample for urinalysis (U/A) and Culture and Sensitivity C&S. Review of the Lab Results Report documented the urine culture specimen was collected on 4/12/22. On 4/15/22 the urine culture result revealed a urine culture greater than 100,000 cfu (colony forming unit- number of bacteria cells)/ml(milliliters) for Escherichia coli (bacteria). Review of the Order Summary Report dated 4/15/22 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order had a start date of 4/15/22 and an end date of 4/22/22. Review of the Medical Visit Note dated 4/18/22 documented Resident #25 had a Foley catheter in place and was at high risk for clinically unavoidable urinary tract infections. Review on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/17/22 at 10:50 AM, RN Unit Coordinator #2 stated the Rehab aide should have secured the drainage bag with the tubing into the privacy bag under the wheelchair, up off the floor to reduce the risk of trauma or infection. During an interview on 5/17/22 at 10:51 AM, the Rehab Aide stated the tubing must have fallen out of the privacy bag and should never touch the ground to prevent contamination and increased the risk for infection. 2. Resident # 157 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #157 was cognitively intact and had an indwelling catheter. During an observation on 5/12/22 at 3:08PM, Licensed Practical Nurse (LPN) # 1 transported Resident #157 from the lobby to their room. The Foley catheter tubing dragged across the floor under the wheelchair for 225 feet. Gross hematuria (bloody urine) was visible in the Foley tubing with approximately 6 inches of the tubing touching the ground. Review of the undated CCP, identified as current by RN Unit Coordinator #1, documented Resident #157 had a urinary catheter. Interventions included to monitor for signs and symptoms of a urinary tract infection; urinary catheter care every shift; and urology consults annually. Review of the undated Visual/Bedside Kardex Report documented to provide urinary catheter care every shift. Review of the Medical Visit Note dated 4/28/22 documented urinary retention, suspected bladder obstruction, and Foley catheter in place. Bacteremia potentially due to traumatic Foley. Completed 7 days of [MEDICATION(S)] (antibiotic) and [MEDICATION(S)] 200mg every 12 hours x 5 days until 5/2/22. During an interview on 5/12/22 at 3:10 PM, LPN #1 stated they transported Resident #157 from the lobby to their room. LPN #1 stated they did not look under the wheelchair upon the residents return to the facility. LPN #1 assumed the Foley catheter tubing was secured and should have been up off the floor to reduce the risk of the spread of bacteria. LPN #1 stated the exposed catheter tubing could be contaminated. During an interview on 5/17/22 at 10:38 AM, RN Unit Coordinator #1 stated Foley catheter tubing and drainage bags were kept below the level of the bladder and secured in a privacy bag while in a wheelchair. To avoid the risk of infection or trauma the tubing should be off the floor and secured in the privacy bag under the wheelchair. During an interview on 5/17/22 at 11:15 AM, LPN #2 Nurse Educator stated Foley catheter care audits were completed monthly. Foley tubing should be contained and fixed to the wheelchair below the bladder, not dragging on the floor to reduce the risk of infection. During an interview on 5/17/22 at 1:14 PM, the Director of Nurses (DON)/Infection Preventionist (IP) stated Foley catheter drainage bags and tubing were expected to be secured in the privacy bag to prevent tugging, infection and not touching the ground. It's obviously an issue that needs correction. 415.12(d)(1)

Based on observations, interviews, and record review conducted during a Focused Infection Control Survey (#NY 626) on 8/21/20, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Unit D and E) of five resident care units reviewed. Specifically, housekeeping staff did not properly don (put on) and doff (remove) PPE (personal protective equipment). Additionally, an Outreach Laboratory Technician (phlebotomist) did not utilize appropriate PPE for residents that were on contact and droplet precautions. The findings are: The facility policy and procedure titled Coronavirus (COVID-19) with a revision date of 8/19/20 documented that all residents within the Yellow Zone (exposed to COVID-19), new admissions and persons under investigation (PUI)) are placed on contact and droplet precautions. Review of an undated facility education packet titled Infection Control Guide provided by Licensed Practical Nurse (LPN) #2 Clinical Instructor included written instructions with diagrams from the CDC (Centers for Disease Control) for donning and doffing PP (personal protective) gowns. A gown should be tied in the back, fully cover the torso from the neck to the knees, wrap around the back and fastened at the back of the neck and waist. To remove a gown, unfasten the ties, pull away from the neck and shoulders, touching inside of the gown only, turn gown inside out and fold or roll into a bundle and discard. 1. During observations on 8/21/20 from 8:09 AM to 8:13 AM on the B Unit (Yellow Zone): - Housekeeper #1 was observed wearing full PPE including gloves, gown, N95 with surgical mask covering, and face shield as she was collecting trash from a trashcan inside the doorway of resident room [ROOM NUMBER]. - Housekeeper #1 exited the room, doffed her gloves, pulled her arms out of the sleeves of gown, and rolled the gown up from the bottom and pulled the gown off over her head while still wearing her face shield. The gown was observed touching and sliding over the face shield. Housekeeper #1 then rolled the gown into a ball and placed the gown on the housekeeping cart on top of a box of gloves and paper towels. - At 8:10 AM Housekeeper #1 retrieved a clean gown from the PPE supply cart in the hall. The neck ties of the gown were tied, and she proceeded to pull the clean gown over her face shield with the gown rubbing against the outside of her face shield as she pulled it over her head, then slipped her arms into the sleeves. She donned clean gloves and entered and retrieved trash from room [ROOM NUMBER]. - When Housekeeper #1 exited the room, she doffed her gloves and attempted to untie the neck ties. She proceeded to remove arms from gown sleeves, rolled up the gown and pulled the gown off over her head while still wearing her face shield. The gown was observed touching and sliding over her face shield. She rolled the gown into a ball and placed it on the top of housekeeping cart, on top of the supplies next to the other soiled gown. - At 8:12 AM Housekeeper #1 retrieved another clean gown from the PPE supply cart in the hall and placed the clean gown on top of her cart next to the two soiled gowns. During an interview on 8/21/20 at 8:14 AM, Housekeeper #1 stated she had been trained on the proper donning/doffing sequence of PPE and pointed to a sign on the wall. She stated her face shield is considered dirty and she could contaminate her clothing by pulling a gown over her face shield. Housekeeper #1 stated she had placed the soiled gowns on top of the cart, but she would usually put them into a bag tied to the cart. During observations on 8/21/20 from 6:45 AM to 7:55 AM on the E Unit (Yellow Zone): - Housekeeper #2 was observed wearing an isolation gown backwards, tied at the neck in the front, exposing her uniform (maroon scrubs) from the neck down when entering to clean resident rooms #125, 126,127, 128 and 129. - Housekeeper #2 did not change her protective gown between each resident's room. When she did remove the protective gown after cleaning a resident's room, she rolled the gown in a bundle and put it in a clear plastic bag attached to the cleaning cart. She then donned the same gown to go into the next resident's room. - During continued observation Housekeeper #2 was cleaning resident room [ROOM NUMBER], there were two residents in the room, and neither were wearing a face mask. Housekeeper #2 was observed to carry cleaning products under her arm which came in contact with her exposed uniform. As she cleaned the room, she picked up wadded tissues off the floor, placed them in a trash can, carried the trash can out of the room, set it on the edge of the cleaning cart, emptied the garbage into the housekeeping cart and reached into her pocket to grab a roll of garbage bags to replace the bag in the can. - Additionally, while in the resident's room Housekeeper #2 attempted to adjust the privacy curtain between the two residents and the curtain came into contact with her exposed uniform (maroon scrubs). During an interview on 8/21/20 at 8:02 AM, Housekeeper #2 stated that she does not always change the precaution gown between cleaning resident rooms, because she prefers the gowns with the long sleeves attached so she does not have to wear the arm protectors as she does with the short sleeved gowns. She added that she does not always have the gowns that she prefers available. Housekeeper #2 stated that she wears the precaution gown backwards because it allows her easier access to reach into her pockets to grab the rolls of garbage bags. During an interview on 8/21/20 at 10:35 AM, Clinical instructor LPN #2 stated housekeepers are to wear precaution gowns with the opening in the back and tied at the back of the neck, so that their clothing is completely covered. They are to wear a gown in every room on a Yellow Zone because of the close contact with the resident's environment and to change the gown between cleaning each resident's room. Precaution gowns should be removed per CDC (Centers for Disease Control and Prevention) guidance: untying from the back of the neck, pulling away from the neck and shoulders, turning inside out, rolling into a bundle and discarding (if disposable) or placing in the appropriate receptacle if reusable; not placed on their cleaning cart for reuse. Gowns should not be shimmied over their heads to remove, as it could lead to contamination and spread of infection. During an observation 8/21/20 at approximately 11:25 AM Housekeeper #2 was observed in the administrative hallway suit wearing the same precaution gown. During an interview on 8/21/20 at 12:15 PM, the Director of Nursing (DON) stated their expectation of staff in the facility is to don/doff PPE as per the signs posted on the wall. The signs are posted everywhere and show the proper sequence. 2. Review of an undated sign titled PPE Directions that was posted throughout the hallway on the E Unit documented any direct contact with residents such as personal care, treatments, collecting of vital signs and assessments the following PPE was required: goggles or face shield, N95 with surgical mask, gown, and gloves. During observations on 8/21/20 between 6:45 AM and 7:25 AM on the E Unit (Yellow Zone): - Outreach Laboratory Technician (phlebotomist) #1 entered and exited resident room #'s 128, 127, 126, 125, and 123 while pushing a wheeled laboratory supply cart used for blood draws. - Lab Technician #1 was wearing a N95 face mask covered with a surgical mask, they did not don or doff a PPE gown or eye protection when entering or exiting any of these rooms. Residents in these rooms were not wearing face masks. - At 7:09 AM the door was closed to resident room [ROOM NUMBER], and there was a sign posted on the door with instructions to see the nurse before entering the room. Lab Technician #1 then walked down the hall to the nurses' station and asked what kind of precautions were needed for room [ROOM NUMBER]. Registered Nurse (RN) #3 stated to the Lab Technician that every resident on the unit was on precautions. Lab Technician #1 walked back down the hall to resident room [ROOM NUMBER], wheeled the laboratory supply cart into room [ROOM NUMBER] without donning a precaution gown or eye protection. - At 7:17 AM Lab Technician #1 exited room [ROOM NUMBER] and entered resident room [ROOM NUMBER] without donning an isolation gown or eye protection. Residents in these rooms were not wearing face masks. During an interview on 8/21/10 at 7:30 AM, Outreach Laboratory Technician #1 stated that she does not work for the facility directly and had not received any education regarding the facility's specific precaution protocols for COVID-19. The Lab Technician stated that she obtained blood samples on 10 different residents (room #'s 128, 127,126,125, and 123) on the E Unit and that drawing blood was considered direct hands on care. The technician stated they did not don or doff an isolation gown or eye protection prior to entering or while in any of the resident's rooms and added that she was not aware that she was supposed to. Additionally, the Lab Technician stated that none of the residents were wearing face masks when she obtained their blood. During an interview on 8/21/20 at 7:35 AM, Registered Nurse RN #2 stated that 10 residents had their blood drawn this morning and that drawing blood was considered direct care and the lab technician should have donned and doffed a different isolation gown for each resident and wore eye protection. Review of the Specimen log sheet dated 8/21/20 revealed Lab Technician #1 initialed that eight residents from E Unit had their blood drawn, as some residents were documented that they refused. During an interview on 8/21/20 at 9:15 AM, the DON stated that drawing blood would be a direct care activity. The Lab Technician should have worn the appropriate PPE for a Yellow Zone (N95 with a surgical mask covering, gowns, eye protection and gloves) for each resident that they had contact with and gowns and gloves should be changed between each resident. The DON stated there was no specific education provided to lab technicians related to the facility's precaution protocols but would have expected the nurses on the unit to explain them, and for the Lab Technician to follow the signs and directions posted throughout the unit for PPE use. During a telephone interview on 8/21/20 at 10:15 AM, the Outreach Laboratory Manager #1 and Lab Technician #1 stated the technician drew blood samples for residents throughout the facility this morning (approximately twelve residents total). The Outreach Manager stated that all Outreach Technicians are required to wear a face mask, goggles or face shield, a gown, gloves and to wash and sanitize their hands between every resident. 415.19 (a)

