Every finding on record at Oneida Health Rehabilitation and Extended Care

Based on observations, record review, and interviews during the recertification survey, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for four (4) out of twelve (12) kitchen staff (Dietary Aides #14, #15, #16, and #17). Specifically, Dietary Aides #14, 15, 16, and 17 had improper hair restraints while preparing food and meal trays in the main kitchen. Findings include:The facility policy Sanitation and Infection Control, revised 05/2023, documented employees would wear hair restraints. Men with beards and/or mustaches would wear beard restraints. The following observations of improper hair restraints were made in the main kitchen on 01/20/2026 at 11:02 AM: -Dietary Aide #14 was walking through food preparation areas with an unrestrained long ponytail. -Dietary Aide #15 was preparing food in the front of the kitchen wearing only a cap on their head, with long, shoulder length hair untied or restrained.-Dietary Aide #16 was preparing lunch trays for residents wearing only a cap on their head, with long shoulder length hair untied or restrained.-Dietary Aide #17 was preparing lunch trays for residents wearing only a cap on their head, with long shoulder length hair untied or restrained. During an interview on 01/21/2026 at 2:46 PM, Resident #13 stated they found a hair in their pasta at lunch that day. They stated it ruined their appetite. During an interview on 01/22/2026 at 8:23 AM, Food Service Director #19 stated staff needed to either wear a hair net or a hat. If the hair was under 18 inches long, they could wear just a cap. When long hair was only covered with a cap, it did not prevent hair from falling into the food. During an interview on 01/27/2026 at 7:50 AM, Dietary Aide #18 stated the policy for restraining hair was to contain hair in a hair net or wear a baseball cap. They stated when food was present, they could wear either one, regardless of hair length. During an interview on 01/27/2026 at 12:54 PM, Dietary Aide #15 stated the hair restraint policy was to wear a hair net on longer hair and a cap only with short hair. They stated preparing food with their long hair not completely restrained was an oversight, as they were trying to hurry to work. During an interview on 01/27/2026 at 1:00 PM, Food Service Director #19 stated hair needed to be fully restrained in the main kitchen. 10 New York Codes, Rules and Regulations 415.14(h)

Based on observations, record review, and interviews during the recertification survey, the facility failed to ensure residents maintained acceptable parameters of nutritional status for one (1) of three (3) residents (Resident #101) reviewed. Specifically, Resident #101 had significant weight loss and did not have a timely nutritional assessment. Findings include: The undated facility policy Nutritional Assessment and Reassessment, documented residents would receive timely and accurate nutrition assessments, including residents with significant nutritional changes.The facility policy Weights, revised 03/2022, documented nursing staff measured resident weights on admission, and weekly for four weeks. If no weight concerns, weights were then measured monthly. Dietary and medical providers would be notified of any weight discrepancies. Weight loss greater than five percent in one month or greater than ten percent in six months were severe.Resident #101 had diagnoses including dementia, chronic respiratory failure, and vascular disease. The 08/19/2025 Minimum Data Set (assessment tool) documented the resident had severe cognitive impairment, had symptoms of social isolation and depression, required supervision for eating, weighed 163 pounds, and had no weight change.The resident's weight record documented the following weights: -06/02/2025, 173.2 pounds-07/01/2025, 168 pounds-08/19/2025, 162.8 pounds-09/10/2025, 159.9 pounds (7.7% loss in 3 months)-10/08/2025, 161.2 pounds-11/07/2025, 157.6 pounds-12/02/2025, 154.2 pounds (11% loss in six months)-01/24/2026, 147.6 pounds (4.3% loss in one month and 12.2% loss in six months). The 08/13/2023 Comprehensive Care Plan, revised 11/25/2025, documented the resident had potential for altered nutritional status due diagnoses and poor intakes. On 09/11/2025 the resident had significant weight loss of 7.6% in 90 days. Interventions included two English muffins and two peanut butter at breakfast; Eight ounces of Ensure (nutritional supplement) and pudding at supper; and eight ounces of milk with three meals. The weight goal was 160 pounds, plus or minus five percent. The 09/08/2025 Physician #9 progress note documented the resident' s weights were trending down, and they received a regular diet. The plan was continue to monitor. The 09/11/2025 Registered Dietitian #11 weight change progress note documented the resident weighed 159.9 pounds and had a significant weight loss of 7.6% in three months. The resident's estimated nutritional needs were 1363 calories per day, and 73 grams of protein based on the current weight. Resident #101 had lower extremity edema and was on diuretic medications to help remove the edema. Intake had decreased to 52% and the nutrition diagnosis documented the weight loss was unintended and caused by dementia and decreased intake. Food preferences were updated, and chocolate Ensure was added to the supper meal. Weights were to be monitored and continued monthly. The 11/18/2025 Diet Technician #10 progress note documented the resident had decreased meal intake, assistance and supervision was needed at meals, the resident weighed 157.6 pounds, and no changes were needed at that time. There was no documented evidence of a comprehensive nutritional assessment and more frequent weights after 09/11/2025 when the resident continued to lose weight. The 01/05/2026 Physician #9 note documented Resident #101 was declining, had decreased intake, and weight loss. Monthly weights were noted. The 01/24/2026 Diet Technician #10 progress note documented a weight of 147.6 pounds with a significant weight loss in 6 months. Ensure was added to breakfast and fortified potatoes to lunch. The resident was changed to weekly weights. During an observation on 01/27/2026 at 8:26 AM, Resident #101 was in their bedroom eating breakfast with an occupational therapist. They only ate bites of their solids but consumed most of their beverages, including Ensure. During an interview on 01/27/2026 at 10:22 AM, Diet Technician #10 stated nursing entered the weights in the electronic medical record. They reviewed the weights and made a list of necessary reweights and weekly weights for nursing every Monday. Weights were obtained weekly for four weeks and then monthly unless nutrition requested weekly weights. They checked intake on quarterly assessments unless notified by nursing or observation. If a resident had significant weight loss, they requested a weight to confirm, then would put an intervention in place and notified the medical provider. Significant weight loss was a significant concern and could imply other medical issues. They documented on 01/24/2026 when they were alerted about the weight loss, implemented interventions, and changed the resident to weekly weights. During an interview on 01/27/2026 at 10:59 AM, Registered Dietitian #11 stated they documented on all significant weight loss and followed up at least monthly and as needed. They observed for decline in intake at meals and received information in morning report as well. They tracked residents with weight loss weekly until they were stable. The weights were obtained in the first week of the month and then nutrition requested reweights and made a list of weekly weights. Nursing recorded all the weights in the electronic medical record. If a resident had confirmed significant weight loss, they would complete a weight change form to assess for necessary inventions and notify the provider. Weight loss was a significant concern in the elderly because it could imply a medical decline or issue. Resident #101 had new significant weight loss this week and intake was 52%. They were unaware of any weight loss prior to this week, and no new interventions were in place since 09/11/2025 until this week. During an interview on 01/27/2026 at 12:29 PM, Registered Nurse #13 stated if a resident did not eat at meals the staff offered something else to eat, documented the intake and notified them. They would alert the interdisciplinary team in morning report and called nutrition staff. Residents were on monthly weights unless they were being watched closer. Nutrition would tell them if they needed a reweight or weekly weights by adding the resident to the weight list in the nursing station. Nutrition staff were not really in the dining room to observe so they were called with issues. Resident #101 started to have a declining intake and was losing weight. They started keeping the resident on the floor for meals this week, to provide more assistance, and occupational therapy was working with them to increase self-feeding. The resident was eating in the main dining room prior to this week. 10 New York Codes, Rules and Regulations 415.12(i)1

Based on observations, record review, and interviews during the survey conducted 01/27/2026-01/27/2026, the facility failed to ensure an indwelling urinary catheter (removes urine from the bladder) was not used unless there was valid medical justification for one (1) of three (3) residents (Resident #18) reviewed. Specifically, Resident #18 had an indwelling catheter without an order, indication, or care plan for its usage.Findings include:Resident #18 had diagnoses including congestive heart failure (the heart does not pump efficiently), chronic kidney disease, and acute cystitis (inflammation of the bladder). The 12/05/2025 Minimum Data Set assessment (screening tool) documented the resident had severely impaired cognition, required maximum/dependent assistance for all activities of daily living and transfers, and did not have an indwelling catheter.Resident #18 was observed with a urinary catheter on 01/20/2026 at 11:58 AM and 01/21/2026 at 8:45 AM. The unsigned 01/16/2026 admission Assessment documented Resident #18 did not have an indwelling urinary catheter.There was no documented physician admission order for an indwelling catheter including size, care, or rationale for use. There was no documented evidence of urinary catheter care plan or care instructions (Kardex) for urinary catheter care. The 01/19/2026 Physician #9 progress note documented Resident #18 had a new urinary catheter placed while in the hospital.During an interview on 01/27/2026 at 11:40 AM Certified Nurse Aide #6 stated urinary catheter care should be on the Kardex. Resident #18 had a urinary catheter, but they did not notice if it was on their Kardex. During an interview on 01/27/2026 at 11:45 AM Licensed Practical Nurse #7 stated urinary catheters should be in the care plan and the Kardex. Catheter orders consisted of the size, the size of the balloon, and the reason for the catheter. They stated Resident #18 had a urinary catheter and they were not sure why they had one. Licensed Practical Nurse #7 confirmed there were no physician orders for the urinary catheter. During an interview on 01/27/2026 at 12:00 PM Registered Nurse #8 stated the licensed practical nurses cared for the urinary catheters and changed them every 30 days per the physician order. Urinary catheters should also be included in the care plan and in the Kardex so urinary output could be documented in the task. When residents were admitted with urinary catheters, orders were placed with a reason why the resident had the catheter. If there was no reason why, nursing needed to find a reason or receive orders to have it removed. They needed to know when it was inserted or last changed so they knew when it had to be changed again. Resident #18 had a urinary catheter. They confirmed there were no physician orders, a diagnosis, or care plan for a urinary catheter. 10 New York Codes, Rules and Regulations 415.12(d)(2)

Based on observations, record review, and interviews during the recertification survey, the facility failed to establish mechanisms for documenting and communicating the resident's choices regarding Advance Directives to the staff responsible for the resident's care for one (1) of thirty-three (33) residents (Resident #63) reviewed. Specifically, Resident #63's electronic Medical Orders for Life-Sustaining Treatment form (a medical order for wishes for life-sustaining treatment completed by a medical provider) documented the resident consented to do not resuscitate (allow natural death) and the resident's electronic medical record documented to attempt cardiopulmonary resuscitation (attempt to restart the heart). Findings include: The facility policy Advance Directives: Advance Care Planning for Healthcare Decisions, revised 7/2024, documented medically appropriate care would be provided to every patient and patient's wishes regarding cardiopulmonary resuscitation and do not resuscitate and other life sustaining treatment and end of life health care decisions would be honored. Resident #63 had diagnoses including metabolic encephalopathy (a brain dysfunction) and diabetes. The 8/14/2025 Minimum Data Set assessment documented that the resident had moderately impaired cognition. The resident was previously admitted to the facility in 1/2025 at which time had an advance directive of Do Not Resuscitate, was discharged home, and was readmitted to the facility from the hospital in 1/2026. The 01/12/2026 physician order documented the resident was a full code. The 1/12/2026 at 8:26 PM Physician # 25 progress note documented the resident was admitted to the facility for rehabilitation after an acute visit to the hospital. The resident wanted to be a full code (receive cardiopulmonary resuscitation if their heart stopped) but there was a previous electronic Medical Orders for Life-Sustaining Treatment which documented do not resuscitate. The resident would remain a full code until it could be reassessed in the morning, and a final decision could be made. The 1/13/2026 Comprehensive Care Plan, revised 1/21/2026, documented full code status with interventions to include cardiopulmonary resuscitation. The 1/13/2026 at 2:38 PM Registered Nurse Unit Manager #22 Clinical admission progress note documented the resident was alert and oriented and was able to understand and be understood when speaking. There was no documentation of the resident's advance directive wishes or verification of wishes. The 1/14/2026 at 1:26 PM Social Worker #35 Plan of Care note documented the resident's admission packet, and all assessments were completed. There was no documentation regarding the resident's advance directive wishes. The 1/21/2026 Medical Orders for Life Sustaining Treatment form documented the resident verbally consented to a do not attempt resuscitation order in the event their heart stopped. The form was signed by Physician #25 on 1/21/2026. During an interview and observation on 1/21/2026 at 11:14 AM, Resident #63 had a bracelet on their left wrist with a red heart on it. They stated they did not know what the bracelet was for. Staff did not ask them if they wanted cardiopulmonary resuscitation. They did not want cardiopulmonary resuscitation and could make their own decisions. During an interview on 1/21/2026 at 11:18 AM, Certified Nurse Aide #23 stated the residents that had bracelets with hearts on them were the residents who wanted to receive cardiopulmonary resuscitation. During an interview on 1/21/2026 at 11:24 AM, Licensed Practical Nurse #7 stated they would start cardiopulmonary resuscitation on an unresponsive resident if they had the red heart bracelet on. The red heart bracelet meant they were a full code. During an interview on 1/21/2026 at 1:56 PM Registered Nurse Manager #22 stated on admission, residents were asked about advance directives preferences. If they want to be full code, an order was put in and a bracelet was placed on the resident. If there was a preexisting Medical Orders for Life Sustaining Treatment and the resident's preferences had not changed then a new Medical Orders for Life Sustaining Treatment did not need to be generated, however if preferences changed then a new one should be generated. During Resident #63's admission assessment the resident told them they wanted to be a full code. They notified Physician #25 who came the next day. Physician #25 left them a note asking them to clarify the resident's preferences as the resident told them they preferred not to be resuscitated. It was not determined who was to make that clarification and was not sure if anyone did. After referring to eMOLST (a web-based application where Medical Orders for Life Sustaining Treatment are uploaded to), they stated the resident's Medical Orders for Life Sustaining Treatment documented do not resuscitate but their order in the electronic medical record was full code. If the resident's heart stopped, they would be resuscitated. They thought they did not generate new Medical Orders for Life Sustaining Treatment because there must have been too many hands in the pot during the admission process. During an interview on 1/21/2026 at 2:45 PM, Social Worker #35 stated usually within 24 hours of a new admission they met with the resident to review advance directives and made sure the order was what the resident wanted. This was documented in either a care plan or a progress note. They met with Resident #63 but did recall the exact conversation. The resident's order documented full code. They assumed the resident told them they wanted to be a full code because that was what was in their care plan. They did not write a progress note, but they should have. During an interview on 1/21/2026 at 3:11 PM, Physician #25 stated they discussed advance directives during their admission visit. The eMOLST was started by nursing, and they filled in the rest and signed it off. During Resident #63's admission visit, the resident's verbalized an advance directive preference that was contrary to what was on their current Medical Orders for Life Sustaining Treatment. Therefore, they did not sign it and instead told the charge nurse it needed to be clarified. On 1/20/2027, Registered Nurse Manager #22 told them the resident's preferences were clarified, and it was okay to go ahead and sign the Medical Orders for Life Sustaining Treatment. They took that to mean that it was clarified and that the resident did not want to be resuscitated so they signed it. The Medical Orders for Life Sustaining Treatment and the orders should match, and it was the responsibility of the charge nurse to make sure they did. If orders did not match what was on the Medical Orders for Life Sustaining Treatment, those orders should be changed immediately. 10 New York Codes, Rules and Regulations 400.21(c)

Based on observations, record review, and interviews during the recertification survey (complaint #466496) the facility failed to ensure a resident's designated representative was notified of changes in condition for one (1) of two (2) residents (Resident #175) reviewed. Specifically, Resident #175 was hospitalized , and their designated representative was not notified of their hospitalization.Findings Include:The facility policy Transfer and Discharges. dated 09/16/2016, documented the proper notification of a transfer or discharge would be made to the resident and/or representative. Notification included the reason for the transfer, and the reason would be documented in the resident's clinical record. The facility would provide the resident and/or representative notice of the bed-hold policies and readmission policies prior to the transfer for hospitalization or therapeutic leave. In the case of an emergency transfer, notice at time of transfer meant that the resident representative would be provided with a written notice within 24 hours of the transfer. The resident's copy of the notice would be sent with the resident to the hospital. Resident #175 had diagnoses including acute respiratory failure with hypoxia (low oxygen in the blood), atrial fibrillation (abnormal heartbeat), and hypertensive heart disease with heart failure (long-term high blood pressure that has damaged the heart). The 04/11/2025 physician orders documented:- monitor vital signs every shift. - 75 milligrams of metoprolol tartrate (used to treat high blood pressure and heart failure) twice daily for hypertension.-0.5 milligrams of lorazepam (antianxiety medication) every 8 hours as needed for anxiety.The 04/12/2025 at 4:22 PM, Registered Nurse #28 progress note documented the resident's pulse was 101 beats per minute and was irregular and chronic. The 04/12/2025 at 7:40 PM, Registered Nurse #29 progress note documented the resident's vital signs were taken at 7:30 PM and their heart rate was 153 beats per minute. Registered Nurse/ Nursing Supervisor #30 was notified and provided the resident with metoprolol. At 8:30 PM, the resident's heart rate was 140 beats per minute, and they were provided with lorazepam. At 9:41 PM, the on call medical provider was called. At 9:50 PM, Medical Provider #31 called back and instructed staff to send the resident to the hospital. Registered Nurse/ Nursing Supervisor #30 was notified, and the resident was transferred to the hospital related to tachycardia (increased heart rate). On 04/12/2025 at 10:00 PM, Registered Nurse/ Nursing Supervisor #30, documented the resident was transported to the emergency room per medical provider request related to tachycardia.There was no documented evidence that the resident's designated representative was notified of the resident's transfer to the hospital. During an interview on 01/27/2026 at 2:19 PM, Registered Nurse Unit Manger #4 stated resident representatives should be notified when there was a change in condition, there was no timeframe in which staff should notify the resident representative, but they should be notified the day the change of condition occurred. They were unsure if Resident #175's resident representative was notified when they were sent to the hospital on [DATE]. During an interview on 01/27/2026 at 9:54 AM, Registered Nurse #29 stated they no longer worked at the facility, but they recalled the resident was sent out to the hospital for an elevated heart rate and returned to the facility within a couple of hours. They spoke with the medical provider and obtained orders to transfer the resident to the hospital but did not recall speaking with the resident's representative. They also notified Registered Nursing Supervisor #30 about the residents' increased heart rate, and they were sent to the hospital. They were under the impression that Registered Nurse/ Nursing Supervisor #30 was going to notify the representative. Anytime a resident had a change of condition their representative should be notified, and it should be documented in the resident's chart. 10 New York Codes, Rules and Regulations 415.3(f)(2)(ii)(c)