Based on interview and record review conducted during the Standard survey completed on 7/24/19, the facility did not ensure that irregularities reported by the pharmacist were acted upon; that the attending physician documented in the resident's medical record that the identified irregularity was reviewed and what, if any, action was taken to address it. If there was no change in the medication, the attending physician should document his or her rationale in the resident's medical record. Specifically, one (Resident #19) of five residents reviewed for drug regimen reviews had an issue that involved the lack of physician documented rationale for disagreeing with the Consultant Pharmacist's recommendations dated 12/31/18 and 6/25/19. The finding is: The policy and procedure (P&P) titled Unnecessary (sic) Medications Medication Regimen Review dated 10/18 documented the Consultant Pharmacist conducts a medical record review and assesses the drug therapy of each resident monthly. Any irregularities noted by the pharmacist during the review are documented on a separate written report. The pharmacy consultant reports irregularities to the attending physician. The Consultant Pharmacist makes comments and recommendations concerning resident medication therapy, identifies any irregularities or additional identified concerns using the Medication Regimen Review Form. When there are pharmacy recommendations that are routine, the Pharmacist will move the Medication Regimen Review form to the physician section of the chart. On the next scheduled visit, the attending physician reviews and documents the irregularity and what/if any action has been taken to address it. Should there be no change, the physician documents his/her rationale. 1. Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated 4/27/19 documented the resident was moderately cognitively impaired, usually understands and was understood. In addition, the MDS documented that the resident received seven insulin injections in the past seven days. Review of a Medication Regimen Review dated 12/31/18 revealed the following recommendation: - Blood sugars continue to be elevated in 300s-400s with increasing insulin doses being covered with sliding scale. Has provider been notified? (MONTH) benefit from addition of GLP1 agonist (diabetic medication) such as Trulicity (diabetic medication) 0.75 mg (milligrams) QW (every week). Review of the Physician Response Section for the 12/31/18 Medication Regimen Review, signed and dated 1/29/19 by the Attending Physician, revealed the documentation regarding whether the physician agreed or disagreed with the recommendation was illegible. During an interview on 7/23/19 at 2:00 PM, the Attending Physician stated, I checked 'Disagree' sloppily on the 12/31/18 Medication Regimen Review. Additional review of the 12/31/18 Medication Regimen Review revealed the Physician did not document a rationale for disagreeing with the Consultant Pharmacist's recommendation on the form or in the resident's medical record. Review of a Medication Regimen Review dated 6/25/19 revealed the following recommendation: - Consider increasing Trulicity to 1.5 mg weekly and d/c'ing (discontinuing) HS (hour of sleep) sliding scale coverage to minimize AM [DIAGNOSES REDACTED] (low blood sugar). Review of the Physician response Section for the 6/25/19 Medication Regimen Review, signed and dated 7/16/19 by the Attending Physician, revealed the Physician agreed with the recommendation. During an interview on 7/23/19 at 2:00 PM, the Attending Physician stated, I agreed to consider the recommendation and he did not act upon the Consultant Pharmacist's recommendation. Further review of the 6/25/19 Medication Regimen Review revealed the Physician did not document a rationale for not acting upon the consultant pharmacist recommendation in the resident's medical record. During an interview on 7/24/19 at 10:04 AM, the Consultant Pharmacist stated, I usually use the word consider in my reviews as they are a recommendation. Agree in the physician response section would mean either the physician will implement the recommendation, or there were no recommendations. I would expect an order to be written by the next day. 415.18(c)(2)

Based on observation, interview, and record review conducted during the Standard survey completed on 7/24/19, the facility did not provide food and drink for resident consumption that was palatable, attractive, and at a safe and appetizing temperature. Specifically, three (Units A, B, C) of five resident units observed for meal service had issues with hot and cold food items that were not served at appetizing temperatures. Residents #A, B, C, and D were involved. The finding is: A policy and procedure titled Food Preparation, Service and Distribution dated 8/2017 documented the following: - Food Serving and Distribution - Dining locations include any area where one or more residents eat their meals. The facility staff will serve hot foods hot and cold foods cold in accordance with resident preference. Serving temperatures are not to be confused with proper cooking and holding temperatures. 1. Review of a Resident Council Concern Form dated 4/29/19 revealed residents complained of food being cold upon arrival for breakfast and/or supper on Units A, B, and E. The Form documented that the issue continues, meetings continue to solve issue, possible resolutions/ still researching solutions. Resident interviews on 7/19/19 revealed the following: - 8:18 AM - Resident A stated his breakfast has a hint of heat. The tray carts sit on the unit for 20 minutes before he gets his tray. - 9:19 AM - Resident C stated breakfast is always cold, and the trays sit on the units for five or more minutes before they are passed. - 10:07 AM - Resident B stated the food was served cold; microwaves were removed from the units. Staff take cold food to the kitchen to reheat. By the time it comes back to the unit, it's cold again. - 11:30 AM - Resident D stated he eats in his room and the trays sit for half an hour before his tray is brought to the room. His hot food was served cold. a.) Observation of the Unit A dining area on 7/22/19 revealed the lunch meal started to be served at 12:23 PM to residents in the dining area and in their rooms. After all trays were served at 12:46 PM, a test tray was conducted. The Diet Technician, using a facility dial thermometer, obtained temperatures of the food on the plate as follows: - Sliced turkey was measured at 116 degrees and tasted barely warm. - Green Beans were 114 degrees and cool to taste. - Chicken Noodle Soup was 115 degrees and was cool to taste. - Milk was 60 degrees and was warm to taste. b.) Observation of the Unit B dining area on 7/22/19 revealed the food cart arrived and lunch trays started to be served at 12:30 PM to residents in the dining area and