Based on observations, record review, and interviews during the recertification survey, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to include services provided to maintain the resident's highest practicable physical well-being for one (1) of one (1) resident (Resident #144) reviewed. Specifically, Resident #144's person-centered comprehensive care plan did not include the diagnoses of type 2 diabetes mellitus (the body does not use insulin properly causing high blood sugars), the use of insulin (used to treat high blood sugars), or the use of an anticoagulant (blood thinner).Findings include:The facility policy Comprehensive Care Plans, revised 04/2024, documented the facility would develop a comprehensive individualized plan of care for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. Care plans would be reviewed and updated at least quarterly, when there was a significant change in the resident's condition, and as needed. Goals, objectives, and interventions would be reviewed and revised by the interdisciplinary team when there was a change in planned interventions, a new diagnosis, new medications or abnormal labs.Resident #144 had diagnoses diabetes and atrial fibrillation (irregular heartbeat). The 01/02/2026 Minimum Data Set assessment documented the resident was cognitively intact, received daily insulin injections, and was on an anticoagulant.Physician orders documented:-on 12/26/2025 Lantus (long-acting insulin) 5 units subcutaneously (under the skin) once daily for diabetes.-on 12/26/2025 insulin lispro (short acting insulin) 5 units subcutaneously before meals for diabetes.-on 12/26/2025 apixaban (blood thinner) 5 milligram tablet by mouth two times a day for atrial fibrillation.There was no documented evidence of a person-centered comprehensive care plan that included the diagnosis of diabetes with the need for insulin administration and monitoring for hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar), and the use of an anticoagulant or monitoring for symptoms and side effects of anticoagulant use. During an interview on 01/27/2026 at 12:12 PM, Licensed Practical Nurse #5 stated all nursing staff were able to review care plans, but the registered nurses were responsible for initiating and updating them. Medications including anticoagulants and insulin should be included in Resident 144's care plan so staff would know to monitor for increased bleeding and bruising or signs of hypoglycemia.During an interview on 01/27/2026 at 12:35 PM, Registered Nurse Manager #4 stated care plans were initiated by a registered nurse upon admission and were reviewed and updated quarterly and as needed. Licensed practical nurses were not allowed to initiate care plans, but they could update them. All staff were expected to review care plans because they told them everything about the residents, and how to properly care for them. Resident #144 was a diabetic who received insulin and was on an anticoagulant for atrial fibrillation. They were not aware the resident's care plan did not include their insulin or anticoagulant use, but it should have so staff would know to monitor for bleeding or bruising, and for signs of hypoglycemia or hyperglycemia.10 New York Codes, Rules and Regulations 415.11(c)(1)

Based on observations, record review, and interviews during the recertification and abbreviated (IQIES 466495) surveys, the facility failed to ensure residents' medications were administered in accordance with accepted professional standards and the prescriber's order for two (2) of two (2) residents (Residents #1 and #39) reviewed. Specifically, Resident #1's and #39's physician orders did not include the amount of fluid used with medication instillation; and Resident #1 was administered ginger ale with medications without a physician order.Findings include:The facility policy Enteral Nutrition, last revised 02/2025 documented adequate nutritional support through enteral nutrition (feeding tube) would be provided to residents as ordered. The dietitian, with input from the provider and nurse calculates the fluids to be provided. Complete orders include instructions for flushing (solution, volume, frequency, timing and 24-hour volume). Documentation of the feedings and flushes will be under the medication administration record in the electronic medical record. 1)Resident #39 had diagnoses including gastrostomy tube and cerebral palsy (affects motor function). The 09/08/2025 Minimum Data Set assessment documented the resident had severely impaired cognition, had a gastrostomy feeding tube, and received 51% of total calories and 501 milliliters per day or more average fluid intakes by feeding tube. The 12/24/24 comprehensive care plan documented the resident had a gastrostomy tube and was at risk for fluid deficit related to the gastrostomy tube. Interventions included estimated fluid needs of 1080 milliliters per day, monitor and document intakes and outputs, provide tube feedings and water flushes per physician orders, enteral tube feedings at 48 milliliters per hour, and see physician orders for tube feeding flushes and rates. The 12/23/2024 physician orders documented flush gastrostomy tube every 6 hours with 60 milliliters of water, flush gastrostomy tube with 30 milliliters of water before and after medications, document amount of formula and water provided every eight (8) hours. The order did not include the amount of water used with the medication instillation. The 01/2026 Medication Administration Record did not include how much water to mix the medications in tablet form with when administering via the feeding tube. During a medication administration observation and interview on 01/27/2026 at 1:07 PM, Licensed Practical Nurse #40 prepared Resident #39's Reglan (treats reflux) 5 milligram one tablet to administer via gastrostomy tube. They checked the medication orders, crushed the tablet, mixed the powder with 60 milliliters of tap water, checked the tube for placement, provided 30 milliliters of tap water via syringe and gravity, administered the medication, and flushed the tube with another 30 milliliters of tap water. They stated there was no order for how much water to use for medication dilution. The nurse stated they gave the resident their medications that morning, crushed them all together, and used 60 milliliters of tap water to dilute them. Licensed Practical Nurse #40 stated without an order for how much fluid to give the medication with the amount could vary from nurse to nurse and affect daily intake amounts. During an interview on 01/27/2026 at 1:27 PM, Registered Nurse Manager #36 stated there should be an order for water to dilute each medication with. The dietitian calculated daily fluid needs, so staff needed to monitor how much fluids the resident was taking in daily. The provider was responsible for entering the order of how much fluid to dilute the medications. They stated they were responsible for reviewing the orders quarterly and did so last on 12/24/2025. They did not notice the residents did not have an order for diluting the medications. After reviewing the gastrostomy medications order set, the manager stated there was no order regarding how much water to use to dilute each medication and that dietary usually entered the flushes order set. 2)Resident #1 had diagnoses including gastrostomy tube (feeding tube) and persistent vegetative state. The 12/30/2025 Minimum Data Set assessment documented the resident had severely impaired cognition, had a gastrostomy feeding tube, and received 51% of total calories and 501 milliliters per day or more average fluid intakes by feeding tube. The 07/15/2020 comprehensive care plan, updated 12/29/2025, documented the resident had a gastrostomy tube and was at risk for fluid deficit related to the gastrostomy tube. Interventions included total dependance on staff for tube feedings and all water flushes to meet their nutritional needs. This included providing enteral feedings, medications as ordered, water flushes to meet estimated fluid needs of 2130 milliliters per day, and documenting intake and output. The 06/14/2025 physician orders documented enteral nutrition orders through their gastrostomy tube included bolus feeds every 4 hours at a rate of 300 milliliters over an hour via pump, a 250-milliliter water flush every shift, and a water flush of 30 milliliters before and after each medication pass and bolus feed. The order did not include the amount of water used with the medication instillation. The 01/2026 Medication Administration Record did not include how much water to mix the medications in tablet form with when administering via the feeding tube. During a medication administration observation and interview on 01/23/2026 at 10:58 AM, Licensed Practical Nurse #34 provided a 30-milliliter water flush, then checked the pump and initiated the enteral feeding for 300 milliliters over the hour. They said after the hour ends, if there is any formula still in the tube they flushed it with another 30 milliliters of water before disconnecting the tube. They said the 250 milliliter water flushes per shift would kick in automatically by the pump. They had already passed the medications that morning and the next medication pass was later in the afternoon. They stated they provided 30 milliliters of water before and after the medication pass and always mixed the crushed meds together with 120 milliliters of ginger ale. They did not have an order for how much fluid to dilute the crushed medications with, or to use ginger ale with medications. They stated any water flushes they administered should be in the orders, including what and how much fluid should be mixed with the medication. They stated that information is missing from the order, so they just give a standard of 240 milliliters of water in that case. They used 120 milliliters of ginger ale instead of 240 milliliters in this case because it just worked better and they used 240 milliliters of water with the Nutrisource Fiber and Juven packets. There was no documented evidence of a physician order for the resident to receive ginger ale with medication administration. During an interview on 01/23/2026 at 11:23 AM, Registered Nurse #13 stated the dietitian wrote all the enteral orders for feedings and water flushes. The nurses just followed the medication administration record when providing the enteral feeding. There should be orders for how much fluid to mix the medications with. For the Nutrisource Fiber and Juven, they followed the packet instructions when there was no order. During a medication administration observation and interview on 01/27/2026 at 7:30 AM, Licensed Practical Nurse #34 had just finished administering all the medications crushed and mixed in ginger ale and was giving the 30 milliliter post medication pass flush. They stated they mixed all the morning meds together with the ginger ale, combined in the cup and administered them all together. During an interview on 01/27/2026 at 10:59 AM, Registered Dietitian #11 stated they knew how many medication passes a resident received daily by looking at the medication administration record. They stated they wrote the enteral order for feeding and water flushes and there are specific water flush amounts for before, with, and after medications, and before and after feedings. Nutrisource Fiber and Juven should be mixed with 240 milliliters to administer, and this should be part of the order. Resident #1 received 30 milliliters before and after medication passes but was not sure how much was mixed with medications. They stated they did not determine how much or what fluid would be provided with the medications but there should be an order for it. All fluids put through the tube should be recorded on the medication administration record, including fluids mixed with medications and supplements. During an interview on 01/27/2026 at 12:05 PM, Licensed Practical Nurse #37 stated when they administered medications through an enteral tube, they usually mixed all the crushed medications together with approximately 60 milliliters of ginger ale. They were not sure if mixing ginger ale with any medications was contraindicated. They were not sure how much water was mixed with Nutrisource Fiber or Juven because there was no order, and they used 120 milliliters to mix those products. If a specific amount was necessary, it would have been part of the order. 10 New York Codes, Rules and Regulations 415.12

Based on observations, record review and interviews during the recertification survey (Complaint #2699879), the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new ulcers from developing for one (1) of two (2) residents (Resident #76) reviewed. Specifically Resident #76 had two Stage 2 pressure ulcers (partial-thickness skin loss) on the buttocks and an unstageable (full thickness tissue loss in which the base of the ulcer is covered with dead tissue) pressure ulcer on the right heel that did not have timely treatment orders or interventions; the medical orders for wound treatments were not followed; and the resident was not turned and positioned as planned. Findings include: The facility policy Prevention and Treatment of Pressure Injuries, last reviewed 9/2025, documented the facility would develop and implement a comprehensive care plan that reflected each residents identified needs and effort to stabilize, reduce or remove the underlying risk factors; interventions would be identified and modified as appropriate and ensure residents with pressure injuries received the necessary treatment and services to promote healing and/or prevention infection. Additionally, a pressure injury was considered avoidable if the facility did not do any of the following: evaluate the resident's clinical condition and pressure injury risk factors; define and implement interventions that were consistent with the resident's needs, goals and recognize the standard of practice; monitor and evaluate the impact of the interventions; and revise the approaches as appropriate.Resident #76 had diagnoses including obesity, anemia, and peripheral vascular disease (poor circulation). The 12/19/2025 Minimum Data Set assessment (assessment tool) documented the resident's cognition was intact; required maximum assistance for bed mobility; was at risk for pressure ulcers; did not have any pressure ulcers; had two venous/arterial ulcers; had a pressure reducing device for chair and bed; and applications of nonsurgical dressing, ointments and medications. The unsigned 12/16/2025 Braden scale (a tool used to determine risk for pressure injuries) documented the resident was at high risk for developing a pressure ulcer.The unsigned 12/16/2025 Clinical admission assessment documented the resident had an abrasion to the right heel. There was no further documentation related to any other skin alterations. The 12/18/2025 Comprehensive Care Plan documented the resident had an infection on both lower extremities and was at risk for pressure ulcers. The infection interventions included follow up with the wound clinic and betadine (a topical antiseptic) to the right heel and leave open to air. Pressure ulcer interventions included weekly skin inspections, a flat bed, follow the facility protocols for prevention/treatment of skin breakdown, and the resident preferred the use of two staff for repositioning. The undated Kardex (care instructions) documented weekly skin inspections, keep the bed in a flat position, follow the facility protocols for prevention/treatment of skin breakdown and turn and position every two (2) hours. BUTTOCKS: The unsigned 12/16/2025 Skin Alert/Body Alert assessment documented there was a Stage 2 (partial thickness loss of skin) pressure ulcer on the right buttock and one on the left buttock, both measuring 1 x 1 centimeters. There was no treatment ordered or any further documentation related to the Stage 2 pressure ulcers on the buttocks until 12/24/2025. The 12/24/2025, weekly wound rounds documented the resident had a Stage 2 on the right buttock measuring 3 x 2 centimeters with no drainage, foul odor or surrounding redness. An addendum on 12/28/2025 documented the resident had a Stage 2 on the left buttock measuring 3.5 x 2.5 centimeters with no drainage, foul odor or redness. The plan was to offload and monitor weekly. The 12/24/2025 physician order documented cleanse both buttocks with soap and water, pat dry and apply A & D ointment every shift and as needed for Stage 2 pressure ulcers. The 12/31/2025 weekly wound rounds documented a Stage 2 on the right buttock measuring 8 x 3.5 centimeters and the wound base contained healing tissue. Puracol powder (a topical wound treatment), off load and monitor weekly. An addendum dated 01/01/2026 documented the resident had a Stage 2 area on the left buttocks measuring 9 x 4 centimeters, with no drainage. The plan was to change the treatment to Puracol powder, off load and monitor weekly. The 12/31/2025 Physician Order documented to cleanse both buttocks with soap and water, pat dry, then apply Puracol powder to wounds every shift and as needed. The 01/07/2026 weekly wound rounds documented a Stage 2 pressure ulcer on the right buttock measuring 13.5 x 5 x 0.5 centimeters with no drainage or odor, and healing tissue to the wound bed. A Stage 2 pressure ulcer to the left buttock measuring 11.5 x 4.5 centimeters with no drainage or odor and some healing tissue to the wound bed. The plan for both pressure ulcers was to continue treatment, offload and monitor weekly. The 1/12/2026 Wound Clinic Consult Report documented the resident had a Stage 3 (full thickness tissue loss) pressure injury to both buttocks with copious drainage and Mupirocin (ointment) and Optifoam (dressing) change daily was recommended. The 1/15/2026 Physician Order documented to clean both buttocks with soap and water, pat dry and apply Muoiricin and cover with Optifoam daily for a Stage 3 pressure ulcer. The 1/20/2026 Wound Clinic Consult Report documented the Stage 3 pressure injuries to both buttocks were excoriated, foul odor and has purulent (pus) drainage. Recommendations were to cover the wounds with Optifoam, change daily, turn and reposition every two (2) hours and limit the resident's time on their bottom. Doxycycline (antibiotic) was ordered for 10 days. RIGHT HEEL: The unsigned 12/16/2025 Clinical admission assessment documented an abrasion to the right heel. There was no further description of the area. There was no documented evidence of any monitoring of the right heel abrasion that was identified on 12/16/2025.Physician orders documented the following:-On 12/17/2025 skin prep (protective barrier) to both heels twice a day for prevention. -On 12/17/2025 float heels while in bed every shift.There was no documented evidence that the intervention to float heels was added to the resident's comprehensive care plan or Kardex. The unsigned 01/6/2026 Skin Alert/Body Alert assessment documented a 5 x 4-centimeter unstageable (full thickness tissue loss in which the base of the ulcer is covered with dead tissue) pressure ulcer to the right heel. The 01/20/2026 Wound Clinic Consult Report documented the unstageable pressure ulcer on the right heel contained dry dead tissue. Recommendations included to apply and change heel cup daily, limit head of bed up to 30 degrees, and float heels as much as possible. The 01/20/2026 physician order documented apply heel cup to right heel daily. The 01/2026 Treatment Administration record documented:-cleanse bilateral buttocks with soap and water, pat dry, apply Muoiricin and cover with Optifoam once daily. -heel cup to right heel, change daily. There was no documented evidence that the heel cup was changed on 01/21/2026. -skin prep to heels two times daily. There was no documented evidence that the skin prep was applied during the day shift on 01/21/2026. -float heels. There was no documented evidence that the heels were floated on 01/21/2026 during the day shift on 01/21/2026. During an observation on 01/22/2026 at 2:35 PM, Licensed Practical Nurse #21 performed a dressing change to the resident's right heel and buttocks. The right heel did not have a heel cup in place. Licensed Practical Nurse #21 cleansed the heel with sterile water and covered the wound with Opticell (a type of dressing), applied the heel cup, and wrapped with kerlix. They did not apply skin prep. Licensed Practical Nurse #21 rolled the resident onto their right side to perform wound care to the buttocks. The old dressing was removed and was fully saturated with brown drainage. The old dressing was not Optifoam dressing. There were a foul odor and the brown drainage extended onto the absorbent pad underneath the resident saturating about 25% of the pad. During an interview on 01/22/2026 at 4:23 PM, Licensed Practical Nurse #21 stated they were not sure what product the old dressing they removed was. They referred to the orders and stated they applied Opticell to the wound when there was only an order for a heel cup. They applied Opticell in the past and they assumed the order was the same. They should have double-checked the orders before doing the treatment and should follow current orders not previous ones. During an observation and interview on 01/23/2026 at 7:59 AM, the resident was lying on their back in bed. Both heels were resting directly on the bed. Registered Nurse Manager #22 entered the room and stated the heels were not floating but they should be. During a continuous observation on 01/23/2026 from 9:30 AM to 1:30 PM, the resident was lying on their back in bed and was not turned and repositioned. During an interview on 01/23/2026 at 1:44 PM, Certified Nurse Aide #23 stated Resident #76's skin on their buttocks was open and they should be turned and repositioned every two (2) hours. They did not turn and reposition the resident today because they could not get to it. They should have turned the resident every two hours and reported to the nurse that it did not get done. During an interview on 1/23/2026 at 1:56 PM, Licensed Practical Nurse #24 stated residents should be repositioned every two (2) hours and heels floated unless care planned differently. The aides were responsible for doing that and if it was not being done it should be reported to them. Resident #76 had wounds, and they should be repositioned frequently. They should not be left in the same position for four (4) hours as it could worsen their wounds. It had not been reported to them that the resident was not repositioned. During an interview on 01/27/2026 at 12:12 PM, Registered Nurse Manager #22 stated any open areas noted on admission would be measured and documented in the clinical admission assessment; non pressure wounds should have a weekly progress note as to the status of the wound by a registered nurse to include measurements; pressure ulcers were reported to the provider immediately as that was the only way to get a treatment order; residents at high risk for skin breakdown should have a potential for skin breakdown care plan with specific preventative interventions; residents with a pressure ulcer should have an actual skin impairment care plan with specific interventions; and they were responsible for making sure those care plans were up to date. Resident #76, on admission, was at high risk for skin breakdown and had stage 2 buttock pressure ulcers and an abrasion to their right heel. The buttock wounds should have had a care plan, treatment, a provider note, and interventions in place prior to 12/24/2025. The heel should have been monitored but they did not see documentation that it was. A chair cushion was put in place on admission, but things like heel floating and turning every 2 hours would not be listed because they were considered standards of care. The resident should not be left in the same position for 4 hours or have any blanks on their treatment administration record as that implied the treatment was not done. During an interview on 01/27/2026 2:56 PM, Physician #25 stated on admission they asked the nurses if there were any skin concerns they needed to look at. They expected preventative skin measures to be put in place for a high-risk resident immediately on admission. They expected if the resident was admitted on [DATE] with an open area to their heel, there would be monitoring notes regarding its status prior to 01/6/2026 when the heel was found to be black and unstageable. They expected interventions to be in place for the open areas on the buttocks immediately. During an interview on 01/27/2026 at 3:40 PM, the Director of Nurses stated on admission the registered nurse did the first skin assessment and Braden scale. If at risk, a care plan with specific interventions such as turn and reposition, skin prep, and floating heels should be put in place within 24 hours. If there was an open area, then an actual skin impairment care plan should be initiated with specific interventions. They expected if a resident was assessed to be a high risk for skin breakdown and had two Stage 2 pressure ulcers to their buttocks and an abrasion on their heel that a care plan with specific interventions was put in place right away. The heel should have been followed by a registered nurse weekly and a progress note entered prior to 01/6/2026 when it was documented as an unstageable pressure ulcer. 10 New York Codes, Rules and Regulations 415.12(c)(1)