in their rooms. After all trays were served at 12:47 PM, a test tray was conducted. The Diet Technician obtained temperatures of the food on the plate using a dial thermometer as follows: - Green beans were 115 degrees and tasted cool and bland. - Chicken Noodle Soup was 130 degrees and tasted lukewarm. - Milk (carton) was measured at 60 degrees and tasted warm. c.) Observation of the Unit C dining area on 7/22/19 revealed the first food cart for lunch was delivered at 12:05 PM. The second food cart was delivered at 12:10 PM. Further observation on 7/22/19 at 12:23 PM revealed a Dietary Aide obtained the food temperatures from a Unit C test tray (last tray to be served) using a facility dial thermometer: - Milk (carton) measured 52 degrees Fahrenheit (F) and tasted warm - Green Beans measured 131 degrees F, tasted slightly warm and were unpalatable During an interview on 7/22/19 at 12:31 PM, the Dietary Aide stated nothing should be under 130 degrees or above 180 degrees. The milk should be 41 degrees or under. During an interview on 7/23/19 at 12:18 PM, the Food Service Director stated the hot food should be served at 141 degrees or greater, and cold beverages should be served at 41 degrees or less. If residents complain of cold food, nursing staff are to either call dietary or take the food item to the kitchen to be reheated. Dietary staff check the food temperature after it is reheated and return the food to the unit. 415.14(d)(2)

Based on interview and record review conducted during the Standard survey completed on 4/26/18, the facility did not ensure that a baseline care plan was thoroughly developed and written summary of the baseline care plan, that included initial goals, list of current medications, dietary instructions, and services/ treatments to be administered by facility and personnel acting on behalf of the facility, was provided to the resident or the resident's representative. Four (Residents #192, 392, 399, and 454) of 10 newly admitted residents reviewed for base line care plans had issues. Specifically, the base line care plan was not thoroughly developed to include smoking and there was no documented evidence that a baseline care plan summary was provided to the resident and the resident's representative by completion of the comprehensive Care Plan. The findings are but not limited to: Review of the policy and procedure entitled Interdisciplinary Comprehensive Care Plan dated 5/2017 revealed the electronic Care Plan will be initiated upon admission (within 4 hours). At a minimum the initial Care Plan consists of the following Focuses: Advanced Directives, Transfer, Bed Mobility, Falls, Bladder, Bowel, Skin Integrity and Nutrition/ Feeding. All remaining Focuses are entered within 24 hours of admission and include etiologies, initial goals and interventions as applicable. The facility will provide the resident and/or representative with a summary of the baseline care in a form and manner the resident can easily understand. Copies are provided within 48 hours of admission to the resident and/ or resident representative in person. In the event that the resident is incapacitated and the resident representative is not in the facility, a copy will be mailed. 1. Resident #399 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of an undated Comprehensive Care Plan (CCP) revealed a Focus area titled Leisure Time Activities initiated on 4/23/18 documenting a goal that the resident will smoke in a safe environment through next review. Interventions included the resident was provided with the smoking policy and the smoker was responsible. The Nursing Admission Evaluation form dated 4/17/18 at 12:00 PM documented the resident had a personal preference to smoke. The Social Work (SW) Smoking Data Collection Tool dated 4/17/18 at 1:19 PM documented Resident #399 smokes often, can smoke safely and does not require supervision or assistance to smoke. During an interview on 4/23/18 at 9:54 AM, the Social Worker (SW #2) stated not all residents have to be supervised when smoking. If the resident was deemed a safe smoker after the assessment was completed, the resident can go out as they want to between the dumpster and the garage. It would be care planned for after the assessment was completed. During an interview on 4/23/18 at 11:05 AM, the resident stated that he just received a copy of his care plan today. It was in an envelope on his dresser when he came back from physical therapy. During an interview on 4/25/18 at 9:09 AM, Registered Nurse Unit Coordinator (RN #1) stated the base line care plan is a team effort. When asked if a resident smokes, should that information be on the base line care plan, the RN stated, Sometimes we don't know the resident smokes for a few days, we wait for the social worker to do the assessment then we put it on the Care Plan. During an interview on 4/25/18 at 9:13 AM, the Director of Rehab stated Occupational Therapy (OT) was responsible for distributing the base line care plan to the residents, and that smoking should be on the baseline care plan. 2. Resident #392 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 3/16/18 revealed the resident has severe cognitive impairment. Review of a Comprehensive Care Plan dated 3/9/18 revealed there was no evidence the care plan was reviewed and provided to the resident or resident's representative. Nursing Progress Notes dated 3/9/18 through 3/29/18 revealed there was no documented evidence the care plan was reviewed or provided to the resident or the resident's representative. Social Work Notes dated 3/9/18 through 3/29/18 revealed there was no documented evidence the care plan was reviewed or provided to the resident or resident's representative. During interview on 4/24/18 at 12:38 PM, the Social Worker stated she was responsible for handing out baseline care plans during the week and OT (Occupational Therapy) was responsible for handing out the baseline care plan on the weekend, if the Social Worker is not in the building. The Social Worker stated she was pretty sure the resident's daughter received a copy of the care plan, but typically they do not keep a copy of what's given but it should be documented in the medical record after it's given and reviewed with the representative. Review of the Occupational Therapy Evaluation dated 3/9/18 revealed there was no documented evidence the care plan was reviewed or provided to the resident or resident's representative. During interview on 4/24/18 at 1:38 PM the Occupational Therapist stated she reviewed the care plan with the care taker but did not document it in her notes. During interview on 4/26/18 at 10:05 AM, the Director of Nursing (DON) stated therapy gives the baseline care plan to the subacute patients within 48 hours of admission on weekdays and weekends. he Social Worker is responsible to do the long-term baseline care plans within 48 hours. If a copy of the Comprehensive Care Plan needs to be given to long term resident or family member on the weekends, the Social Worker is responsible to alert the Nursing Supervisor assigned for that day. 3. Resident #454 was admitted [DATE] and has [DIAGNOSES REDACTED]. Review of a Progress Note dated 1/30/18 revealed the resident had increased confusion and lethargy. Following an evaluation, the resident was sent to emergency room (ER) and admitted to hospital. Review of the Nursing Progress Notes dated 1/27/18 through 1/30/18 revealed there was no documented evidence a baseline care plan was provided to the resident or the responsible party within 48 hours. During an interview on 4/25/18 at 1:00 PM, the DON revealed they didn't start documenting that the baseline care plan was provided to the resident or residents responsible party within 48 hours of admission until (MONTH) (YEAR) following an email we received from corporate. Review of emails provided by the DON revealed the following: - from the DON to corporate dated 12/6/17, at our facility therapy gives subacute residents or the responsible party the baseline care plans within 48 hours of admission during the week days and the on weekend. Social work is responsible for long term care residents within 48 hours. - from corporate to the DON dated 1/29/18, please make sure whoever is handling this, puts a quick note in the resident's medical record when the baseline care plan is given. Additionally, the DON added I'm sure we gave the resident or responsible party a copy of the baseline care plan but it doesn't appear they document it in the record. During a telephone interview on 4/26/18 at 10:30 AM, the responsible party revealed they were not provided with a copy of the baseline care plan within 48 hours or at all. The responsible party stated if it was provided to the resident we would have known about it. 415.11 (c)(1)

Based on interview and record review conducted during an Abbreviated Survey (Complaint #NY 567) completed on 4/7/16, the facility did not inform the resident's Physician of a significant change in the resident's physical condition and a need to alter the resident's treatment. One (Resident #1) of three residents reviewed for notification of change had issues with the lack of Physician notification regarding the resident's low blood glucose level and the nurse's decision not to administer insulin as ordered by the Physician. The finding is: 1. Resident #1 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 1/26/16 revealed the resident has moderate cognitive impairment, understands and is understood. Review of physician's orders [REDACTED]. -12/20/15 1800 (6:00 PM) Physician Telephone/Verbal Order for Rainbow Insulin Coverage: Humalog (fast acting insulin) with meals and q hs (every bedtime). 100-150 - no units, 201-250 - 2 units, 251-300 - 4 units, 301-350 - 6 units, 351-400 - 8 units, greater than 400 - give 10 units, if above 400 call MD (medical doctor) call MD less than 70. -12/21/15 9:00 AM Physician Telephone/Verbal Order for [MEDICATION NAME] (slow acting insulin) increase 30 units AM. Humalog 5 units with meals. HbA1C (glycated hemoglobin-a test of the average plasma glucose concentration over a prolonged period of time). Review of the physician progress notes [REDACTED]. [MEDICATION NAME] 20 units, increase to 30 units. Add 5 units of Humalog with each meal. Continue sliding scale and monitor clinically twice weekly until further glycemic control has improved. Review of Weekly Subacute Rehabilitation follow-up note written by the Physician Assistant on 1/5/16 revealed Recent increase of his [MEDICATION NAME] 20 units to 30 units daily. Added 5 units of Humalog with each meal recently. BGT (blood glucose test) has continued to improve since above changes made, will continue to monitor. Review of the electronic Medication Administration Record [REDACTED]. Further review of the January 2016 eMAR revealed the Licensed Practical Nurse (LPN) did not administer Humalog 5 units sq (subcutaneous) with meals for diabetes on 1/6/16 as ordered. Review of the electronic Progress Notes Report revealed on 1/6/16 at 10:12 PM, the LPN documented the resident FS (fasting sugar) was 64 and HS (bedtime) was 249. No s/s(signs/symptoms) hyper/[DIAGNOSES REDACTED] (high or low blood sugar) noted. Pt (patient) alert and able to make needs known. No c/o (complaints) when asked. 240 OJ (orange juice), FS rechecked- 116, sched (schedule) insulin held. All tx (treatments) as ordered. There is no documentation in the medical record that the Physician was notified of the resident's blood sugar level on 1/6/16 at 4:30 PM was 64 or that the LPN did not administer the scheduled dose of Humalog 5 units sq with meals as ordered. During an interview with the Registered Nurse Director of Nursing (DON) on 4/7/16 at approximately 9:00 AM, the DON stated the LPN should have informed the Physician if not administering medications as ordered and stated that the Physician orders [REDACTED]. 415.3(e)(2)(ii)(b)

Based on interview and record review conducted during an Abbreviated survey (Complaint # NY 567) completed on 4/7/16, the facility did not ensure that residents were free of significant medication errors. One (Resident #1) of three residents reviewed for medication administration received two doses of Humalog insulin (fast acting insulin) after the Physician had discontinued the medication. The finding is: 1. Resident #1 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 1/26/16 revealed the resident has moderate cognitive impairment, understands and is understood. Review of physician's orders [REDACTED]. Review of physician's orders [REDACTED]. Review of the electronic Medication Administration Record (eMAR) for January 2016 revealed the resident received Humalog 5 units sq (subcutaneous) with meals on 1/9/16 at 8:00 AM and again at 12:00 PM. During an interview on 4/6/16 at approximately 9:00 AM, the Registered Nurse (RN) Director of Nursing (DON) stated Medication Error Reports were being completed for the two doses of Humalog that were administered after the medication was discontinued by the Physician Assistant. The DON stated she thinks the order to discontinue the Humalog 5 units with meals was not sent to the pharmacy timely. At approximately 2:45 PM, the DON further stated that the Physician's Telephone Order form is faxed to the pharmacy and they will remove discontinued medications from the eMAR and then a second check is conducted by the nurse overnight that physician's orders [REDACTED]. 415.12(m)(2)