Based on observation, record review, and interviews during the recertification survey, the facility failed to ensure each resident received adequate supervision and the environment remained as free of accident hazards as possible for one (1) of six (6) residents (Resident #123) reviewed. Specifically, Resident #123 was at risk of falls, and their call light was not within reach as care planned.Findings include:The facility policy Falls, revised 08/2016, documented on admission, a fall risk assessment would be completed along with a fall care plan with specific individual interventions necessary to prevent resident falls. Fall interventions would be added to resident's care plan, certified nurse aide assignment sheet, and communicated through the 24-hour nursing office report. Nursing supervisors, unit managers, and team leaders would be responsible for ensuring the care plan was being followed.Resident #123 had diagnoses including right side paralysis and weakness and need for assistance with personal care. The 09/12/2025 Minimum Data Set assessment (screening tool) documented the resident had severely impaired cognition, did not have any falls since admission or reentry, and was dependent with dressing, personal hygiene, and bed mobility. The Comprehensive Care Plan initiated 06/05/2025 documented the resident was at high risk for falls related to deconditioning. Interventions included ensuring the residents' call light was within reach, encouraging the resident to use the call light for assistance as needed, and respond promptly to all requests for assistance.The 12/09/2025 Fall Risk Assessment documented the resident had no falls in the past three months, had intermittent confusion, was chairbound and incontinent, and was a fall risk.Resident #123 was observed lying in bed with their call light on the floor under the top part of the bed and not within reach:-on 01/20/2026 at 11:42 AM.-on 01/20/2026 at 1:51 PM.-on 01/21/2026 at 3:19 PM.-on 01/22/2026 at 9:41 AM.-on 01/22/2026 at 3:56 PM.-on 01/23/2026 at 12:48 PM.During an interview on 01/27/2026 at 11:47 AM, Certified Nurse Aide #3 stated Resident #123 was care planned for falls and should always have their call light within reach. They cared for Resident #123 on 01/22/2026 during the day shift and they assisted and rounded on them other days that week. They did not recall seeing the residents' call light on the floor and thought they should put a clip on it, so it did not continue to fall off the bed.During an interview on 01/27/2025 at 12:06 PM, Licensed Practical Nurse #5 stated if a resident was a fall risk it was documented in their orders, on the care plan, and they would have specific fall interventions the staff had to follow for the resident's safety. Resident #123 was a fall risk and care planned for 2-hour checks, a low bed, and to have their call light within reach so they could call for assistance. All staff were responsible for ensuring call lights were within reach. They did not recall seeing Resident #123's call light on the floor but they knew the resident was able to yell out if they needed assistance.During an interview on 01/27/2026 at 12:46 PM, Registered Nurse Manager #4 stated Resident #123 was a fall risk and their fall care plan interventions included ensuring the call light was within reach and prompt response from staff to the call light. All staff who went into Resident #123's room were responsible for ensuring the call light was within reach. They stated if they were aware the call bell was falling onto the floor they would have put a clip on it and attached it to the bed. 10 New York Codes, Rules, and Regulations 415.12(h)(2)

Based on record review and interviews during the abbreviated survey (NY00377944), the facility failed to ensure that Advance Directives were implemented in a manner that was consistent with residents' wishes for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Resident #1 had a physician order for a Full Code (consent to receive life-saving measures in the event of cardiac or respiratory arrest). When the resident was found unresponsive, facility staff failed to timely initiate a Code Blue (signal indicating a medical emergency) and perform cardiopulmonary resuscitation (CPR). Resident #1 was subsequently transferred to the emergency department where they expired. This resulted in Resident #1's death that is Immediate Jeopardy past non-compliance, and likelihood of serious harm, serious injury, serious impairment, or death to all residents in the facility who had Advance Directives in place. Findings include: The facility policy, Advance Directives: Advance Care Planning for Healthcare Decisions, reviewed on [DATE] included: -An Extended Care Facility resident who wished cardiopulmonary resuscitation would have a Full Code order and a heart bracelet placed on them as this would indicate the resident requested cardiopulmonary resuscitation. -Nurses would be checking for cardiopulmonary resuscitation bracelets every shift and initialing in the Medication Administration Record. Resident #1 had diagnoses including chronic respiratory failure and tracheostomy (a surgical opening in the windpipe for breathing). The [DATE] Minimum Data Set assessment documented the resident had severely impaired cognition, received tracheostomy care and continuous high concentration oxygen. Their advance directives were Full Code. Physician orders dated [DATE] included: -CPR: attempt cardiopulmonary resuscitation. -Apply heart bracelet for Full Code. The resident did not have a Medical Orders for Life Sustaining Treatment (MOLST) form. The Comprehensive Care Plan, initiated on [DATE], documented the resident had decided, after making an informed decision, to be a Full Code. The [DATE] Medication Administration Record, documented to check placement of the heart bracelet every shift. The Medication Administration Record was signed on [DATE] by Licensed Practical Nurse #2 during the evening shift and during the day shift on [DATE] by Licensed Practical Nurse #17. The facility investigative summary, dated [DATE] by the Assistant Director of Nursing, documented: - On [DATE] at 10:45 PM, Registered Nurse Supervisor #3 received a call from Licensed Practical Nurse #1 that a resident on the third floor had died . Registered Nurse Supervisor #3 was on their way up to the third floor and at that time received another phone call from the fifth floor (ventilator unit) that there was a Code Blue on a ventilator resident. Registered Nurse Supervisor #3 attended to the resident on the fifth floor. - At approximately 11:30 PM, Registered Nurse Supervisor #3 returned to the third floor. They received the deceased resident's name (Resident #1) and learned the resident was a Full Code.- Registered Nurse Supervisor #3 notified the Director of Nursing the resident was a Full Code, and they advised Registered Nurse Supervisor #3 that a Code Blue needed to be called for Resident #1. A Code Blue was called over the intercom system and cardiopulmonary resuscitation was initiated at approximately 12:07 AM on [DATE]. - Resident #1 was transported to the hospital emergency department (in the same building as the nursing home) where resuscitation efforts continued. - Resident #1 expired on [DATE] at 12:37 AM in the emergency department. - The conclusion of the facility investigative summary documented based on Resident #1's record review and staff interviews, it was determined that although the nurses believed Resident #1 was deceased , they did not act appropriately per policies in place for a Code Blue. A [DATE] at 11:05 PM, Licensed Practical Nurse #1 progress note documented a call was placed to the resident's spouse to notify them resident had expired. During an interview on [DATE] at 1:00 PM, the Director of Nursing stated on [DATE] around midnight, they received a call from Registered Nurse Supervisor #3 that Resident #1 was deceased , was a Full Code, and the two nurses, Licensed Practical Nurse #1 and Licensed Practical Nurse #2, did not initiate cardiopulmonary resuscitation when they found the resident deceased . After Registered Nurse Supervisor #3 called to inform them about the incident, they directed Registered Nurse Supervisor #3 to call a Code Blue and to start cardiopulmonary resuscitation. The Director of Nursing was informed that Licensed Practical Nurse #1 had been told by Certified Nurse Aide #4 that Resident #1 was unresponsive, so they had gone to the resident's room. Licensed Practical Nurse #2 came to Resident #1's room moments later. The Director of Nursing stated that neither of the Licensed Practical Nurses followed protocol for a Code Blue. During interviews for the facility investigation, Licensed Practical Nurse #1 told them they had a lapse in judgment, and Licensed Practical Nurse #2 said they had no explanation as to why they had not started cardiopulmonary resuscitation on Resident #1. Licensed Practical Nurse #2 was at the end of their shift on [DATE] as they worked 3:00 PM - 11:00 PM when Resident #1 was discovered unresponsive, and Licensed Practical Nurse #1 was working 7:00 PM - 7:00 AM on [DATE]. Licensed Practical Nurse #1 and Licensed Practical Nurse #2 were immediately suspended and later terminated from employment at the end of the facility investigation. The Licensed Practical Nurses were reported to the New York State Office of Professions Licensing Board. Since the incident, the facility had done full-house audits on Advance Directives, audits on residents with Full Code bracelets, education of staff on basic life support, cardiopulmonary resuscitation and Code Blue procedure, mock Code Blue drills and cardiopulmonary resuscitation certification/certification renewal classes for staff. During a phone interview on [DATE] at 3:05 PM, Licensed Practical Nurse #1 stated on the night of [DATE], they were in another resident room providing tracheostomy care when Certified Nurse Aide #4 came to them and stated they thought Resident #1 was deceased . Even though Resident #1 was on Licensed Practical Nurse #2's assignment, they were the closest nurse to the room, so they went to Resident #1's room. They saw that the resident's lower extremities were discolored and cool to the touch. They only looked at the resident's right arm for a code bracelet, and did not see one. Licensed Practical Nurse #2 came into the room moments later and agreed that the resident was deceased . They both walked out of the room and Licensed Practical Nurse #1 contacted Registered Nurse Supervisor #3 and informed them Resident #1 was deceased . Later that night they were told by Registered Nurse Supervisor #3 the resident had a code bracelet on their left arm. If they had checked the resident's other arm for a code bracelet they would have started cardiopulmonary resuscitation. During an interview on [DATE] at 3:45 PM, the Administrator stated they were notified immediately of the incident on [DATE] by the Director of Nursing. They expected any staff who were cardiopulmonary resuscitation certified, who came upon an unresponsive resident they would call for help, verify advance directive orders, call a code on the overhead paging system and start cardiopulmonary resuscitation if a resident was a Full Code. During a phone interview on [DATE] at 4:29 PM with Registered Nurse Supervisor #3, they stated they worked the night shift (7:00 PM - 7:00 AM) on [DATE]. All staff were supposed to know what to do in a Code Blue situation. On [DATE] around 10:45 PM, they received a call from Licensed Practical Nurse #1 that a Resident #1 had expired. As they were making their way to the third floor via the elevator to assess Resident #1, they received a phone call from the fifth floor, which was the ventilator unit, informing them they had a Code Blue. At that point, because a Code Blue had not been called on the third-floor resident (Resident #1), and because Licensed Practical Nurse #1 did not state it was emergent, they assumed the resident had the Advance Directive of Do Not Resuscitate (do not perform cardiopulmonary resuscitation). They continued to the Code Blue on the fifth floor and assisted with the transport of that resident to the emergency department. When they finally arrived on the third floor between 11:30 PM - 11:45 PM to assess Resident #1, Licensed Practical Nurse #2 stated the resident was a Full Code (perform cardiopulmonary resuscitation). They called the Director of Nursing and the Medical Doctor around midnight on [DATE] and told them Resident #1 was a Full Code and had not been given cardiopulmonary resuscitation for at least a half hour. The Director of Nursing told them they needed to call a Code Blue and to start cardiopulmonary resuscitation. Respiratory therapy and the rapid response team attempted to resuscitate the resident for about 25 minutes until the resident was transported to the emergency department and pronounced deceased . The last time they were aware the resident was seen by Licensed Practical Nurse #2 was between 9:45 PM - 10:00 PM on [DATE], when they complained of being hot and wanted the window open. The Certified Nurse Aides had discovered the resident unresponsive at 10:45 PM when they were doing their initial rounds, as their shift started at 10:00 PM. Registered Nurse Supervisor #3 spoke with both Licensed Practical Nurse #1 and Licensed Practical Nurse #2 as to why they did not call a Code Blue and start cardiopulmonary resuscitation, and they had no explanation. Licensed Practical Nurse #1 told them they did not think Resident #1 had been wearing a code bracelet on their arm. During a follow-up interview on [DATE] at 9:10 AM with the Administrator, they stated all the licensed nursing staff had been re-educated on basic life support, cardiopulmonary resuscitation, and Code Blue procedures. Certified Nurse Aides had been re-educated as well. There were two (2) certified nurse aides who were per diem that had not received the education yet, but they would be educated upon return to work. During an interview on [DATE] at 10:00 AM with the Medical Director, they stated they were called about Resident #1 by Registered Nurse Supervisor #3 on [DATE] around midnight after the resident had been discovered unresponsive, had been determined to be a Full Code, and cardiopulmonary resuscitation had not been initiated. Resident #1 had probably been deceased an hour or an hour and a half at that point based on what they had been told by Registered Nurse Supervisor #3. The Director of Nursing, Administrator and Registered Nurse Supervisor #3 were all involved in that situation. The expectation for nursing was to follow a resident's Advance Directives order. Any staff with cardiopulmonary resuscitation certification should initiate cardiopulmonary resuscitation on a resident without a pulse who was designated as Full Code. They had no explanation as to why staff delayed starting cardiopulmonary resuscitation on Resident #1. On [DATE] at 11:06 AM, Certified Nurse Aide #4 was called for an interview, and did not return the call. During a phone interview on [DATE] at 11:50 AM with Licensed Practical Nurse #2, they stated the last time they checked on Resident #1 was around 10:00 PM on [DATE] and the resident appeared to be sleeping. They were finishing up their medication pass on one side of the unit when they heard staff calling up the hall around 10:45 PM. They went into Resident #1's room and saw Certified Nurse Aides doing incontinence care on the resident who appeared quite deceased . Licensed Practical Nurse #1 said the resident was deceased . They left the resident's room and went back to doing their nursing tasks on their side of the hall. They checked the resident's code bracelet, and the resident did not have a pulse. They knew the resident was a Full Code. They knew the protocol for a Code Blue, but because Registered Nurse #3 had been called by Licensed Practical Nurse #1, they thought they would take over. Looking back on the situation, once they had determined Resident #1 was a Full Code, they should have called a Code Blue and started cardiopulmonary resuscitation. They were not thinking straight and did not have any further explanation as to why they did not follow the Code Blue protocol. 10NYCRR 400.21(c) __________________________________________________________________________________ Immediate Jeopardy past non-compliance was identified, and the Administrator on Record was notified on [DATE] at 2:36 PM. The facility provided verification the following corrective actions were completed: -Licensed Practical Nurse #1 and Licensed Practical Nurse #2 were suspended immediately following the incident on [DATE]. -Facility policies for Basic Life Support and Cardiopulmonary Resuscitation, Code Blue, Cardiopulmonary Resuscitation Certification, Advance Directives and Determination of Death were all reviewed and completed by [DATE]. -Re-education and staff knowledge competencies of licensed nursing staff and certified nurse aides for Basic Life Support and Cardiopulmonary Resuscitation, and Code Blue Procedure, were initiated on [DATE]. -The facility would add and conduct cardiopulmonary resuscitation and basic life support training to a semi-annual schedule with competencies. -The facility would add and conduct semi-annual cardiopulmonary resuscitation drills across all shifts, initiated [DATE]. -All residents' Advance Directives were audited and completed on [DATE]. -All residents' Full Code (heart symbol) bracelets were audited and completed on [DATE]. -All licensed staffs' cardiopulmonary resuscitation certifications were audited and completed on [DATE]. -All staff present on the unit at the time of the [DATE] incident were interviewed, with interviews completed on [DATE]. -Resident #1's medical record and staff statements were reviewed and completed on [DATE]. -A Root Cause Analysis of the incident and Quality Assurance and Performance Improvement meeting was initiated on [DATE] with a completion date of [DATE]. -Resident deaths in the last six (6) months were reviewed, initiated [DATE] and completed on [DATE]. -A Quality Assurance and Performance Improvement for Basic Life Support and Cardiopulmonary Resuscitation was initiated on [DATE]. -Licensed Practical Nurse #1 was terminated from employment on [DATE] and reported to the New York State Office of Professions Licensing Board on [DATE]. -Licensed Practical Nurse #2 was terminated from employment on [DATE] and reported to the New York State Office of Professions Licensing Board on [DATE]. An addendum to the Action Plan on [DATE] documented: -There would be unannounced, random staff knowledge competencies for Code Blue and Cardiopulmonary Resuscitation 10 times weekly times three months and the results would be reported to the Quality Assurance and Performance Improvement Committee monthly. The Quality Assurance and Performance Improvement Committee would determine the need for ongoing monitoring after three months. The responsible party would be the Director of Nursing/Assistant Director of Nursing. -Mock Code and Cardiopulmonary Resuscitation Drills and post-review would be done across all shifts weekly times four weeks; then monthly times two months; then a minimum of semi-annually. The performance reviews/results would be presented to the Quality Assurance and Performance Improvement Committee monthly times three months; then the Quality Assurance and Performance Improvement Committee would determine the need for ongoing reporting. The responsible party would be the Director of Nursing/Director of Education. -The audits on Full Code (cardiopulmonary resuscitation) identifier bracelets would be done weekly times three months and results would be reported to the Quality Assurance and Performance Improvement Committee monthly. The Quality Assurance and Performance Improvement Committee would then determine the need for ongoing reporting. The responsible party would be the Director of Nursing/Assistant Director of Nursing. -An audit tool was developed to track every admission and re-admission's Advanced Directives. The responsible party would be the Director of Nursing/Assistant Director of Nursing. -A comprehensive education syllabus was in development for presentation at orientation and annually on the following topics: Advance Directives, Code Blue, Cardiopulmonary Resuscitation, and Nurse Scope of Duties. The responsible party would be the Director of Nursing/Assistant Director of Nursing. -As of [DATE], during the onsite visit, all licensed nursing staff were educated on Acute Changes in Condition: Basic Life Support and Cardiopulmonary Resuscitation, and Code Blue Procedure.