Based on observation, interview, and record review conducted during the standard survey completed on 11/16/15, the facility did not store, prepare, distribute and serve food under sanitary conditions. During one of one kitchen tray line service, two cooks were observed to serve tray line foods while touching other surfaces and products without washing their hands or changing their gloves. In addition, one of five unit nourishment refrigerators had non-food items being stored in the freezer. The findings are: 1. During an observation on 11/13/15 between 11:30 AM through 12:10 PM, Cook #1 was moving between the lunch tray line serving bowls of soup and pulling food out of the stoves to replenish the tray line while touching counters, carts and door surfaces, without washing or changing his gloves between tasks. Cook #1 was then observed accessing bowls touching the inside with his gloved fingers and serving up the soup in them. At approximately 11:55 AM Cook #1 left the tray line and opened the stove and placed his gloved hand in a pan approximately three inches () length x (by) two' wide x 6 deep of baby carrots, mixing them with his hand without changing his gloves or washing his hands. During an interview on 11/13/15 at 12:14 PM Cook #1 stated, I should change my gloves every time I leave an area and go to another area or when I touch other things or switching to other food products. I do change my gloves quite often. I mixed the carrots in the steamer with my hands because I was checking to see if they were still frozen. I did have gloves on my hands when I touched the carrots. I guess I should have used a spoon or something. During an observation on 11/13/15 at approximately 11:40 AM Cook #2 was serving up grilled cheese sandwiches with her gloved hands. When the pan of grilled cheese sandwiches was empty Cook #2 took the parchment paper from the bottom of the pan and walked over to the garbage can and lifted the lid, threw the parchment paper out and placed the lid back on the garbage can. Without washing her hands or changing her gloves she went back to the tray line and continued serving the grilled cheese sandwiches with the same gloves on her hands. During an interview on 11/13/15 at 12:21 PM Cook #2 stated, I should change my gloves when I go touch other surfaces or other things. I should change them in between jobs. I did not even realize I opened the garbage can and threw out the paper from the grilled cheese and did not change my gloves. If I did that I should have changed them. During an interview on 11/16/15 at 10:41 AM the Foods Service Director (FSD) stated, I expect the staff to change their gloves when they are coming in actual contact of food and are touching other surfaces or foods in between. When Cook #2 touched the garbage can she should have changed her gloves before going back and serving the food. Anytime the workers change jobs or handle different foods their gloves should be changed. When I witnessed the staff putting their fingers in the bowls after touching other things, I agree they should have changed their gloves first and should be touching the bowls on the outside of the bowl. Cook #1 should not have mixed the carrots with his hand. He should have used a utensil to mix it. 2) During an observation of the unit nourishment refrigerator/ freezer on 11/9/15 at approximately 9:30 AM revealed five reusable freezer ice packs located on top of the ice cream. During an interview on 11/9/15 at approximately 9:33 AM the Licensed Practical Nurse (LPN #2), Unit Manager stated, These ice packs are therapies and they should not be in here. I will take them back to therapy. They are the packs they place on the residents. Review of a facility policy entitled Food Preparation, Service and Distribution dated 7/2008 revealed the facility will ensure safe and sanitary food preparation, holding, transport and distribution to prevent foodborne illness. Food distribution- the facility staff will wash hands prior to distributing trays/ meals and wash after collection of soiled plates and food waste. Review of a facility policy entitled Gloves and Handwashing in the Dietary Department dated 1/1/2000 revealed proper food handling practices are essential in preventing contamination and foodborne illness. Gloves and utensils will be utilized at appropriate times when handling and preparing food following the guidelines of the N.Y.S. Sanitation Code. Gloved hands/ utensils are considered a food contact surface that can get contaminate or soiled and are changed as needed. 415.14(h) 14-1.80(b) 14-1.60(d)

Based on record review and interview conducted during a complaint investigation (NY# 573) completed during the Standard Survey ending [DATE], the facility did not honor advance directives as directed by the resident's Health Care Agent. One (Resident #322) of three residents reviewed for advanced directives had an issue involving the lack of honoring the resident's Health Care Agent's request to send the resident to the hospital if needed and the hospitalization directive was not included on the MOLST (Medical Orders For Life Sustaining Treatment) form. The finding is: 1. Resident #322 has [DIAGNOSES REDACTED]. Review of the Interim Resident Care Plan dated [DATE] revealed the resident is severely impaired cognitively, rarely/ never understands, and is rarely/ never understood. Review of a Medical Alert Sticker Sheet revealed the resident's Advanced Directives included DNR (Do Not Resuscitate - to withhold CPR- cardiopulmonary resuscitation and emergency life saving measures in the event of the absence of a heartbeat and/ or respiration), DNI (Do Not Intubate a directive not to insert a tube into the airways to provide artificial respiration), and a HCP (Health Care Proxy). Review of a Health Care Proxy form dated [DATE] revealed the resident designated his son as his Health Care Agent Review of a Medical Orders for Life-Sustaining Treatment (MOLST) form revealed orders for DNR and DNI dated [DATE] and the Health Care Agent signed as giving consent. Additional review of the MOLST form revealed there was no documentation related to future hospitalization s/transfer. Review of a Health Care Proxy Activation form, signed by two Physicians dated [DATE] and [DATE], revealed that the Physicians determined the resident lacked capacity to make health care decisions due to a [DIAGNOSES REDACTED]. Review of a Multidisciplinary Social Work Note dated [DATE] revealed that the Social Worker (SW) spoke to the resident's son (Health Care Agent) and discussed rehab (rehabilitation therapy- with the hope of improved strength and self-care abilities) versus Hospice care for the resident. The SW documented that the Health Care Agent and the resident's family wanted rehab and not Hospice at this time. The SW offered to add possible comfort measures to the MOLST form and the Health Care Agent declined any further comfort measures at that time. Interview with the SW on [DATE] at approximately 9:25 AM revealed the SW had a very long talk with the resident's son (HCP Agent) regarding the activation of the HCP and what the Health Care Agent and family wanted for the resident while at the facility. The SW stated that the Agent and the resident's family did not want Hospice or Comfort Care (conservative, supportive measures to be provided at the end of life) and the Agent wanted the resident sent to the hospital if a change in status occurred. During the interview, the SW reviewed the MOLST form and stated that the MOLST was not updated to reflect that the resident was to be sent to the hospital if necessary. Review of a facility policy and procedure (P&P) entitled MOLST: Medical Orders for Life-Sustaining Treatment dated ,[DATE] revealed the MOLST document is a New York State-wide form in which a resident delineates the specific type of care the resident wishes to receive if unable to give verbal consent. Utilization of the MOLST delineates levels of care for the resident. A Health Care Agent (proxy) is appointed to make decisions when a resident can no longer decide for him/ herself. A Health Care Agent can decide about all treatment for [REDACTED]. Review of a Multidisciplinary Note dated, written by a Licensed Practical Nurse (LPN #5), dated [DATE] at 1:33 AM revealed at 11:10 PM, the resident had a temperature of 99.2 (normal 98.6), a heart rate of 120 (average 80) and respiratory rate of 24 (normal ,[DATE]). Blood pressure was noted to be ,[DATE] (low) and attempts to measure the oxygen level in the resident's blood were unsuccessful and the resident's extremities noted to be cool to touch. The Physician's Answering Service was contacted at 11:30 PM regarding the resident's status. The LPN documented that respirations were labored at times and the resident's eyes were noted to be fixed at 11:40 PM. At 11:45 PM, the resident had emesis (vomited) and mottling (a discoloration of the skin indicating a decreased blood pressure and that death may be near) of the feet. Review of a Multidisciplinary Note dated [DATE] at 12:15 AM revealed a Registered Nurse (RN #2) was called to the resident's room to assess the resident. Upon arrival, the resident was noted to be unresponsive with fixed pupils (pupils that do not respond to light or other stimuli). The RN documented that respirations were slightly labored, skin was cool to touch, and the bottom of the resident's feet were discolored. Review of a Multidisciplinary Note dated [DATE] at 12:56 AM revealed RN #3 documented that the family was notified at 12:00 AM regarding the resident's change in condition. The RN documented that the resident had no blood pressure, no respirations, and no heart beat at 12:52 AM. During an interview on [DATE] at approximately 9:03 AM, RN #3 stated that she would document in the Clinical Record if she had reviewed the Advanced Directives and MOLST with the family when they were contacted regarding the change in resident status. The RN was unable to recall why the family was not notified until 12:00 AM. RN #2 stated she was not aware that the Health Care Agent had expressed wishes for the resident to be transferred to the hospital if needed for a change in care. Interview with RN #2 on [DATE] at approximately 9:06 AM revealed she recalled the resident and that he passed away in the facility. The RN stated that if she had reviewed the MOLST with the resident's son, she would have documented it in the Clinical Notes. The RN stated that when she called the resident's son, she did not tell the son that the resident was close to death because she did not want the son driving upset. The RN was not aware that the Health Care Agent wanted the resident transferred to the hospital if needed for a change in care. Review of a facilities P&P Advanced Directives dated ,[DATE] revealed the facility SW or designee checks the Care Plan for accuracy and adds any additional advanced directives. Changes of an advanced directive by the HCP must be placed in writing. The Care Plan team will be informed of such changes and appropriate changes made to the Care Plan . Copies of changes to an advanced directive must be filed in the resident's Medical Record. 415.3(e)(2)(iii)

Based on interview and record review conducted during a complaint investigation (complaint #NY 510) completed during the Standard survey on 8/13/13, the facility did not provide the necessary care and services for each resident to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. One (Resident #307) of three residents reviewed for quality of care who was on an essential anticoagulant (medication used to prevent blood from clotting) medication experienced a fall resulting in a large facial hematoma (collection of blood under the skin) and the facility did not provide a timely medical provider exam or adequate evaluation to rule out further internal bleeding or injury. The resident was diagnosed with [REDACTED]. This resulted in actual harm that is not immediate jeopardy. The finding is: 1. Resident #307 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - an assessment tool) dated 2/7/13 revealed the resident has intact cognition, has no history of falls and takes an anticoagulant medication. Review of physician's orders [REDACTED]. Additional review of the physician's orders [REDACTED]. Review of the Comprehensive Care Plan for Cardiac (heart related) Conditions dated 4/11/13 revealed that the resident's cardiac medications included [MEDICATION NAME] and approaches included to monitor INR per physician's orders [REDACTED]. Review of a [MEDICATION NAME] Log for Resident #307 included a handwritten entry that the [MEDICATION NAME] "range per MD" was "2-3". Further review of the [MEDICATION NAME] Log revealed that on 4/15/13 the resident's INR was 1.80 and the [MEDICATION NAME] dose was increased from 3 milligrams (mg) every night to 3.5 mg every night (on 4/15/13). The [MEDICATION NAME] Log documented that the PT/INR was to be done every Monday. Review of a [MEDICATION NAME] Flow Sheet dated 4/2013 revealed documentation that the resident received [MEDICATION NAME] 3.5 mg every night from 4/15/13 to 4/21/13. Review of a Continuous Quality Improvement report (Incident Report) dated 4/20/13 revealed the resident was found lying prone (lying face down) on the floor of the bathroom at approximately 8:35 PM. The Incident Report documented that a registered nurse (RN #3) assessed the resident and observed an 8 centimeter (cm) by 5 cm hematoma (collection of blood under the skin) above the left eye and an ecchymotic (bruise - purplish patch caused by blood under the skin) area on the left knee that was approximately 2 cm in diameter. Review of a Nursing Progress Note, written by RN #3 on 4/20/13 at approximately 9:30 PM, revealed the resident's range of motion (ROM) and neurological checks were within normal limits (WNL). The RN documented that the resident was assisted back to the chair, ice was applied to the forehead and pain medication was given as ordered. The RN documented that the Nurse Practitioner (NP) and the resident's designated representative were updated. Review of a Nursing Progress Note, written by a licensed practical nurse (LPN #2) on 4/21/13 at approximately 2:33 AM, revealed that the resident was alert and verbal with normal confusion and neurological checks were WNL. The LPN documented that the resident's left eye and forehead were ecchymotic, the resident was unable to open her left eye and that the resident complained of left arm pain. Review of a Nursing Progress Note, written by LPN #2 on 4/21/13 at approximately 5:27 AM, revealed the resident had increased confusion and was "calling out". The LPN documented that the resident opened her left eye with difficulty, vision was intact and the swelling increased and that "ice packs (were) applied but removed by (the) resident". Review of a