Based on observation, record review, and interview during the recertification survey conducted 4/9/2024-4/12/2024, the facility did not maintain an effective pest control program so that the facility was free of pests in four isolated areas (the main kitchen, and the 2nd, 3rd, and 4th floor tub rooms) reviewed. Specifically, there were fruit flies in the main kitchen and drain flies in the 2nd, 3rd, and 4th floor tub rooms. Findings include: The third-party pest control vendor service inspection reports from 11/17/2023 to 4/10/2024, did not include documentation of the presence of fruit flies or drain flies in the facility. The facility's Pest Activity/Sightings Log documented that fruit flies were present in the main kitchen on 1/4/2024, 2/12/2024, 3/22/2024, 4/2/2024, and 4/5/2024. The following observations were made: - on 4/9/2024 at 9:30 AM, the main kitchen had 15 live fruit flies by dish machine area. - on 4/9/2024 at 11:55 AM, the 4th floor tub room had 3 live drain flies and multiple dead drain flies on the floor. - on 4/9/2024 at 12:18 PM, the 2nd floor tub room had 15 live drain flies. - on 4/9/2024 at 12:50 PM, the 3rd floor tub room had 10 live drain flies and multiple dead drain flies on the floor. During an interview on 4/12/2024 at 10:35 AM, the Environmental Services Manager stated they were not aware there were drain flies in the 2nd, 3rd, or 4th floor tub rooms. They stated the tub rooms on the 2nd, 3rd, and 4th floors were actively used by residents. The Environmental Services Manager stated the fruit fly traps in the 4th floor tub room were not put there by the environmental services department or the maintenance department. They stated they expected staff to report pests found in the facility via a phone call, and they would then contact the pest control vendor. They were aware of fruit flies in the main kitchen and was not aware that the main kitchen had its own internal pest log sheet. They stated, between 11/17/2023 and 4/10/2024, the monthly pest control vendor service inspection reports did not document any fruit flies or drain flies. It was important that pest maintenance was maintained for comfort and safety of residents and staff. 10NYCRR 415.29(j)(5)

Based on observation, record review, and interviews during the recertification survey conducted 4/9/2024-4/12/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 of 8 residents (Residents #12, #38, #40 and #58) reviewed. Specifically, Resident #12 had unclean and untrimmed fingernails; Resident #40 was not assisted out of bed for toileting; Resident #58 was not assisted with toileting every 2 hours as care planned; and Resident #38 had unclean fingernails. Findings include: The facility policy Activities of Daily Living (ADL) revised 10/2023 documented appropriate care and services would be provided for residents who were unable to carry our activities of daily living independently in accordance with the plan of care, including support and assistance with hygiene, mobility, elimination, dining, and communication. 1) Resident #12 was admitted to the facility with diagnoses including right sided hemiplegia and hemiparesis (paralysis and weakness) following cerebrovascular disease and dementia. The 2/2/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, did not exhibit behavioral symptoms, had upper extremity impairment on one side, required substantial/maximal assistance with showering/bathing, and partial/moderate assistance for personal hygiene. The comprehensive care plan revised 7/25/2023 documented the resident required assistance with activities of daily living related to a stroke. Interventions included total assistance of 2 for showering/bathing and extensive assistance of 1 for personal hygiene. The 4/2024 resident care instructions (Kardex) documented the resident required total assistance of 2 for showering/bathing, extensive assistance of 1 for personal hygiene, and used a wheelchair. Resident #12 was observed: - On 4/9/2024 at 10:33 AM, seated in their wheelchair in the hallway. The resident's fingernails were long, unkept, and had a dark brown/black substance under all 10 of their fingernails. - On 4/10/2024 at 2:53 PM, seated in their wheelchair in the hallway. The resident's fingernails were long, unkept, and had a dark brown/black substance under all 10 of their fingernails. - On 4/11/2024 at 10:15 AM, seated in their wheelchair in front of the nursing station. The resident's fingernails were long, unkept, and had a dark brown/black substance under all their fingernails except for their left thumb nail. At 4:11 PM, the resident's fingernails were long and unkept. The 4/11/2024 skin assessment documented the resident received a shower during the day shift, their skin had no open areas, and their fingernails were not trimmed. During an interview on 4/11/2024 at 5:02 PM, certified nurse aide #14 stated certified nurse aides were responsible for resident showers. On shower days they completed nailcare, hair care, and the resident's skin was assessed by the nurse. If the resident was a diabetic the nurse was responsible for cutting their nails. They stated Resident #12 never refused care and they gave them a shower during the day shift. They could not recall if they trimmed their nails. The stated it was important to perform personal hygiene and to keep Resident #12's fingernails from getting too long for resident safety. During an interview on 4/11/2024 at 5:11 PM, licensed practical nurse #9 stated Resident #12 received their weekly shower that morning. Certified nurse aides were responsible for trimming fingernails on shower days. During a shower the certified nurse aide would turn on the call light so the nurse could go in and do a skin check. They documented their skin and nail findings in a skin assessment in the electronic medical record. They stated Resident #12 did not refuse care or showers. Licensed practical nurse #9 observed Resident #12 during the interview and stated they needed their nails cut. They stated having long fingernails placed Resident #12 at risk for cutting themselves or someone else, and it was not sanitary to have a dark substance under their nails. During an interview on 4/12/2024 at 10:29 AM, Registered Nurse Manager #15 stated on shower days certified nurse aides were expected to cut residents' fingernails. Resident #12 received their shower on 4/11/2024 so their nails should have been cleaned and trimmed. They stated it was important to keep Resident #12's nails clean, trimmed, and filed for safety. If the resident received a cut, it could have led to an infection. During an interview on 4/12/2024 at 12:38 PM, Assistant Director of Nursing #4 stated staff should look at the resident's care plan and care instructions to know how to care for the resident. On shower days the certified nurse aide was responsible for haircare, nail care, and grooming. If a resident was a diabetic the licensed nurse would complete the nail care. If Resident #12 had long/dirty fingernails, they expected staff to notice and take care of it. If there was no documented refusal, there was no reason it should not have been done on the resident's shower day. They stated it was important to keep nails cleaned and trimmed for infection control purposes. Long fingernails put Resident #12 at risk for cutting themselves or others. 2) Resident #40 had diagnoses including compression fracture of the thoracic vertebrae (mid-spine), muscle weakness, and need for assistance with personal care. The 1/10/2024 Minimum Data Set documented the resident was cognitively intact, required substantial/ maximum assistance with toileting, was frequently incontinent of bowel and bladder, and did not reject care. The comprehensive care plan initiated on 6/21/2023 and revised on 7/19/2023 documented the resident has functional nocturnal (nighttime) bladder incontinence related to weakness. Interventions included monitor toileting scheduled every 2 hours, take resident to bathroom before bedtime and at 3:00 AM. The comprehensive care plan initiated 11/3/2023 documented the resident had an activity of daily living deficit related to weakness. Interventions included the resident was dependent on toileting and required extensive assistance of 2 for transfers with a sit to stand lift (mechanical lift). During an observation and interview on 4/9/2024 at 11:17 AM, Resident #40 was lying on their back in bed. The resident stated they would like to get out of bed a couple of times a week, but they needed assistance of 2 and there was not enough staff, so they did not get out of bed. They stated staff did not let them go into the bathroom because they fell approximately 6 months ago in the bathroom. Now they had to use an incontinence brief in the bed when they needed to urinate and then ring the call bell for staff to come and change the brief. They stated they had not gotten up to go into the bathroom at all since they fell 6 months ago. They stated they knew when they needed to urinate and would often ask for a bedpan when they had to defecate. They stated they would prefer to get up and go into the bathroom. Resident #40's care instructions (Kardex) as of 4/12/2024 documented the resident required a mechanical sit to stand life with extensive assistance of 2 for transferring and was dependent for toileting. The resident's voiding routine documented to take the resident to the bathroom before bedtime, wake the resident at 3:00 AM to take to the toilet. During an interview on 4/12/2024 at 12:46 PM certified nurse aide #24 stated Resident #40 required assistance of 2 with the sit to stand lift. The resident usually urinated in their brief but would ask for a bedpan for a bowel movement. The resident told them when they were wet and needed to be changed. Residents should be encouraged to function at their highest level. They stated the resident was afraid to fall and afraid to get out of bed, because staff would not get them back into bed timely. During an interview on 4/12/2024 at 12:59 PM licensed practical nurse #21 stated the certified nurse aides followed the level of care on the Kardex for toileting. They stated if a resident was able to get out of bed they should. Lying in urine or feces could contribute to skin irritation and breakdown. They had never seen Resident #40 out of bed. 3) Resident #58 had diagnoses including dementia, need for assistance with personal care, and anxiety. The 2/11/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, rejected care 1-3 of 7 days, was dependent with toileting, hygiene, and toilet transfers, was on a toileting program to manage urinary continence, was frequently incontinent of bladder, and received a diuretic (water pill). The 12/11/2019 comprehensive care plan documented the resident had an activity of daily living self-care performance deficit due to disease process. Interventions included extensive of assistance of 2 with toileting from 9:00 AM-10:00 AM following their diuretic, and then every 2 hours and as needed. The resident required extensive assistance of 2 using a mechanical stand lift to move between surfaces. The revised 1/16/2024 comprehensive care plan documented the resident was at risk for skin breakdown related to decreased mobility and occasional incontinence. Interventions included monitoring skin. The 2/10/2024 physician orders documented the resident received 20 milligrams of torsemide (diuretic) one time a day every other day. The undated care instructions (Kardex) documented the resident required extensive assistance of 2 with toileting via mechanical stand lift and was to be toileted every 2 hours and as needed. The 4/11/2024 6:00 AM-2:00 PM unit assignment sheet documented certified nurse aide #25 was responsible for assignment one, which included Resident #58. On 4/11/2024 certified nurse aide #25 documented Resident #58 was toileted every 2 hours at 7:58 AM, 8:07 AM, 10:39 AM, and 1:40 PM. During an observation on 4/11/2024 at 11:12 AM, Resident #58 returned to the unit from an off-unit activity and self-propelled their wheelchair into their room. At 12:34 PM, the resident remained in their wheelchair in their room. At 12:48 PM, the resident was provided their meal tray in their room by an unidentified staff. At 1:18 PM, an unidentified staff removed the resident's meal tray from their room. At 2:21 PM, an unidentified activity staff asked the resident if they wanted to go off the unit to an activity which they declined. At 2:30 PM, the resident had not been provided toileting assistance since returning to the unit at 11:12 AM. During an interview on 4/11/2024 at 4:36 PM, licensed practical nurse #26 stated they started working on the unit that morning at around 11:00 AM. They expected staff to reapproach any resident who refused care and let the nurse know. If staff was unable to provide care, they should let the nurse know as well so they could help or find additional help. If they were made aware staff was unable to provide care, they would let a supervisor know. They stated they were not aware of any residents who did not receive care today. During an interview on 4/11/2024 at 5:10 PM, certified nurse aide #25 stated staff reviewed the care instructions which let staff know what level of assistance the residents required and any special instructions. If the care instructions documented the resident required extensive assistance of 2 that meant 2 people were needed to provided care and staff did most of the task for the resident. They could not recall what assignment they were scheduled today but they were familiar with Resident #58. They were unsure if the resident was on a toileting program and the resident was usually continent and could tell staff if they needed to use the bathroom. The resident usually required extensive assistance of 2, but sometimes could be extensive assistance of 1. They knew they charted wrong, and the only care they provided besides passing them their meal tray was toileting assistance around 7:30 AM. Prior to that the resident was going to an activity off the unit in the morning. They stated staff was supposed to follow the care plan and at least ask the resident if they needed to use the bathroom. They did not tell anyone that they did not place the resident on the toilet or ask them if they needed to use the bathroom. During an interview on 4/12/24 at 12:06 PM, Registered Nurse Unit Manager #3 stated staff was expected to follow the care plan and care instructions. If they were unable to provide care, they should alert a nurse so care could be provided. If a resident was on a toileting program staff should check to ensure the resident did not need to be changed or brought to the bathroom. If a resident was care planned for extensive assistance of 2 that meant 2 staff members should have been in the room to provide care for safety reasons. Resident #58 was on a 2-hour toileting program and required extensive assistance of 2 with transfers and toileting. They were unaware the resident had not been provided toileting assistance as care planned. The resident had very fragile skin and 4 hours was a long time to go without being assisted to the bathroom. During an interview on 4/12/2024 at 2:03 PM, Assistant Director of Nursing #4 stated staff should always follow the care plan. If a resident refused care or staff were unable to provide care, they should let a nurse know. If a resident was on a toileting program staff should have at least asked the resident if they needed to use the bathroom. 4 hours was a long time to go without being assisted to the bathroom. It was important to follow the care plan, so the resident's abilities did not diminish. 10NYCRR 415.12 (a)(3) 48675 49448

Based on observation, record review, and interviews during the recertification survey conducted 4/9/2024-4/12/2024 the facility did not ensure sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for 12 of 12 anonymous residents. Specifically, during a confidential resident group meeting residents stated their call bells were not answered timely and meals were not hot when served due to the lack of staff. Additionally, deficiencies related to staffing levels were identified in the areas Activities of Daily Living (F 677), Food Palatability (F804), and Activities (F 679). Finding include: The facility policy Nursing Service Staffing Schedule revised 6/2021 documented the facility would provide a working schedule for each member of nursing services that would meet staff needs and the needs of all the patient care units. The Nurse Managers were responsible for coordinating with shift supervisors regarding the scheduling of nursing personnel, collaborating with the supervisors regarding transfers and replacements, and reviewing the daily needs and developing staffing patterns. The supervisors were responsible for assigning the float nurses from the nursing office and reassigning staff as needed to meet patient needs. The Facility Assessment, last updated 12/26/2023, documented the facility was licensed for a total of 160 skilled nursing bed. There were 149 residential health care facility (RHCF) beds and 11 ventilator (breathing machine) beds. Most residents required assistance with mobility, bathing, dressing, toileting and transferring. The facility's staffing plan was based on resident population and their needs for care. The staff plan included the following positions with the desired number total for the facility, by shift: certified nurse aides, desired number for day shift 20; evening shift 16; and night shift 8. Licensed practical nurses, desired number for day shift 8; evening shift 8; and night shift 4. Registered nurses, desired number for day shift 4; evening shift 4; and night shift 4. During the entrance conference interview on 4/9/2024 at 9:50 AM the Administrator stated the facility census was 130 residents. Scheduled Staffing: The facility staffing schedule provided on day 1 of survey documented the following nursing schedule for 4/9/2024 through 4/12/2024 (there were 4 nursing care units: Units 2, 3, 4, and 5 which included the 11 ventilator beds): Tuesday 4/9/2024, day shift staffing documented the following schedule for 130 residents: - 3 registered nurses. - 6 licensed practical nurses. - 12 certified nurse aides (1 worked 6:00 AM- 10:00 AM) Tuesday 4/9/2024, evening shift staffing documented the following schedule for 130 residents: - 1 registered nurse. - 5 licensed practical nurses. - 10 certified nurse aides. Tuesday 4/9/2024, night shift staffing documented the following schedule for 130 residents: - 1 registered nurse. - 5 licensed practical nurses. - 9 certified nurse aides (1 worked 3:00 AM- 6:00 AM). Actual staffing documented: Tuesday 4/9/2024, day shift staffing: - Unit 2: registered nurse supervisor (covering all units), 1 licensed practical nurse, 1 certified nurse aide for 15 residents. - Unit 3: 1 registered nurse manager, 1 licensed practical nurse, and 4 certified nurse aides for 40 residents. - Unit 4: 2 licensed practical nurses, 3 certified nurse aides for 37 residents. - Unit 5: 1 registered nurse manager, 2 licensed practical nurses, 4 certified nurse aides (1 worked 6:00 AM- 10:00 AM) for 38 residents. Tuesday 4/9/2024, evening shift staffing: - Unit 2: 1 registered nurse supervisor (covering all units), 1 licensed practical nurse, 2 certified nurse aides (1 worked 7:00 PM- 10:00 PM) for 15 residents. - Unit 3: 1 licensed practical nurse, 4 certified nurse aides (1 worked until 6:00 PM) for 40 residents. - Unit 4: 1 licensed practical nurse, 3 certified nurse aides for 37 residents. - Unit 5: 2 licensed practical nurses, 3 certified nurse aides for 38 residents. Tuesday 4/9/2024, night shift staffing: - Unit 2: 1 registered nurse supervisor (covering all units), 1 licensed practical nurse, 1 certified nurse aide for 15 residents. - Unit 3: 1 licensed practical nurse, 2 certified nurse aides for 40 residents. - Unit 4: 1 licensed practical nurse, 2 certified nurse aides for 37 residents. - Unit 5: 2 licensed practical nurses, 3 certified nurse aides for 38 residents. Scheduled Staffing: Wednesday 4/10/2024, day shift staffing documented the following schedule for 130 residents: - 3 registered nurses (1 worked 11:00 AM- 3:00 PM). - 6 licensed practical nurses. - 15 certified nurse aides. Actual staffing documented: Wednesday 4/10/2024, day shift staffing: - Unit 2: 1 registered nurse supervisor (covering all units), 1 licensed practical nurse, 1 certified nurse aide, 1 unit helper. - Unit 3: 1 registered nurse manager, 1 licensed practical nurse, 5 certified nurse aides. - Unit 5: 1 registered unit manager, 2 licensed practical nurses, 5 certified nurse aides. Scheduled Staffing: Thursday 4/11/2024, day shift staffing documented the following schedule for 130 residents: - 3 registered nurses. - 7 licensed practical nurses. - 15 certified nurse aides. Actual staffing documented: Thursday 4/11/2024, day shift staffing: - Unit 2: 1 licensed practical nurse, 1 certified nurse aide, 1 unit helper. - Unit 3: 1 registered nurse manager, 1 licensed practical nurse, 5 certified nurse aides, 1 unit helper. - Unit 5: 1 registered nurse manager, 3 licensed practical nurses, 4 certified nurse aides. Activities of Daily Living (refer to F 677) Resident #40 was not assisted out of bed for toileting, and Resident #58 was not assisted with toileting every 2 hours as care planned. During an observation and interview on 4/9/2024 at 11:17 AM, Resident #40 was in bed and stated they would like to get out of bed a couple of times a week, but it took assistance of 2 and there was not enough staff, so they did not get out of bed. They stated the staff did not let them go to the bathroom because they fell approximately 6 months ago in the bathroom and now, they would use an incontinence brief in the bed when they needed to go to the bathroom and then ring the call bell for staff to come and change them. They stated they knew when they needed to urinate and would often ask for a bedpan to defecate in although they stated they would have preferred to get up and go to the bathroom. During an observation and interview on 4/11/2024 at 4:48 PM, Resident #40's call light was on. Their call light was answered at 5:11 PM. They stated they needed their incontinence brief changed after they urinated and stated that was a short call bell response time. Food Palatability (refer to F 804) Food was not served at appetizing temperatures during lunch meals on 4/12/2024. During a resident meeting with 12 anonymous residents on 4/9/2024 at 1:35 PM, they stated the meal carts would arrive to the unit, but there was not enough staff to pass the meal trays timely. During an interview on 4/12/2024 at 10:51 AM, certified nurse aide #14 stated unit staff passed the meal trays as quickly as they could, but it depended on the number of staff that were on the unit how quickly the meal trays were passed. The meal carts were not separated where the residents ate their meals. Activities (refer to F 679) Resident #79 was not provided meaningful activities that met their interests and preferences. During an interview on 4/12/24 at 9:47 AM, certified nurse aide #30 stated they worked on unit 5 and the ventilator unit. Some residents liked to go to activities, they rarely saw activities on the unit, and they did not see a lot of 1:1 room visits. Resident #79 had not gone to any recent activities, therapy would occasionally take them off the unit, and they liked to use fidget toys, handheld games, and their preferences were TV and music. They stated 10 of 11 residents required assistance of 2 for care, 2 certified nurse aides were usually scheduled to work on the unit, but there was usually only 1 nurse, 1 certified nurse aide and 1 respiratory therapist working which could have caused extended wait times for Resident #79 to get up. General Staffing During an interview on 4/11/24 at 4:20 PM, certified nurse aide #29 stated Resident #102 required assistance of 2 or more due to limited range of motion and sometimes needed assistance of 3. The lack of staff could have led to the resident having to wait to use the bed pan, get transferred, repositioned, or receive incontinence care. When there was 1 certified nurse aide, 1 nurse, and 1 respiratory therapist on the unit it made it difficult to provide care timely. During an interview on 4/12/2024 at 5:00 PM, the Administrator stated resident care needs were included when they determined staffing levels on each unit. Staff retention was being monitored and reported to Senior Management. They had identified the biggest turnover was certified nurse aides that stayed for less than 1 year. They were developing a strategy to change that. They had recent job fairs and were able to recruit nurses and certified nurse aides. Their biggest staffing factor was having 5 nurses out on medical leave since December 2023. They had been filling the staffing gap with agency staff, management had to sometimes step in, and they had to sometimes pull staff from other units. They were unsure if the resident's wait time was increased due to staffing. They stated last October pay rates were raised and they were looking at raising rates again, offering a night shift sign on bonus, and they were working with Human Resources to streamline the onboarding process. 10 NYCRR 415.13(a)(1)(i-iii) 49448

Based on observation, record review, and interview during the recertification survey conducted 4/9/2024-4/12/2024, 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 3 of 5 residents (Resident #37, #105, and #280) reviewed. Specifically, Resident #280 was admitted to the facility with a diagnosis of COVID-19 and transmission based precautions were not maintained; and Residents #37 and #105 had indwelling medical devices and were not placed on enhanced barrier precautions as required. Additionally, during a medication administration observation licensed practical nurse #8 did not perform hand hygiene between residents. Findings include: The facility policy Extended Care Facility Transmission Based Precaution Guidelines revised 2/2024 documented standard precautions would be used with every resident in the facility. Other precautions would be utilized depending on the mode of transmission of the organism in question. -Standard precautions were to be used for the care of all residents. Hand hygiene was performed before and after resident care regardless of whether gloves were worn. -Enhanced barrier precautions included the use of gowns and gloves for high contact resident care activities, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of multi-drug resistant organism colonization as well as well as for residents with multi-drug resistant organism infection or colonization. Examples of high contact resident care activities requiring gown and glove use for enhanced barrier precautions include (but are not limited to): dressing, bathing, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator), and wound care. The procedure included place enhanced barrier precaution sign on the door. Gown and gloves were worn whenever high contact resident activities were performed. -Enhanced droplet precautions were to be used in addition to standard precautions if the resident had suspected or confirmed COVID-19. The procedure included place enhanced droplet precautions sign on the outside of the room door with the door closed. Wear N95 mask, eye protection, gown, and gloves while in the resident room (wear surgical mask over the N95 mask to preserve the integrity of the N95 mask). 1) Resident #280 was admitted to the facility with a diagnosis of COVID-19. The admission Minimum Data Set assessment was not yet completed. Physician orders dated 4/3/2024 documented the resident was to be on contact and droplet precautions for COVID-19. The comprehensive care plan dated 4/3/2024 documented the resident was on isolation with contact/droplet precautions related to COVID-19 positive testing. Approaches included enforce strict hand hygiene by resident, staff, and visitors, and provide education to resident and staff. The resident care instructions (Kardex) documented contact/droplet precautions for COVID-19 illness. The following observations were made: - on 4/9/2024 at 11:40 AM, unit helper #22 delivered a lunch tray to Resident #280's room. They put on a gown, gloves, and surgical mask before entering. They left the room with the dirty gown in their hand and took it to the dirty utility room. There was no dirty linen receptacle setup in or out of Resident #280's room. The sign outside the room documented enhanced barrier precautions, and not droplet precautions as required for COVID-19. The room door remained open. - on 4/9/2024 at 12:27 PM, certified nurse aide #23 took N95 masks to place outside of Resident #280's room. They stated they ran out of them this morning and was supposed to wear them. - on 4/10/2024 at 10:02 AM, a dirty linen cart was setup outside of Resident #280's room and the door remained open. - on 4/10/2024 at 2:53 PM, unit helper #22 went to answer the resident's call bell. They put on a gown, gloves, and a N95 mask, and did not wear eye protection. - on 4/10/2024 at 3:03 PM, licensed practical nurse #16 responded to the resident's call bell. They put on a gown, gloves, a surgical mask, and did not wear eye protection. During an interview on 4/12/2024 10:25 AM, unit helper #22 stated transmission based precautions were identified by signs outside of doors. The signs identified the personal protective equipment needed. Resident #280 was on enhanced droplet precautions because of COVID-19. On Tuesday morning (4/9/2024) there were no N95 masks available outside of room. They stated at that time they entered the resident's room wearing a surgical mask and no eye protection. It was important to use proper personal protective equipment to prevent the spread of infection. During an interview on 4/12/2024 at 11:05 AM licensed practical nurse #16 stated transmission based precautions were communicated by the sign on the door. Resident #280 was on enhanced droplet precautions for COVID-19. Enhanced droplet precautions for COVID-19 required a N95 mask, gown, goggles (eye protection), and gloves to enter the room to protect yourself and prevent the spread of infection. They stated on 4/10/2024 they just went in the room too fast and did not put a N95 mask on and they should have put on the N95 mask and eye protection. Regular glasses would not provide enough protection and they should have used goggles or a face shield. They were not aware the sign outside of the door was not correct and was not sure who put it up. It was important to have correct signage for all who may enter the room to prevent the spread of infection. During an interview on 4/12/2024 at 10:38 AM, Registered Nurse Supervisor #13 stated Resident #280 should be on enhanced droplet precautions due to COVID-19. The current sign outside of their room documented enhanced barrier precautions, which was not correct. They were not sure who put the sign up. The incorrect sign made it difficult for staff to know what to wear to protect themselves and prevent the spread of COVID-19. COVID-19 was very dangerous to this population. The personal protective equipment required for enhanced droplet precautions included a gown, gloves, a N95 mask, and eye goggles or a face shield. Personal eyeglasses were not sufficient for protection. During an interview on 4/12/2024 at 12:41 PM, Infection Control Preventionist #31 stated infection control education was done at orientation, annually, and on the spot training if needed. Any needs for transmission based precautions were communicated to the Unit Manager, the Director of Nursing, and the Assistant Director of Nursing. They were responsible for ensuring the proper signs and personal protective equipment were placed per policy. COVID-19 positive residents required enhanced droplet precautions. The required personal protective equipment was gloves, gowns, a N95 mask, and eye protection. Hand hygiene should always be performed before and after glove use as well. The facility's population was especially vulnerable to COVID-19 due to risk of complications and possible death from the disease. Enhanced droplet precautions should be adhered to every time, by everyone entering the room. Eyeglasses did not count as eye protection, and staff must wear approved goggles or a face shield. 2) Resident #37 had diagnoses including acute and chronic respiratory failure with hypoxia (low oxygen levels), tracheostomy (breathing tube), and gastrostomy (feeding tube). The 1/25/2024 Minimum Data Set assessment documented the resident received oxygen, suctioning, tracheostomy care, and invasive mechanical ventilation. Resident #37's physician order summary report with active orders as of 4/12/2024 documented tracheostomy size #8 double cannula tube, tracheostomy care every 8 hours, and tracheostomy change as needed. Suction oral secretions as needed. Physician orders did not document enhanced barrier precautions. Resident #37's comprehensive care plan revised 5/15/2023 documented the resident was ventilator (breathing machine)/tracheostomy dependent related to respiratory failure and a diagnosis of myotonic dystrophy (progressive muscle wasting and weakness). Enhanced barrier precautions were not documented in the care plan. Resident #105 had diagnoses including chronic respiratory failure with hypercapnia (high levels of carbon dioxide in the blood), tracheostomy (breathing tube), gastrostomy (feeding tube), and ventilator (breathing machine) dependence. The 2/25/2024 Minimum Data Set assessment documented the resident received oxygen, suctioning, tracheostomy care, and invasive mechanical ventilation. Resident #105's physician order summary report with active orders as of 4/12/2024 documented a urinary catheter 16 French (size) with a 10 milliliter balloon (used to keep the catheter in place); urinary catheter care every shift; a size 8 cuffed double cannula tracheostomy tube; suction oral secretions as needed; a vacuum assisted wound closure device applied every Monday, Wednesday, and Friday for sacral wound; and dressings for lateral ankle wound. Resident #105's comprehensive care plan documented: - on 10/19/2023 the resident had a percutaneous endoscopic gastrostomy tube (feeding tube). - on 1/18/2024 the resident had actual impairment to skin integrity. - on 2/11/2024 the resident depended on a ventilator. Residents #37 and #105 resided together in a room on the ventilator unit. The following observations were made: - on 4/9/2024 at 12:36 PM, all rooms on the ventilator unit had personal protective equipment caddies and enhanced barrier precautions signs except for Residents #37's and #105's room and room [ROOM NUMBER]. There was no sign present outside of either room indicating enhanced barrier precautions were in place. - on 4/10/2024 at 8:48 AM, respiratory therapist #18 was observed going into the residents' room (the ventilator alarm was sounding) wearing gloves and a surgical mask. No enhanced barrier signs were posted outside the room. - on 4/10/2024 at 2:01 PM, certified nurse aides #29 and #39 entered Residents #105's and #37's room to provide repositioning and incontinence care to Resident #105. Both certified nurse aides wore only gloves. They did not put on gowns. During an interview on 4/12/2024 at 9:35 AM, certified nurse aide #29 stated that care information for residents was found in the care plan and Kardex. Ventilator unit precautions had been changed in the past couple of months. Paper gowns were used to help reduce spread of infection. They stated enhanced barrier precautions were used for any residents with colonized bacteria. If they were not performing personal care up close, staff only needed to perform hand hygiene in and out of the room. Personal protective equipment was used to protect all residents and staff from the spread of infection. Resident #105 was on standard precautions and staff only needed to wear gloves for care. During an interview on 4/12/2024 at 9:47 AM, certified nurse aide #30 stated the care plan and Kardex contained all care information needed for resident care. Enhanced barrier precautions meant they could enter the room without personal protective equipment. Gowns, gloves, and a mask were required for hands on care. Contact or droplet precautions required personal protective equipment all the time. They were not sure if Resident #105 was on transmission based precautions. During an interview on 4/12/2024 at 11:59 AM, Assistant Director of Nursing #4 stated transmission based precautions were communicated to staff by the signs placed in front of a resident room. The sign documented the personal protective equipment needed to enter the room. Any staff could request more personal protective equipment if needed. COVID-19 positive residents needed enhanced droplet signs. A registered nurse directed the signage to make sure it was correct. Enhanced droplet precautions required N95 masks, goggles, gown, and gloves. Proper personal protective equipment usage was important to prevent the spread of infection. The population at the facility was vulnerable to infection and COVID-19 was a dangerous disease. Enhanced barrier precautions were just recommendations for residents with a history of multi drug resistant organisms. The Centers for Medicare/Medicaid Services wanted them used for residents with indwelling medical devices such as tracheostomies, urinary catheters, or any wounds. All residents on the ventilator unit should be on enhanced barrier precautions. It was not safe to enter a COVID-19 positive room without proper personal protective equipment. During an interview on 4/12/2024 at 12:41 PM, Infection Control Preventionist #31 stated enhanced barrier precautions were implemented in the past 3 months. Enhanced barrier precautions should be followed for anyone with a history of a multi drug resistant organisms, indwelling medical devices, or wounds. Enhanced barrier precautions were used to protect the most vulnerable residents. The ventilator unit should have enhanced barrier precautions in place for every resident. Those residents had a direct portal for infection. Enhanced barrier precautions required gloves, gowns, and a surgical mask for close direct care. The proper use of protective equipment was important to decrease the possibility of spreading pathogens from staff's clothing, hands, or respiratory tract to the residents. 3) During a medication administration observation with licensed practical nurse #8 on 4/11/2024 from 9:07 AM to 9:52 AM the following was observed: - at 9:07 AM, licensed practical nurse #8 exited the dining room and approached the medication cart and wheeled it down the hallway to Resident #381's room. Hand hygiene was not performed after they exited the dining room and before they pushed the medication cart down the hallway. Licensed practical nurse #8 realized they had the wrong medication cart at 9:10 AM, wheeled the incorrect medication cart back to the nurse's station and returned with the correct medication cart at 9:11 AM. The cart was unlocked at 9:12 AM, and 11 medications were emptied from the medication sleeves at 9:15 AM, directly onto the top surface of the medication cart. Licensed practical nurse #8 scooped up the medications with two connected unopened alcohol wipe packages and placed the medications in a plastic medication cup. Miralax was poured from a large bottle and mixed with water. No hand hygiene was performed. At 9:17 AM, licensed practical nurse #8 entered Resident #381's room, hand hygiene was performed, and they handed the medication cup to the resident. The resident requested pain medication. At 9:18 AM, licensed practical nurse #8 exited the room, did not perform hand hygiene, and prepared the requested 2 pain medication pills for Resident #381. At 9:19 AM, licensed practical nurse #8 returned to Resident #381's room and did not perform hand hygiene. At 9:20 AM, licensed practical nurse #8 touched their lips with their hand to blow the resident's roommate a kiss. At 9:21 AM, licensed practical nurse #8 exited the room, hand hygiene was not performed, and they went back to the medication cart and unlocked it. The cart was then wheeled to Resident #118's room. - at 9:22 AM, licensed practical nurse #8 performed hand hygiene with an alcohol-based rub located outside of Resident #118's room. At 9:27 AM, the medication packages were opened, 8 medications were placed in a plastic medication cup, and one was later removed as they did not see an active order for it. Miralax was mixed with water. At 9:29 AM, the nurse locked the cart and entered Resident #118's room and administered the medications. At 9:31 AM, the nurse exited the resident's room, and did not perform hand hygiene. The nurse re-entered the room and asked the resident if they had any pain. At 9:34 AM, the nurse exited the room, did not perform hand hygiene, and disposed of a medication they did not provide, and returned to the medication cart. - At 9:38 AM, licensed practical nurse #8 locked the medication cart and went down the hall and obtained a blood pressure machine. At 9:39 AM, the nurse entered Resident #44's room with the blood pressure machine and did not perform hand hygiene. Resident #44 was on enhanced barrier precautions for an undocumented condition. The resident had an enhanced barrier precaution sign outside the room next to the door frame that instructed everyone who entered or exited the room to perform hand hygiene. At 9:40 AM, the resident's blood pressure was obtained and at 9:42 AM, the nurse left the room and did not perform hand hygiene. At 9:47 AM, licensed practical nurse #8 poured Resident #7's medications into a plastic medication cup with applesauce. At 9:48 AM, the nurse entered the resident's room with the medications and did not perform hand hygiene. The resident requested pain medication and at 9:48 AM, the nurse exited the resident's room, and did not perform hand hygiene. At 9:49 AM, the nurse returned to the medication cart and prepared the additional 2 medication pills and returned to the resident's room and did not perform hand hygiene. At 9:50 AM, the additional medication was provided to the resident. At 9:51 AM the nurse handed the resident their ordered inhaler. At 9:52 AM, licensed practical nurse #8 exited the room and returned to the medication cart and did not perform hand hygiene. During an interview on 4/11/2024 at 9:53 AM, licensed practical nurse #8 stated they should have performed hand hygiene in between each resident to prevent the spread of infection. They did not perform hand hygiene in between residents but they should have to prevent the spread of germs. They were not sure what enhanced barrier precautions were or why Resident #44 was on precautions. They confirmed after reading the enhanced barrier precaution signage that they should have performed hand hygiene each time they entered or exited the room. During an interview on 4/12/2024 at 12:12 PM, Infection Control Preventionist #31 stated hand hygiene should be performed in between residents when medications were passed. Hand sanitizers were located on the medication carts and outside of all resident rooms. It was important because lack of hand hygiene was the leading way infections were prevented. If hand hygiene was not performed it could put the residents at risk for infections. It was important that hand hygiene was performed before entering enhanced barrier precaution rooms as it prevented the spread of germs/infection. Hand hygiene should be performed again when exiting the room because it prevented the spread of germs from the resident to anyone outside of the room. Everyone was at risk for infection if the nurse did not perform hand hygiene. Appropriate hand hygiene was discussed in orientation, during in-services, and when any issues were identified. 10 NYCRR 415.19(a)(2) 48675 49448

Based on observation, record review, and interview during the recertification survey conducted 4/9/2024-4/12/2024, the facility did not ensure residents' right to privacy and confidentiality of medical records was maintained for 3 of 3 residents (Residents #44, #118, and # 381) reviewed. Specifically, the electronic medication administration records that displayed health information for Residents #44, #118, and # 381 were left open on the medication cart and were visible to passersby in the hallway. Findings include: The facility policy Patient Confidentiality revised 5/2021 documented every patient would be assured that their right to privacy was maintained and every aspect of their visit was held in strict confidence. Patient information was never disclosed to any unauthorized person (s) without the consent and authorization of the patient or the patient's legal representative (when applicable), except when required by law. During a continuous observation on 4/11/2024 from 8:34 AM through 9:07 AM, the Unit 4 medication cart was unattended in the hallway next to the nurse's station. The electronic medication administration record computer screen was open, facing outward, in plain view of passersby, and displayed a photograph and identifying health information for Resident # 381. The following observations were made on 4/11/2024 during a medication administration review: - at 9:17 AM licensed practical nurse #8 entered Resident #381's room to administer medications and the medication cart was left unattended in the hallway outside of Resident #381's room. The computer screen was left open while licensed practical nurse #8 was in the resident's room. The electronic medication administration record's screen displayed a photograph and identifying health information for Resident #381 and was visible to passersby. Licensed practical nurse #8 returned to the cart at 9:21 AM. - at 9:29 AM licensed practical nurse #8 entered Resident #118's room to administer medications and the medication cart was left unattended in the hallway outside of Resident #118's room. The computer screen was left open while licensed practical nurse #8 was in the resident's room. The electronic medication administration record's screen displayed a photograph and identifying health information for Resident #118 and was visible to passersby. Licensed practical nurse #8 returned to the cart at 9:34 AM. - at 9:38 AM licensed practical nurse #8 went down the hallway to obtain a blood pressure machine and the medication cart was left unattended in the hallway outside of Resident #44's room. The computer screen was left open, and the electronic medication administration record's screen displayed a photograph and identifying health information for Resident #44 and was visible to passersby. Licensed practical nurse #8 returned to the cart at 9:42 AM. - at 9:49 AM, licensed practical nurse entered Resident #44's room to administer medications and the medication cart was left unattended in the hallway outside of Resident #44's room. The computer screen was left open while licensed practical nurse #8 was in the resident's room. The electronic medication administration record's screen displayed a photograph and identifying health information for Resident #44 and was visible to passersby. Licensed practical nurse #8 returned to the cart at 9:52 AM. During an interview on 4/11/2024 at 9:52 AM licensed practical nurse #8 stated the computer screen that displayed identifying health information should not have been left open in the hallway. It was a breach of resident privacy. The Health Insurance Portability and Accountability Act protected patient health information from being disclosed. It was not appropriate that passersby could see residents' personal health information. They stated they should not have left the computer screen open when it was unattended. During an interview on 4/12/2024 at 2:03 PM the Assistant Director of Nursing stated when medications were administered it was not appropriate for the nurse to leave the electronic Medication Administration Record open in the hallway. There was a button that locked the screen to hide residents' personal health information. If the screen was not locked, they expected the nurse to at least manually flipped the computer screen down, so it was not visible to passersby in the hallway. It was important this information was not displayed in the hallway for patient confidentiality. Confidentiality was important for dignity and quite simply, others did not need to know what was going on with any other person. 10NYCRR 415.3(d)(1)(ii)