Nursing Progress Note, written by RN #4 on 4/21/13 at approximately 8:41 AM revealed that the physician was notified of the left eye ecchymosis and swelling and a Facial X-Ray was ordered. Review of a Nursing Progress Note, written by RN #4 on 4/21/13 at approximately 2:07 PM revealed that the Facial X-Ray was done and revealed no osseous (bone tissue) abnormalities of the facial bones or skull and that a CT scan would be considered Gold Standard (a diagnostic test that is widely recognized as the best available) in evaluation for a facial bone fracture. Further review of the note revealed that the resident complained of left arm and shoulder pain. The RN documented that the PA was notified of the resident's Facial X-Ray results and pain and that a new order was obtained for X-Rays of the left shoulder, left humerus (long bone in the arm that runs from the shoulder to the elbow), left rib and left wrist. During a telephone interview on 7/18/13 at approximately 9:30 AM, RN #3 stated that she assessed the resident after the fall on 4/20/13 and left a voice mail with the Physician's Assistant (PA). The RN stated that the PA called back a short time later and RN #3 informed the PA of the resident's fall and the resident's status. RN #3 stated that she did not realize the resident was on [MEDICATION NAME] at the time and did not inform the PA of this information. RN #3 stated that she received no new orders from the PA. RN #3 stated that the resident remained alert and oriented with normal behavior and that neurological checks were WNL. During a telephone interview on 7/18/13 at approximately 9:45 AM, RN #4 stated that she informed the physician and a "NP" of the resident's increased swelling and obtained an order for [REDACTED]. During the interview RN #4 stated that she did not recall if she knew at the time that the resident was on [MEDICATION NAME] or if she informed the Physician or NP. RN #4 further stated that when she received the results of the Facial X-Ray she read the entire report over the phone to the NP including that a CT is considered Gold Standard for evaluation of a facial bone fracture. RN #4 stated that she did not recall which NP she spoke to. RN #4 stated that she informed the NP of the resident's left arm and shoulder pain and received new orders for X-Rays of the left shoulder, ribs and arm. Review of a Nursing Progress Note, written by RN #4 on 4/21/13 at approximately 8:39 PM, revealed that the X-Ray results of the left shoulder, ribs and humerus showed there was no fracture. The RN documented that the NP was notified of the results and a message was left for the Physician. During a telephone interview on 7/18/13 at approximately 10:00 AM the Physician stated that when the nurse called her on 4/21/13 regarding the resident's increased facial swelling, she was not informed that the resident was on [MEDICATION NAME]. The Physician stated that she did not know the resident was on [MEDICATION NAME] and would expect to be informed of this by the nurse. The Physician stated that it would be standard practice to send a resident receiving [MEDICATION NAME] for a CT scan after a head injury. During a telephone interview on 7/18/13 at approximately 10:20 AM, the PA stated that she received the call from the nurse about the resident's fall and head injury. The PA stated that she did not know the resident was on [MEDICATION NAME] and was not informed by the nurse. The PA stated that even if she had known the resident was on [MEDICATION NAME] she would not necessarily have ordered a CT scan. The PA stated that she would expect the resident's vital signs (blood pressure, temperature, pulse, respiratory rate) to be monitored and that the resident be observed for mental status changes. During a telephone interview on 7/18/13 at approximately 10:00 AM, the NP stated that she would expect nursing staff to relay information regarding a resident's medications when they are calling about a change of condition. During an interview on 7/18/13 at approximately 11:30 AM the Director of Nursing (DON) stated that when nursing staff call the physician or NP regarding an incident or change of condition, she expects the nurse to have either the chart or the MAR (medication administration record) at hand so that the nurse could relay any pertinent medical information to the medical staff. Review of a Continuous Quality Improvement report dated 4/21/13 at approximately 7:45 PM revealed that Resident #307 fell to the floor in the bathroom while a CNA (Certified Nurse Aide #2) was with her and that there was no injury. Review of CNA #2's written statement revealed that Resident #307 slid off the toilet and slowly fell to the floor. The CNA documented that the resident did not hit her head or hit any objects in the room. The Report documented that the resident was assessed by RN #4 and neurological checks and ROM were WNL. RN #4 documented that the resident had no apparent injuries and no complaints of new pain. The document indicated that the NP and resident's designated representative were notified. Review of the entire medical record revealed no documented evidence of a medical provider exam of the resident after the fall on 4/20/13, until 4/22/13. Review of an Acute Visit note, written by the NP on 4/22/13 revealed that the resident was seen following two falls off the toilet. The NP documented that "all X-Rays per preliminary results are negative". The NP documented that the resident complained of left shoulder and rib pain and had a "large" hematoma involving the left eye orbit, ecchymosis above the left eye and [MEDICAL CONDITION] (swelling) of the eye lid. The NP documented that there was no alteration in mentation or level of alertness and that the resident's family requested a visit to the hospital for evaluation of the resident's complaints. Further review of the note revealed the neurological exam included that the resident's speech was clear with no [MEDICAL CONDITION] and the resident has [MEDICAL CONDITION]. The note did not include a full neurological exam including an evaluation of the resident's pupils and hand grips. Review of a Nursing Progress Note, written by RN #5 on 4/22/13 revealed the resident left the facility via ambulance at approximately 1:45 PM. Review of a Nursing Progress Note, written by RN #5 on 4/22/13 at approximately 2:22 PM revealed that the resident's INR result for 4/22/13 was 4.24 and a new order was received from the NP to discontinue the [MEDICATION NAME]. Review of a hospital Discharge Summary Report dated 4/24/13 revealed that Resident #307 fell two days prior to admission and hit her head. The Discharge Summary Report documented that a CT of the head revealed evidence of a right sided temporal hemorrhage. The resident was placed on anti-epileptics (medicine to prevent [MEDICAL CONDITION]) and was admitted to the neurological intensive care unit. The resident was given vitamin K and FFP (fresh frozen plasma - liquid portion of blood that contains significant amounts of clotting proteins to reverse the effect of [MEDICATION NAME]). 415.12