48675 Based on observation, record review, and interviews during the recertification survey conducted 4/9/2024-4/12/2024, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for 5 of 6 residents (Resident #43, #58, #92, #97 and #102) reviewed. Specifically, Resident #58's care plan did not include the use of a video monitoring device in their room; Resident #43's care plan did not include the use of anticoagulants (blood thinner) or insulin (a medication to control high blood sugar); Resident #102's care plan did not include the use of anticoagulants; Resident #97's care plan did not include the use of antipsychotics (medication used to treat psychosis); and Resident #92's care plan did not include the use of antidepressants or anticoagulants. Findings include: The facility policy Comprehensive Care Plans revised 4/2024 documented the interdisciplinary team developed a comprehensive, individualized plan of care for each resident that included measurable objectives to meet a resident's medical, nursing, mental, and psychosocial needs. The care plan guided the care and treatment provided to each resident. The interdisciplinary team developed the comprehensive care plan in coordination with the physician's plan of medical care. The care plan should be individualized and addressed the residents medical, nutritional, psychosocial, physical, functional, and spiritual needs and the severity of the resident's condition, impairments, disability, or disease. The care plans would be reviewed by all staff that provided care to the resident and updated at least quarterly, when there was a significant change, and as needed. 1) Resident #58 was admitted with diagnoses including dementia and anxiety. The 2/11/2024 Minimum Data Set Assessment documented the resident had severely impaired cognition, rejected care 1-3 of 7 days, was dependent for dressing, toileting, personal hygiene, and transfers, and received an antipsychotic medication. A 10/1/2021 registered nurse #35 progress note documented the resident awoke at approximately 11:55 PM, was screaming, distraught, and saying that they had been sexually assaulted. No one had been in or out of their room. The resident was being checked every 15 minutes and prior to this was sleeping soundly. On 10/1/2021 the Chief Medical Officer documented the resident was seen for an evaluation of their endorsement of sexual assault. The resident was recently transferred from the 3rd floor to the 5th floor to be in a private room and closer to the nursing station due to unfound prior complaints of sexual assault. The resident was examined and there were no signs of assault. The case was discussed with the resident's representative. The plan included to reach out to the psychiatrist to address delusions of sexual thoughts, and the representative agreed with placing a video camera in the resident's room for a few days to rule out sexual delusions. The 11/11/2021 comprehensive care plan documented an electronic monitoring optic recording device (camera) was placed in the entry way to the resident's room to track and review comings and goings of staff as needed. Interventions inform family, maintain the dignity of the resident, position the camera in the least invasive manner, and refer to recorded footage as needed to assure the resident that their space was not breached, and they were not abused. On 3/2/2023, social worker #34 resolved (discontinued) the electronic monitoring care plan. The undated care instructions did not include documentation of placement of an optic recording device the resident's entry way to their room was monitored via an optic recording device. During an observation on 4/9/24 at 11:20 AM the resident was seated in their wheelchair in their room. There was a functioning camera in the corner of the room above their wardrobe facing the opposite wall. During an interview on 4/9/2024 at 4:07 PM the resident's representative stated the camera was placed in the resident's room by the facility due to the resident's history of sexual delusions. During observations on 4/10/2024 at 8:38 AM and 10:19 AM the resident was in their room. There was a camera in the corner of the room above their wardrobe facing the opposite wall. During an observation on 4/11/2024 at 9:35 AM, a computer monitor behind the nursing station was playing live video footage of Resident #58's room. The video footage showed the entryway to the resident's room and the opposite wall was seen. The area of the room from the left side of the bed to the doorway and the bottom 2-3 feet of the resident's bed was also viewed. The was no documented evidence the resident's care plan included current video camera monitoring. During an interview on 4/11/2024 at 4:26 PM certified nurse aide #27 stated the camera in the resident's room had been there awhile. It was placed due to the resident's history of making allegations of sexual assault. Staff knew the camera was there and did not provide care in the viewing area of the camera and the camera played live footage on a monitor behind the nursing station. During an interview on 4/11/2024 at 5:10 PM certified nurse aide #25 stated the camera in the resident's room was used to see who entered and exited the resident's room. The video footage played on a monitor behind the nursing station. The camera was placed in a location it was unable to show when the resident was provided care. The camera was never turned off. During an interview on 4/12/2024 at 10:42 AM certified nurse aide #8 stated the camera in Resident #58's room had been in a place for over a year. They thought the camera was on the care instructions. During an interview on 4/12/2024 at 12:06 PM Registered Nurse Unit Manager #3 stated registered nurses initiated the care plans and each department updated their sections as needed. The interdisciplinary team met to review the comprehensive care plans at least quarterly. During those meetings, all areas of the care plan were reviewed and updated as needed. Resident #58 had a camera in their room due to their allegations of sexual assault. It had been put in place prior to them starting on the unit 2 years ago. At one time they remembered a discussion of removing the camera, but it was decided to leave it in place. They stated the camera should be on the resident's care plan, so staff were aware it was in the room to ensure dignity. They were unaware the camera was no longer on the care plan. During an interview on 4/12/2024 at 1:25 PM social worker #34 stated the interdisciplinary team met to review the comprehensive care plans at least quarterly. During those meetings, all areas of the care plan were reviewed and updated as needed. Resident #58 did have a camera in their room, and they did not recall resolving the electronic monitoring care plan. They did not write a progress note as to why they resolved the video recording on the comprehensive care plan. It was important for staff to know the camera was in the room to maintain the dignity of the resident. During an interview on 4/12/2024 at 2:03 PM Assistant Director of Nursing #4 stated the comprehensive care plans were created by registered nurses and were reviewed at least quarterly or as needed by the interdisciplinary team to ensure interventions remained appropriate and the care areas were accurate. Resident #58 had a camera in their room due to their history of sexual abuse. The camera monitored who was entering and exiting the room. They were unaware the camera usage was no longer on the resident's care plan and should be. It was important for staff to know the camera was in the room to maintain the resident's dignity. 2) Resident #43 was admitted to the facility with diagnoses including dementia, diabetes, and atrial fibrillation (irregular heartbeat). The 2/6/2024 Minimum Data Set assessment documented the resident had severely impaired cognition and received daily insulin injections and an oral anticoagulant. The 1/31/2024 Physician orders documented the resident was to receive: - Novolog (short-acting insulin) according to a sliding scale (the amount of insulin administered was based on results of finger stick blood sugar levels) for blood glucose management. - Insulin glargine (long-acting insulin) via pen injector twice daily. - apixaban (anticoagulant, blood thinner) twice a day for atrial fibrillation. There was no documented evidence the resident's comprehensive care plan included the use of insulin or an anticoagulant. During an interview on 4/12/2024 at 1:27 PM, registered nurse Supervisor/Staff Development Coordinator #13 stated the admitting nurse did the initial care plan. Insulin should be included in the care plan, so staff were aware to watch for signs and symptoms of hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar). Anticoagulants were not required to be included in the care plan but should be to monitor the risk for bleeding and ensure bleeding precautions and safety razors were implemented. If anticoagulant use was not on the care plan, the certified nurse aides would not know the safety precautions for bleeding should be implemented. 3) Resident #97 was admitted to the facility with diagnoses including dementia with psychotic disturbances, and Parkinson's disease (a progressive disorder of the nervous system). The 1/18/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, had no behavioral symptoms, and received an antipsychotic routinely. The 3/27/2024 physician orders documented the resident was to receive: - Seroquel (antipsychotic) 25mg tablet; 1 tablet in the evening for dementia. -Seroquel 25mg tablet; 2 tablets at bedtime for dementia. The comprehensive care plan initiated on 10/25/2023 documented the resident had impaired cognitive function related to dementia. Interventions included reviewing medications and recording possible causes of cognitive deficit. The care plan did not include the use of an antipsychotic. During an interview on 4/12/2024 at 10:08 AM, licensed practical nurse #9 stated they looked at the resident's care plan to know how to properly care for them. The care plan included activities of daily living and medications the resident was on. They did not have the ability to initiate or update a care plan and if they noticed something was missing, they would notify the registered nurse Manager or Supervisor. They stated if Resident #97's care plan was not updated it could negatively impact them. During an interview on 4/12/2024 at 10:12 AM, registered nurse Manager #15 stated all staff should look at a resident's care plan to know how to care for them. The care plan included falls, skin issues, oxygen use, and medications. Medications should be listed in the care plan so staff knew what side effects they should monitor for. Registered nurses were responsible for initiating and updating nursing related care plans quarterly, annually, and as needed. They stated it was important to keep Resident #97's care plan updated because care plans were resident specific and could put the resident at risk if it had wrong information. During an interview on 4/12/2024 at 12:33 PM, Assistant Director of Nursing #4 stated care plans were resident specific, and all staff had access to them. Care plans included activities of daily living and medications. If a resident was taking an antipsychotic, anticoagulant, or insulin they expected them to be included in the care plan so staff would know why they were on it and what side effects to monitor for. Registered nurses were responsible for initiating and updating care plans quarterly, annually, and as needed when changes occurred. They stated it was important to keep Resident #97's care plan updated with accurate information so they could be safely cared for. 10NYCRR 415.11(c)(1) 49448

Based on observation, record review, and interviews during the recertification survey conducted 4/9/2024-4/12/2024, the facility did not ensure residents were provided an ongoing program to support their choice of activities, designed to meet their interests and support their physical, mental, and psychosocial well-being for 2 of 3 residents (Residents #40 and #79) reviewed. Specifically, Residents #40 and #79 were not provided meaningful activities that met their interests and preferences. Findings include: The facility policy Activities revised 3/2019 documented the main purpose of the activity program was to enable the individual to continue to enjoy the experience of life and to enable the individual to participate successfully in whatever pursuits they preferred. Pursuits included recreational, spiritual, intellectual, and other activities which were basic to a balanced and rewarding life. The April 2024 Activity Calendar documented: -On 4/9/2024: at 8:15 AM Talk to Me, at 10:00 AM BINGO in the central dining room, at 11:30 AM unit visits, at 2:30 PM [NAME] the Riveter in the central dining room, at 3:30 PM card club in the central dining room, and at 5:00 PM individual visits on the 3rd floor. -On 4/10/2024: at 8:15 AM Good Morning Greetings, at 10:00 AM morning stretch on units 3, 4, and 5, at 11:30 AM unit visits, and at 2:00 PM movie in the central dining room. -On 4/11/2024: at 8:15 AM Boredom Buster, at 10:00 AM BINGO in the central dining room, at 2:30 PM paper tulips in the central dining room, and individual pet visits, and at 5:00 PM [NAME]. -On 4/12/2024: at 8:15 AM Daily Chronicles, at 10:00 AM Crazy Cooking in the central dining room, at 11:30 AM unit visits, and at 2:30 PM Happy Hour. 1) Resident #40 was admitted to the facility with diagnoses including macular degeneration (a disease affecting vision), glaucoma (a disease that causes vision loss and blindness), and difficulty walking. The 1/10/2024 Minimum Data Set assessment dated documented the resident was cognitively intact, considered it very important to listen to music and participate in religious services, and somewhat important to go out and get fresh air. The comprehensive care plan initiated 1/30/2024 documented personalized care would be provided, and the resident would be reminded of activities. Interventions included nursing arranged to have the resident up and ready for Catholic services and personal preferences included music and going outside. During an interview on 4/9/2024 at 11:17 AM, Resident #40 stated there was a music activity twice a month they would have liked to attend but could not because there was not enough staff to get them out of bed. They had not been to any activities recently and they were fearful to get out of bed because they would be left in the chair and not be put back to bed after the activity was over. They stated they would also love to go outside and enjoyed flowers and gardening. During a follow up interview on 4/11/2024 at 12:22 PM, Resident #40 stated no one had asked them if they wanted to attend an activity in several months. The April 2024 activity records documented the resident participated in 4 (in room activity) on unit activities from 4/1/2024-4/12/2024. There was no documented evidence the resident refused attendance at additional activities. During an interview on 4/12/2024 at 12:46 PM, certified nurse aide #24 stated Resident #40 used to attend a lot of activities and enjoyed watching entertainers and going outside. It was important for residents to attend activities for socialization and go outside for fresh air instead of being cooped up indoors. During an interview on 4/12/2024 at 1:28 PM, the Director of Activities stated activities were important for the resident's quality of life. Resident #40 refused to get out of bed and refused all out of room activities. They recently were provided with an ice cream sundae in their room. Staff might not invite them to off unit activities due to their continuous refusals. Staff should offer all residents to go to off unit activities and document refusals. They stated the resident had refused 6 activities recently and it would be important to know why the resident refused activities. 2) Resident #79 had diagnoses including limitation of activities due to disability, adjustment disorder with depressed mood, and cognitive communication deficit. The 12/23/2023 Minimum Data Set assessment documented the resident had severely impaired cognition, had verbal behaviors directed towards other 1-3 of 7 days, did not reject care, considered it important to listen to music, to be around animals, keep up with the news, to do their favorite activities, and go outside to get fresh air when the weather was good. The 4/3/2024 comprehensive care plan documented the resident was able to make their needs known and was made aware of group activities through verbal invitation. The resident did better when staff would state it was time to go to an activity. The resident allowed individual visits, was fidgety, liked to socialize with others, and listen to music and television. Interventions included ask yes or no questions, provide fidget items as able, and transport the resident to and from activities. During an interview on 4/9/2024 at 3:05 PM, the resident's representative stated the resident did not leave the unit to attend activities. The resident required assistance of 2 using a mechanical lift and there were not always enough staff on the unit to assist with transfers. The resident was observed: - On 4/10/2024 at 8:56 AM, in bed with their eyes closed and at 12:52 PM sitting in a recliner chair. - On 4/11/2024 at 4:14 PM, in their room lying in bed in a gown. The April 2024 activity records documented the resident participated in 6 activities on the unit and 1 activity off the unit from 4/1/2024- 4/12/2024. During an interview on 4/11/2024 at 4:20 PM, certified nurse aide #29 stated the resident care instructions were listed on the care plan. The care plan alerted staff to what type of activities the resident preferred. They stated Resident #79 was able to express their desire to go outside, but they typically only wanted to stay outside for a short period of time and wanted to return to the unit. The resident did not see well. They stated they put the news on the television for the resident yesterday. The resident had a fidget toy they used. Typically, the unit had 1 certified nurse aide, 1 licensed practical nurse, and 1 respiratory therapist assigned for the day. During an interview on 4/12/2024 at 9:47 AM, certified nurse aide #30 stated the resident's care instructions were listed on the care plan. The care plan alerted staff to what type of activities the resident preferred. The ventilator (breathing machine) unit had a couple of residents that liked to go off the unit to activities. They rarely saw activities staff on the unit, and there were not a lot of 1:1 visits conducted on the unit. Resident #79 had not gone to any activities lately. The resident used a fidget toy or handheld games and enjoyed music and watching television. During an interview on 4/12/2024 at 1:28 PM, the Director of Activities stated activities were important for the resident's quality of life. Resident #79 loved video games and had them provided but the games could not be left alone with the resident because they would disappear. The resident's family would play games with them when they visited every other day. The resident refused some activities and had recently been down to watch a movie. 10 NYCRR 415.5(f)(1) 49448

Based on observation, record review, and interview during the recertification survey conducted 4/9/2024-4/12/2024, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #278) reviewed. Specifically, Resident #278 was admitted to the facility with congestive heart failure (the heart does not pump efficiently often causing fluid buildup) with hospital discharge orders for torsemide (diuretic, water pill) and instructions for monitoring weights; the torsemide was not ordered until 5 days after admission; and weights were not monitored as recommended. Findings include: The facility policy Extended Care Facility: Admission/Readmission Documentation revised 6/2023 documented the multidisciplinary team obtained information from the resident's most recent hospital records, resident and/or legal representative, transfer/discharge summary and the most recent history and physical information from the resident's attending physician upon admission to the facility. The checklist worksheet for day 1 included (but not limited to) that physician orders were entered into the electronic record and was checked by two nurses on admission orders that included a diagnosis for all medications and labs or medications that needed therapeutic level monitoring. Weights were also obtained on day 1 for admission/ readmission. Resident #278 had diagnoses including acute (sudden onset) on chronic (long term) congestive heart failure, hypertensive heart disease (damage to the heart from high blood pressure), and diabetes. The Minimum Data Set admission assessment had not yet been completed. The 3/29/2024 hospital discharge summary documented the resident was hospitalized [DATE]-[DATE]. The resident had a diagnosis of chronic combined heart failure, systolic and diastolic. The resident had good response to intravenous Lasix (diuretic) and had been switched back to oral torsemide. The resident weighed 229 pounds upon discharge. Discharge medications included torsemide 20 milligram tablet, take 2 tablets by mouth every day, if 3 pounds were gained in 2 days increase dose to 2 tablets twice daily for 24 hours. The 3/29/2024 at 2:20 PM General Admission Assessment completed by Registered Nurse Unit Manager #3 documented the resident had no edema (fluid buildup). Orders were received from the admitting physician. The assessment did not include an admission weight. The 3/29/2024 facility admission physician orders did not include torsemide or weights. The comprehensive care plan dated 3/29/2024 documented the resident had an alteration in cardiovascular status related to arrythmia (irregular heartbeat) and congestive heart failure. Approaches included to monitor and report any edema and changes in weight, monitor and report any changes in lung sounds, and monitor and report any chest pain or shortness of breath. The resident's 3/30/2024 weight record documented a weight of 216.0 pounds. A 4/2/2024 physician order documented torsemide oral tablet 20 milligrams, give 2 tablets by mouth one time a day for congestive heart failure, with a start date of 4/3/2024. The 4/2024 Medication Administration Record documented torsemide oral tablet 20 milligrams, give 2 tablets by mouth one time a day for congestive heart failure with a start date as 4/3/2024. The medication was documented as administered at 9:00 AM from 4/3/2024-4/12/2024. During an interview on 4/9/2024 at 11:04 AM, Resident #278 stated they were worried that on admission they did not receive their diuretics for the first few days. They stated they had taken torsemide and weighed themself daily at home but had only been weighed once since the day they were admitted . They stated they were receiving their diuretic now but was still not being weighed daily. The resident's weight record documented weights on 4/9/2024 of 219.5 pounds and on 4/11/2024 of 220.5 pounds. A 4/12/2024 physician order documented daily weights in the morning for edema. During an interview on 4/12/2024 at 10:38 AM, registered nurse Supervisor #13 stated new admission medications were entered into the electronic health record by a registered nurse. A second check was done by another registered nurse, before a verbal approval by the medical provider. Reconciliation was done from the hospital discharge summary, compared with home medications, and then entered into the electronic health record. Any registered nurse could do the transcribing of orders, activation was done by the registered nurse with medical approval after the orders were checked at least twice. During an interview on 4/12/2024 at 11:59 AM, Assistant Director of Nursing #4 stated new admission orders were obtained from the hospital discharge packet. A registered nurse would put the orders in the computer, and then a second registered nurse would check them. The orders would then show as active, and the medical provider would sign off. The orders for Resident # 278 were entered by Registered Nurse Unit Manager #3, and a second check was done by registered nurse #32. The Assistant Director of Nursing was not aware of any problem with Resident #278's torsemide on admission. There was an admission checklist used, but it was not kept after the admission was completed. If there was an order that was not clear, the medical provider should have been called for clarification. An order for a diuretic for a resident with congestive heart failure would be very important for their health. During an interview on 4/12/2024 at 3:00 PM, Registered Nurse Unit Manager #3 stated medications for new admissions were entered into the electronic health record by a registered nurse, with a 2nd check by another registered nurse, then signed by the medical provider. If an order was not clear they would call medical for clarification as soon as possible. When transcribing orders, they reviewed medical history and discharge orders from where the resident was coming from. The danger of not receiving a diuretic that was on the discharge orders was increased edema, shortness of breath, or further exacerbation of congestive heart failure. They did not remember entering admission medications for Resident #278 and was not aware the resident did not receive torsemide upon admission. During an interview on 4/12/2024 at 4:35 PM, physician #33 stated they counted on the nurses for reconciling medications from the hospital discharge summary. They would then review and approve the medications in the electronic health record. If torsemide was recommended on the hospital discharge with weight parameters, they would have expected the medication to be ordered as well as daily weights. If a resident with congestive heart failure did not receive the proper diuretics, they have increased edema, shortness of breath, and possibly re-hospitalization due to those symptoms. During an interview on 4/12/2024 at 5:55 PM, registered nurse #32 stated medication orders for a new admission were put in the computer by a nurse with a 2nd nurse check. Medical would then approve the orders. The medical providers depended on nursing for entering medication orders by using the hospital discharge summary and home medication lists. They did not remember if they reconciled Resident #278's medications when they were admitted . They did remember hearing there was a problem with the torsemide. It had been on the home medication list and discharge summary but was missed. Adverse effects might have been edema or shortness of breath. They used an admission check list, and it should have been caught. The 2nd nurse check should have also caught the error. 10NYCRR415.12

Based on observation, record review, and interview during the recertification and abbreviated (NY00336433) surveys conducted 4/9/2024-4/12/2024, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new pressure ulcers from developing for 1 of 3 residents (Resident #119) reviewed. Specifically, Resident #119 developed facility acquired pressure ulcers and had a physician order for a specialty mattress (a powered pressure reducing air mattress). There was no documented evidence the mattress was checked for function for 14 days after it was ordered, and the mattress was observed not connected to the pump and the pump was not operational. Findings include: The facility policy Prevention and Treatment of Pressure Ulcer revised 12/2020, documented the facility ensured residents that developed pressure ulcers received the necessary treatment and services to promote healing and/ or prevent infection. The registered nurse or the supervisor, initiated skin protocols and obtained physician orders. Standards included treatments were completed as ordered and the need for an anti-pressure mattress was assessed. Treatments were documented in the electronic medical record. Resident #119 had diagnoses including left femur (hip) fracture, facility acquired Stage 2 pressure ulcer (partial thickness loss of skin presenting as a shallow crater) on the back, and facility acquired Stage 2 pressure ulcer of sacral region (end of spine/ buttocks). The Minimum Data Set assessment dated [DATE] documented the resident was cognitively intact, was dependent for bed mobility and transfers, had pressure ulcers that were not present on admission, received daily pressure ulcer care, application of ointments/ medications other than to feet, and had pressure reducing devices for the bed and chair. The 2/16/2024 admission assessment by registered nurse Supervisor/Staff Development Coordinator #13 documented the resident had a surgical incision to the left hip and dry skin to bilateral heels. The comprehensive care plan initiated on 2/16/2024 and revised on 2/21/2024 documented the resident had suspected deep tissue injury (purple or maroon discoloration due to damage to underlying tissue) to bilateral heels related to recent hip surgery and weakness. The areas would be followed by the skin team weekly. Approaches included turning and repositioning every 2 hours, treatment per physician order, and pressure relieving boots per physician order. The 2/16/2024 Braden Score Assessment (a tool for assessing risk of development of pressure ulcers) by registered nurse Supervisor/ Staff Development Coordinator #13 documented the resident was at risk for pressure ulcers. The 2/18/2024 Physician orders documented Juven oral packet, mix with 240 milliliters liquid twice a day for wound healing. The 2/21/2024 weekly skin check by licensed practical nurse #8 and the 3/20/2024 weekly skin check by licensed practical nurse #7 documented the resident had open areas, red marks, rashes, or bruises. Details were not documented. Skin/Wound progress notes dated 2/21/2024 and 2/28/2024 by Assistant Director of Nursing #4 documented the bilateral heel deep tissue injuries were assessed and measured during weekly wound rounds. The bilateral heels measured 5 centimeters by 5 centimeters by 0 centimeters on first assessment. The physician was notified and an order for skin prep (protectant) to bilateral heels was obtained. The resident had pressure relieving boots in place although the resident frequently refused the boots. The resident also had an abductor pillow for use while in bed but frequently refused its use as it was uncomfortable. The 3/1/2024 physician #5 progress note documented the resident had lower back discomfort, had Stage 2 pressure ulcers to the lower back and sacral area and the plan was for dressing changes, air mattress, and off-loading. The 3/6/2024 physician #6 telephone order documented the resident was to have an air mattress set per weight and check function every shift. The 3/6/2024 Skin/Wound progress note by Assistant Director of Nursing #4 documented the resident had small pillows under their heels and was told this added more pressure and was advised to wear the pressure relieving boots. The heels were assessed, and the right heel deep tissue injury measured 2.5 centimeters x 3 centimeters x 0 centimeters, the left heel deep tissue injury measured 3 centimeters x 3 centimeters x 0 centimeters. There was no documented evidence a specialty mattress was recommended or ordered. The 3/13/2024 and 3/20/2024 Skin/Wound progress notes by Assistant Director of Nursing #4 documented he bilateral heel deep tissue injuries were assessed and measured. The wound measurements were without significant change. The March 2024 Treatment Administration Record documented specialty air mattress, settings per weight, and check function every shift with a start date of 3/6/2024. There was no documented evidence the mattress was checked for functioning every shift as ordered from 3/6/2024 through 3/20/2024. A 3/20/2024 nursing progress note by Assistant Director of Nursing #4 documented an unidentified licensed practical nurse requested an assessment as the resident had wounds to their buttocks. Four new wounds were identified and included an unstageable ulcer to the coccyx (end of tailbone) measuring 1.5 centimeters x 1.5 centimeters x 0.1 centimeters with yellow slough (dead tissue) covering 100% of the wound bed; an unstageable ulcer to the left buttocks measuring 1.5 centimeters x 0.5 centimeters x 0.1 centimeters with slough covering 100% of the wound bed; an unstageable wound to the right buttocks measuring 1.5 centimeters x 1 centimeter x 0.1 centimeters with slough covering 100% of the wound bed; and an unstageable wound to left upper buttocks measuring 0.5 centimeters x 0.2 centimeters x 0.1 centimeters with slough covering 100% of the wound bed. The physician was notified and orders for wound dressings included debriding ointment (used to remove dead tissue) to all wounds, cover with gauze, and dry sterile dressing. The resident was currently on an alternating air mattress and did not want to shift weight off their buttocks. The resident was advised staff would continue to attempt repositioning. Skin/Wound progress notes by Assistant Director of Nursing #4 documented: - on 4/3/2024 the suspected deep tissue injury to the right heel measured 2.5 centimeters x 3 centimeters x 0 centimeters. The suspected deep tissue injury to the left heel measured 3.5 centimeters x 4 centimeters x 0 centimeters. The unstageable pressure ulcer to the coccyx measured 1.5 centimeters x 1.5 centimeters x 0.1 centimeters. The unstageable pressure ulcer to the right buttocks measured 1 centimeter x 1 centimeter x 0.1 centimeters. The unstageable pressure ulcer to the left buttocks measured 5 centimeters x 5.5 centimeters x 0.3 centimeters. - on 4/10/2024 the suspected deep tissue injury to the right heel measured 2.5 centimeters x 3.5 centimeters x 0 centimeters. The right heel wound now had drying edges of wound lifting revealing pink skin underneath. The suspected deep tissue injury to the left heel measured 3.5 centimeters x 4 centimeters x 0 centimeters. The left heel wound was drying. The Stage 2 pressure ulcer to the coccyx measured 1.5 centimeters x 1 centimeter x 0.1 centimeters. The coccyx wound was previously unstageable with slough covering wound bed, now Stage 2 with 100 percent granulation (pink, new tissue) tissue. The Stage 2 pressure ulcer to the right buttocks measured 0.5 centimeters x 0.5 centimeters x 0.1 centimeters. The right buttocks wound was previously unstageable with slough covering the wound bed. The wound bed was now visible with 100% granulation tissue. The unstageable pressure ulcer to the left buttocks measured 5 centimeters x 5 centimeters x 0.3 centimeters. The left buttocks wound had dark slough covering the entire wound bed and remained unstageable. The following observations were made: - on 4/9/2024 at 10:32 AM, in the resident's room there was an air mattress device pump on the floor under the resident's bed, the pump was not on, and the pump device was cracked. At 2:31 PM, the resident was lying in bed, the pump device was not on, the control was set for weight of 225 pounds, the cracked pump device was in between the foot of mattress and the foot of bed frame, and the tubing from the pump device to the air mattress was not connected. The mattress was fully inflated. - on 4/10/2024 at 8:58 AM and 3:38 PM, the resident was lying in bed, the air mattress pump device was not on, the tubing from pump device to air mattress was not connected, and the cracked pump device was in between the foot of the mattress and the foot of bed frame. The mattress was fully inflated. - on 4/11/2024 at 10:02 AM and 1:26 PM, the resident was lying in bed, the air mattress pump device was not on, the tubing from the pump device to the air mattress was not connected, and the cracked pump device was in between the foot of the mattress and the foot of bed frame. The mattress was fully inflated. The April 2024 Treatment Administration Record documented the air mattress function was checked: - on 4/9/2024 day shift by licensed practical nurse #11; and evening and night shift by licensed practical nurse #10. - on 4/10/2024 day shift by licensed practical nurse #9; evening and night shift by licensed practical nurse #10. - on 4/11/2024 day shift by licensed practical nurse #8 During a dressing change observation on 4/11/2024 at 1:39 PM with licensed practical nurse #8 the left buttocks wound was approximately the size of a billiard ball with serosanguinous (blood tinged fluid) drainage. The wound bed had yellow tissue with dark slough. There were two small wounds approximately the size of a pencil eraser with pink wound beds on the left and right buttocks. Licensed practical nurse #8 stated the wounds were improving and interventions included the resident was turned and positioned every 2 hours. They stated Resident #119 was on a regular mattress and if they were on an air mattress there would be an air mattress machine and there was not. There were air mattress cords on the floor that were attached to the mattress, but an air mattress must not have ever been hooked up. Resident #119 was at risk for pressure ulcers and if they had an air mattress ordered it should be on and in use. If they had an order, it would be signed off on the Treatment Administration Record. If it was signed off on the Treatment Administration Record, it meant that it was verified as on and working. If the mattress was not on it could make the pressure ulcers worse. They did not remember the resident having an air mattress despite them documenting on the Treatment Administration Record the mattress function was checked on 3/22/2024, 3/30/2024, 4/4/2024, 4/5/2024, and 4/8/2024. During an interview on 4/12/2024 at 1:45 PM, the Director of Plant Operations stated that broken air mattresses would be discarded and replaced with a new air mattress. They stated the device would be checked for electrical safety upon being brought into the facility. The Director of Plant Operations stated the biomedical department was not aware of the broken air mattress and did not have any work orders prior to the observation on 4/11/2024. They verified that the electrical pump for the mattress was broken. During an interview on 4/12/2024 at 2:03 PM Assistant Director of Nursing#4 stated they assessed all pressure wounds in the facility weekly. They made recommendations and obtained physician orders. If they recommended and received an order for an air mattress it would be entered in the Treatment Administration Record. The air mattress was checked every shift and documentation meant it was checked that it was on and functioning. Air mattresses were important to reduce pressure and if an air mattress was not on or not functioning properly wounds could get worse or they could develop new wounds. Resident #119 was at risk for pressure and had currently had 5 facility acquired pressure sores. The areas on the bilateral heels were discovered on 2/21/2024 and the 3 wounds to the back/ sacral area were discovered on 3/20/2024. Some of the wounds were healing and the large left buttocks wound was slightly smaller, but the wound bed was not getting better. Resident #119 had orders for an air mattress and pressure relieving boots but frequently refused the boots. If staff had determined the machine was not functioning properly, they should have put a ticket in with biomedical to have the unit repaired or a new system installed. They had done a wound assessment on 4/10/2024 but did not check the air mattress or the pump device as they normally did. They were made aware of the broken air mattress device for the resident yesterday afternoon after the dressing change observation. During an interview on 4/12/2024 at 5:41 PM physician #6 stated if an air mattress was ordered, they expected that it was used as it was medically indicated. Air mattresses were indicated for residents with pressure ulcer or at risk for pressure sores. If an air mattress was ordered but was not in place, they expected to be notified to order alternate therapies if an air mattress was not available. They expected their orders to be followed. An air mattress would only be useful if it was functioning properly and if it was not, it should have been addressed immediately as this could make the pressure ulcers worse. They could not recall if they had provided a telephone order for an air mattress for Resident #119. They sometimes had telephone orders in the computer they did not remember giving. They did not normally care for this resident unless they were on call. 10NYCRR 415.12(c)(1)

Based on observation, record review, and interview during the recertification survey conducted 4/9/2024-4/12/2024, the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 1 of 2 residents (Resident #278) reviewed. Specifically, Resident #278 received continuous positive airway pressure therapy (a machine used to keep the airway open by delivering continuous air through the nose and mouth) without a plan to regularly clean the machine to prevent contaminations. Findings included: The facility policy Noninvasive Ventilation BiPAP (bilevel positive airway pressure) /CPAP (continuous positive airway pressure) last revised 10/2021 documented noninvasive ventilation was a means of delivering ventilation support through a noninvasive interface rather than an invasive artificial airway. Setup, maintenance, and monitoring was the responsibility of the respiratory therapist. An indication for use was sleep apnea (breathing repeatedly stops and starts during sleep) /nocturnal hypoventilation (breathing too shallow or slow during sleep). Manufacturer's recommendations for maintenance of continuous positive airway pressure equipment were for daily cleaning of the mask cushion and the humidifier tub (reservoir for placing water), and weekly cleaning of the tubing. Resident #278 had diagnoses including acute on chronic congestive heart failure, hypertensive heart disease, and sleep apnea. The Minimum Data Set admission assessment had not yet been completed. The 3/29/2024 physician order documented continuous positive airway pressure at night use resident home settings in the evening for sleep apnea. There were no documented orders for cleaning and maintaining the machine. The comprehensive care plan dated 3/29/2024 documented continuous positive airway pressure therapy for obstructive sleep apnea, encourage resident use of therapy, and maintain same settings as at home. Assist resident with applying continuous positive airway pressure therapy. The care plan did not include cleaning/disinfecting instructions. Resident care information (Kardex) included encourage use of continuous positive airway pressure therapy. The care information did not include cleaning/disinfecting instructions. The April 2024 electronic medication administration record documented continuous positive airway pressure at night use resident home settings in the evening for sleep apnea with a start date of 3/29/2024. The therapy was signed as administered 4/1/2024-4/11/2024. The electronic medication or treatment administration records did not include directions for cleaning/disinfecting the continuous positive airway pressure machine components (tubing, mask, or humidifier reservoir). During an interview on 4/9/2024 at 4:00 PM, Resident # 278 stated they were concerned that staff were not cleaning their continuous positive airway pressure equipment. They had asked for it to be cleaned and at least be hung to dry to prevent mold and bacteria from getting into their lungs. So far nobody had assisted them with cleaning of the unit. During an interview on 4/12/2024 at 10:38 AM, Registered Nurse Supervisor #13 stated continuous positive airway pressure therapy should have orders for use and settings. Only sterile water should be used for humidification. The reservoir, mask, and tubing should be cleaned daily by nursing and should be on the treatment administration record for completion. During an interview on 4/12/2024 at 11:05 AM, licensed practical nurse #16 stated care information was found in the care plan. Continuous positive airway pressure therapy required orders and the machine should be cleaned daily. Cleaning instructions should be in the electronic treatment administration record. Resident #278 did not have cleaning instructions in the treatment record. If the equipment was not cleaned properly, bacteria could build up and possibly cause infection. During an interview on 4/12/2024 at 2:53 PM, respiratory therapist #18 stated their main duties were on the ventilator unit. They assisted with continuous positive airway pressure therapy if needed. Continuous positive airway pressure therapy required orders for use. Continuous positive airway pressure therapy tubing and masks should be cleaned to prevent respiratory infections. If there was moisture present in the tubing or mask bacteria could breed and cause infections. During an interview on 4/12/2024 at 3:00 PM, Registered Nurse Unit Manager #3 stated medications and treatments for new admissions were entered into the electronic health record by a registered nurse, then approved by a medical provider. If continuous positive airway pressure therapy was ordered, cleaning should be put on the treatment administration record for nursing to complete. 10 NYCRR 415.12(k)(6)

Based on observation, record review, and interview during the abbreviated survey (NY 263) conducted on 11/24/21, the facility failed to ensure attempts were made to use appropriate alternatives prior to installing a side or bed rail; failed to assess residents for risk of entrapment from bed rails prior to installation; failed to review the risks and benefits of bed rails with the resident or resident representative, and failed to obtain informed consent prior to installation for 2 of 6 residents (Residents #1 and 2) reviewed. Specifically: - There was no documented evidence Residents #1 and #2 had risks and benefits of bed rails (transfer handles) reviewed with the resident/resident representative and no evidence informed consent was obtained prior to installation of transfer handles. - Resident #1 had a change in physical condition and cognition and was not reassessed for use of a transfer handle (enabler bar). The resident became entrapped in the transfer handle resulting in a dislocated right shoulder. After Resident #1's incident with the transfer handle, Residents #1 and #2 were re-assessed to not require transfer handles, and both were observed with transfer handles in place. This resulted in actual harm to Resident #1 that was not immediate jeopardy. Findings include: The facility policy Acute Change of Condition & Notification of Changes dated 6/2005 and revised 11/2021 documents changes in a resident's condition or treatment are immediately shared with the resident and/or resident representative, according to their authority and reported to the attending physician or delegate. The nurse will immediately notify the resident, resident's physician, and the resident representative for the following: a significant change in the resident's physical, mental, or psychosocial status that is a deterioration in the health, mental or psychosocial status in either life threatening conditions or clinical complication. Educate the resident and/or representative about the proposed plan to treat, manage or monitor the resident's change in condition. Educate the resident and/or resident representative about the risks and benefits of the proposed treatment change and provide an opportunity for the resident to make an informed choice of the treatment or alternative that they prefer and update the resident's care plan. The Bed Rail Use Policy dated 12/2001 and revised 11/2021, documents it is the policy of this facility to identify and reduce safety risks and hazards commonly associated with bed rail use. A duo-faceted approach will be used to achieve sustainable quality outcomes, including: regular bed maintenance and individual bed rail evaluation. The facility will ensure individual resident bed rail evaluations are performed on a regular basis. Individual bed rail evaluations will include data collection analysis and determination of potential alternatives to bed rail use. When bed rail(s) are deemed necessary and appropriate, the facility will provide education to resident or resident's representative pertaining to the risk and benefits of bed rail use. The facility's priority is to ensure safe and appropriate bed rail use. 1) Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had no falls since the prior assessment and had no restraints. The 4/5/18 initial occupational therapy (OT) evaluation documented the resident was status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required maximum assistance from 2 staff for bed mobility. The evaluation did not document the resident was approved for the use of transfer handles. OT evaluations and progress notes from 5/2018 to 10/2021 did not document the resident used transfer handles. The registered nurse (RN) Restraint/Device Assessments documented on 6/15/21, the resident had a right transfer handle that was to be up at all times and on 7/9/21, the resident had no devices in place (the use of the transfer handle was no longer documented). The 7/23/21 medical provider's progress note documented the resident was seen for a follow-up and review of dementia. They had no significant decline, continued to self-propel in the Geri-chair (wheeled recliner) on the unit and was able to self-feed. The updated 7/27/21 comprehensive care plan (CCP) documented the resident had an activity of daily living (ADL) deficit. Interventions included the resident was non-ambulatory, assistance was needed of 1-2 staff for turning and repositioning, and they needed assistance with ambulation and transfers utilizing therapy recommendations. The 9/16/21 nurse practitioner (NP) #12's progress note documented the resident was seen for a biannual history and physical and review of chronic medical conditions. Nursing felt the resident had been declining, had been needing more assistance with ADLs, and overall cognition continued to decline. The RN Restraint/Device Assessments documented on 10/9/21, the resident used a right transfer handle that was always up and was used for repositioning and bed mobility. The device was not considered a restraint. There was no documented evidence Resident #1's CCP was update for use of the transfer handle. The 11/1/21 NP #12's progress note documented the resident was seen for an overall decline. Nursing reported the resident had increased difficulty taking medications and was pocketing them even after crushing. The resident's intake was decreased, they lost weight, level of alertness declined, and they were minimally responsive. A call was placed to family who also noticed a decline in the resident. The plan was for comfort care, routine medications were discontinued, and [MEDICATION(S)] and [MEDICATION(S)] were ordered. The 11/1/21 at 3:20 PM, licensed practical nurse (LPN) #11's progress note documented they spoke to the NP regarding the resident, the NP spoke with the family and there were new orders to make the resident complete comfort care. All oral medications were discontinued, and the resident was started on routine [MEDICATION(S)] (anti-anxiety medication) and as needed [MEDICATION(S)] (narcotic [MEDICATION(S)]). The Kardex (care instructions) in place on 11/6/21 documented the resident used a right transfer handle. There was no documented evidence of an assessment to determine continued appropriateness of the transfer handle and no documented evidence the CCP was reviewed given the resident's change in condition and status. The 11/7/21 at 1:30 AM, Accident & Incident report documented the resident was found lying face down next to the bed with their right arm caught in the transfer handle. The report documented the care plan was followed at time of the incident. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . An x-ray confirmed the resident had a right shoulder dislocation and the resident's transfer handle was removed from the bed on 11/7/21. The 11/7/21 CCP documented the resident was a fall risk and had an ADL deficit. Interventions included the resident was non-ambulatory, they transferred using a Hoyer (mechanical lift), and their transfer handle was discontinued as it was no longer utilized to assist with bed mobility. The Kardex (direct care instructions) updated 11/7/21 documented the resident's transfer handle had been removed. The 11/8/21 NP #12's progress note documented the resident had a shoulder dislocation after a fall with their right arm caught in the transfer handle. The resident's shoulder was reduced (placed in its original position) yesterday at the hospital and the transfer handle was removed from the bed. The resident remained nonresponsive to verbal and tactile stimuli during the exam which was consistent with their behavior early last week. The plan was to continue end of life care. The 11/12/21 facility work order, completed by maintenance worker #6 documented they brought a Big Boyz bed (bariatric bed) to Resident #1's room. The 11/14/21 RN Restraint/Device assessment documented the resident had no devices being used. On 11/15/21 at 9:40 and 10 AM, Resident #1 was observed lying in bed. The bed was a bariatric bed in the low position and transfer handles were in place and up on both sides of the bed. On 11/15/21 at 10:36 AM, RN Manager #4 stated in an interview, when a new bed was needed, a work order was initiated and nursing worked with maintenance to get the bed the resident was assessed for. On 11/12/21, the resident got a new bed because the length of the bed was not long enough for them. They were not aware Resident #1 had transfer handles on their current bed and they should not have them. On 11/15/21 at 11:57 AM, licensed practical nurse (LPN) #1 stated in an interview, the resident was not capable of using transfer handles due to a recent decline in cognition. They last worked with the resident on 11/11/21 and they had no transfer handles on their bed at that time. On 11/15/21 at 12:10 PM, the Director of Plant Operations stated they were not sure if the bed Resident #1 had now was instructed to be delivered as is with the transfer handles in place. On 11/15/21 at 3 PM, RN Manager #4 was interviewed and stated the RN Restraint/Device assessment was completed for residents upon admission and quarterly. When RN #4 completed the assessment, they knew a resident was safe to use transfer handles if they were awake and alert, could follow commands, and were physically capable to hold onto the transfer handle. RN Manager #4 stated on 11/1/21, they did not think the resident was capable of using their transfer handle and probably should have been reassessed. RN #4 stated no one brought it to their attention to reassess the resident. On 11/12/21, RN #4 spoke with direct care staff about the resident needing a longer bed and they initiated a work order for a different bed. The bed came after 1 PM that day, RN #4 did oral care on the resident after they got the new bed, and did not recall seeing transfer handles on the bed. RN #4 had the weekend off and no one brought it to their attention the resident had transfer handles on the bed. RN #4 stated they expected the certified nurse aides (CNA) to check the Kardex and the CNAs should have notified someone the resident had transfer handles on the bed. RN #4 stated they were not aware of a process to ensure a resident got the correct bed. On 11/16/21 at 11:15 AM, maintenance worker #6 stated in a telephone interview, nursing told them where to get a bed and where they wanted it moved to. The maintenance department never removed transfer handles from a bed unless they were directed to do so. On 11/12/21, they moved a bed with transfer handles to the resident's room and nobody asked them to remove the transfer handles prior to moving it. The 11/12/21 work ordered documented please take big boy bed from room [ROOM NUMBER]W and bring down to 416P. The work order contained no documentation related to transfer handles that may have been on the bed or whether they needed to remain in place or being removed prior to the bed being moved. On 11/16/21 at 1:10 PM, the Director of Rehabilitation stated in an interview, OT was responsible to determine upon admission if a resident was appropriate for transfer handles. In the previous electronic medical record (EMR), there was a tab that OT could document transfer handle determination. The new EMR did not have the tab to document transfer handles. They stated they believed OTs were still assessing transfer handle use but just not documenting it on the form in the new EMR. The OT assessments from the previous EMR did not include documentation of transfer handle assessments. On 11/16/21 at 2 PM, CNA #10 stated in an interview, they worked on 11/15/21 and noticed the resident had transfer handles on their bed. They checked the care plan, and it was documented the transfer handles were removed. They told RN Manager #4 about the transfer handles and they did not recall what RN #4 said they were doing about the transfer handles. On 11/24/21 at 8:13 AM, the Director of Rehabilitation was interviewed and stated they did not believe the therapists were discussing the risks and benefits of transfer handles or obtaining informed consent. On 11/24/21 at 9:49 AM, the Director of Nursing (DON) stated in a telephone interview they expected an assessment to be completed if a resident required transfer handles and they expected the CCP and Kardex to be updated. The DON stated beds in the facility should not have transfer handles unless approved for use. The nurse, either an LPN or RN, was responsible for ensuring the resident received the correct bed once it arrived to the unit. The DON stated, they saw the resident after the incident on 11/8/21 and there were no transfer handles on the resident's bed. The DON stated, they were made aware Resident #1 had transfer handles on their bed on 11/15/21, and there should not have been transfer handles. On 11/23/21 at 1:02 PM, NP #12 stated in a telephone interview, they first met the resident in 8/21 and the resident was able to follow simple commands at that time. When they evaluated the resident on 11/1/21, the resident was minimally responsive, not talking, and not responding to verbal stimuli. The resident's eyes were shut, and they were not alert enough to follow commands. There was a definite decline from the way the resident presented in 8/21 to how they presented on 11/1/21. NP #12 reported their findings to nursing and did not recall which nurse they spoke with. NP #12 stated, they doubted the resident was alert enough to understand what a transfer handle was or how to use it at that time. They stated they could not be sure whether nursing should have reassessed the resident's transfer handles at that time of their decline on 11/1/21. On 11/23/21 at 2:02 PM, the Medical Director stated in a telephone interview they reviewed the Resident #1's record after the incident on 11/7/21 to attempt to figure out how to prevent a transfer handle incident from occurring again. The resident was on comfort care and [MEDICATION(S)] was recently added. The Medical Director stated the resident was sedated from the [MEDICATION(S)], and they slipped, and their arm got caught in the transfer handle. When someone was on comfort care, they would not expect an evaluation by therapy for an ADL decline because the decline was to be expected. With the addition of strong medications like [MEDICATION(S)], therapy would not be able to truly assess the resident. Many residents on comfort care had transfer handles and used them appropriately. The Medical Director stated they thought after this incident occurred, residents on comfort care should be reevaluated for transfer handle use to be sure they were safe. They were not sure if the resident had been reassessed for the transfer handle on 11/1/21. On 11/23/21 at 2:50 PM, LPN #1 stated in a telephone interview, Resident #1 used to be able to hold a conversation but recently they would only answer yes or no questions. On 11/1/21, the resident was seated in the hall for a meal, they were not rousable and not eating and found holding medications in their mouth. This was not the normal as the resident was very meal driven and always ate. When NP #12 was on the unit, they asked them to look at the resident and they made the resident full comfort care. The LPN stated they were not sure if they reported the resident's condition to RN #4 Manager or to the Supervisor. They stated as of 11/1/21, they did not think the resident could understand what a transfer bar was for. The resident might be able to grab onto it but would not be able to do a sustained hold on it. 2) Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/3/21 registered nurse (RN) Restraint Device Assessment documented the resident had no devices. The 8/11/21 occupational therapy (OT) evaluation and plan of treatment documented the resident was at the facility for rehabilitation to increase ability to participate in ADL and functional mobility to reach their maximum level of function. The assessment did not document the resident required transfer handles, if risks and benefits were reviewed with the resident or the resident representative, and if informed consent was obtained. The 8/30/21 comprehensive care plan (CCP) documented the resident had an ADL deficit. The CCP did not document the resident used transfer handles. The undated Kardex did not document transfer handles were in place for the resident. The 10/16/21 CCP documented the resident's cognition was intact, they required limited 1 person assist with bed mobility, and they had no falls and no restraints. There was no documentation the resident used transfer handles. On 11/15/21, Resident #2 was observed at 9:35 AM, in bed with both transfer handles up. On 11/15/21 at 3 PM, RN Manager #4 was interviewed and stated the RN Restraint/Device assessment was completed upon admission and quarterly. When they completed the assessment, they knew a resident was safe to use transfer handles if they were awake and alert and could follow commands, and physically capable to hold on to the transfer handle. RN #4 stated, they felt Resident #2 was safe to use transfer handles and the resident did not want them removed. Transfer handles should be in the CCP and Kardex and they had not updated the plan yet. They were not sure why the Resident/Device assessment documented the resident had no transfer handles. On 11/16/21 at 9:14 AM, Resident #2 was observed in bed with both transfer handles in the up position. On 11/16/21 at 1:10 PM, the Director of Rehabilitation stated in an interview, OT was responsible to determine if a resident was appropriate for transfer handles upon admission. In the previous EMR (electronic medical record), that had not been in use in the last 1.5 years, there was a tab that OT would document transfer handle determination. The new EMR did not have the tab to document transfer handles. They stated they believed OTs were still assessing transfer handle use, just not documenting it on the form in the new EMR. On 11/24/21 at 8:13 AM, the Director of Rehabilitation was interviewed and stated they did not believe the therapists were discussing the risks and benefits of transfer handles or obtaining informed consent. On 11/24/21 at 9:49 AM, the Director of Nursing (DON) stated in a telephone interview they expect an assessment to be completed if a resident required transfer handles and they expected the CCP and Kardex to be updated. Beds in the facility should not have transfer handles unless approved for use. 10NYCRR 415.12(h)(1)(2)

Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not ensure care was provided that prevented residents from developing pressure ulcers and/or did not ensure residents with pressure ulcers received the treatment and services needed to promote healing and prevent infection for 1 of 3 residents (Resident #6) reviewed for pressure ulcers. Specifically, Resident #6, who required assistance with re-positioning, developed a pressure ulcer on her left hip, and a physician-ordered physical therapy consultation for positioning was not performed. Subsequently, Resident #6 developed a pressure ulcer on her right hip. This resulted in actual harm that is not immediate jeopardy to Resident #6. Findings include: The facility policy Skin Care, revised 5/2014 and dated 5/21/2015, documented that pressure ulcers most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips, and tailbone. People with a medical condition that limits their ability to change positions, requires them to use a wheelchair, or confines them to a bed for a long time are most at risk. Facility standards of care include to use a pressure-relieving cushion in a wheelchair, and educate resident/family on pressure-relieving techniques. Avoidable pressure ulcers means that the resident developed a pressure ulcer and that the facility did not do one or more of the following: evaluate the resident's clinical condition and pressure ulcer risk factors; define and implement interventions that are consistent with resident needs, resident goals, and recognized standard of practice; monitor and evaluate the impact of the interventions; and revise the approaches as appropriate. Resident #6 was admitted [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact. She required extensive assistance for bed mobility and transfers and limited assistance for walking. The resident used a walker and a wheelchair for mobility. She was at risk for the development of pressure ulcers, had a pressure reducing device for her chair and bed, and did not have any pressure ulcers. The comprehensive care plan dated 4/5/2016 documented the resident had a BIMS (Brief Interview for Mental Status) score of 14, showing little to no cognitive impairment. The resident had short term memory loss, but was able to make needs known. She needed extensive assistance with ADLs (activities of daily living) due to recent weakness, gait disturbance, and history of stroke. The resident required assist of 1 for turning and positioning at least every 2 hours in bed and in chair. A nursing progress note dated 5/20/2016 at 11:07 AM documented the nurse was informed by the certified nurse aide (CNA) that a quarter-size area was found on the resident's left hip and was bleeding. The physician and nursing supervisor were notified. A wound care nursing note dated 5/20/2016 at 12:45 PM documented the area on the resident's left hip measured 2 centimeters (cm) x 2 cm with a dark, red/maroon-colored partial thickness open area and a small circle of drainage on the dressing. The area was located directly over the left trochanter (hip bone). A nursing progress note dated 5/20/2016, and created 5/23/2016 at 5:21 AM, documented the physician and nurse observed the open area on the resident's left hip. The resident had a circular wound that was red/maroon in color. The resident was lying on her right side and the wound was convex with an open area at the peak. The open area measured 2 x 2 (no units of measurement documented) with the convex area measuring 5 x 5. Physician orders [REDACTED]. An assignment sheet (care instructions) dated 5/20/2016 documented the resident had a pressure ulcer and was to lie on her back and right side only and to keep off the left hip. A nursing progress note dated 5/21/2016 at 1:39 PM documented the physician was aware of the left hip area, and a new order was received for a physical therapy (PT) consult for positioning. A physician order [REDACTED]. A physician progress notes [REDACTED]. The area measured 2 cm x 2 cm with surrounding redness and induration (hardness). The plan was to continue with [MEDICATION NAME], consult PT for educating the resident on positioning, and have the resident lie on her right side and alternate to her back. A physician order [REDACTED]. There was no documentation the PT consultation ordered by the physician on 5/21/2016 for positioning, and on 5/22/2016 for ambulation with walker, was completed. The comprehensive care plan (CCP) dated 5/26/2016 documented the resident had a left hip area with dark brown eschar/scab (dry dead tissue). Approaches included to reposition the resident on her back and right side in bed, treatment per physician order, and pressure relieving cushion and mattress. A nursing progress note dated 7/16/2016 at 11:35 PM documented the resident was observed with an area on right hip. A deep tissue injury was noted, measuring 2 cm x 1 cm darkened area in center of reddened 4 cm x 3 cm, nonblanching. The resident was repositioned off her right side with pillows and cushions, and the physician and dietary were notified. An assignment sheet dated 7/16/2016 documented the resident was to lie on her back only and to keep her positioned off her right and left sides using pillows. The CCP dated 7/16/2016 documented a DTI on the right hip. Approaches included repositioning and evaluation and treatment by physician order. A wound care nursing progress note dated 7/18/2016 at 2:03 PM documented the left hip wound measured 1 cm x 0.7 cm and remained unstageable. The resident had a new circular deep tissue injury to the right hip measuring 2.5 cm with a purple/red center and a golf ball sized firm area. The wound care nurse documented she found the resident to be seated on a thin seat cushion and the wheelchair bars were felt when pressing on the cushion in the chair. The resident remained out of bed most of day and was positioned to the right side and back when in bed. The wound care nurse escorted the resident to occupational therapy (OT) and explained that a new DTI area had developed on the opposite hip and she felt the wheelchair crossbar under the seat may have been a contributing factor. The OT examined the chair and issued a new, thick cushion. The CCP documented on 7/18/2016 the resident received a new wheelchair cushion. A nursing progress note dated 7/19/2016 at 12:36 PM documented the nurse updated the physician about the resident's current skin condition. The nurse reviewed with him that staff were walking with the resident more, and they obtained a new wheelchair cushion and a new and better fitting wheelchair for her. An OT progress note dated 7/21/2016 documented a late entry for 7/19/2016. The resident had a new deep tissue injury and an alternate cushion for the wheelchair was issued and the resident reported it was comfortable. A wound care nurse progress note dated 8/1/2016 documented the staff reported the areas were not improving and the right hip was following the same progression as the left hip had. The staff reported the resident continued to sit tilted to the right side in her wheelchair and the resident did not recognize her altered positioning. The resident would frequently stand for short periods of time and would tire. There was no documentation the resident's positioning concerns were addressed. A nursing progress note dated 8/16/2016 at 2:20 PM documented both of the resident's hips were assessed. The left hip was essentially healed and the Santyl ([MEDICATION NAME] ointment) would be discontinued and [MEDICATION NAME] would be changed every 5 days and prn. The right hip remained necrotic (dead tissue) in the center. The resident was to have her mattress changed to Span America (alternating air mattress that distributes even pressure). Physician orders [REDACTED]. Lightly pack with 2 x 2 gauze, cover with 4 x 4 gauze and secure with Opsite (transparent, adhesive) dressing. Change daily, check every shift, change prn if dressing was saturated, and re-evaluate in 1 week. Physician orders [REDACTED]. A physician progress notes [REDACTED]. It is quite deep and appears to be tunneling. The plan was to refer to the wound care clinic. The resident was seen at the wound care clinic on 9/20/2016. The wound care physician documented the resident had a Stage III (full thickness skin loss) pressure ulcer on the right hip that was debrided (dead tissue removed). The recommendation was to position the resident to off-load the right hip. Physician orders [REDACTED]. The new treatment was to cleanse and dry the wound, apply [MEDICATION NAME] Ag (antimicrobial dressing) or similar product, loosely pack into wound, cover with a 4 x 4 and Opsite, and change every other day and prn if wet. The orders documented to turn and position off the area every 2 hours and to position to off-load the right hip. An assignment sheet dated 9/23/2016 documented to offload right hip when the resident was in bed and in the chair. The resident was seen at the wound care clinic on 10/4/2016. The wound care physician documented the Stage III pressure area on the right hip was debrided. Recommendations included a [MEDICATION NAME] border dressing and positioning on the left side to off load the right hip while in bed or a recliner. Physician orders [REDACTED]. Cleanse the right hip wound with NS, pat dry, pack with [MEDICATION NAME] Ag, cover with [MEDICATION NAME], and change every other day for 2 weeks. On 10/6/2016 at 10:02 AM, the right hip wound was observed during a dressing change with licensed practical nurse (LPN) #1. LPN #1 stated the resident had a bar on her old wheelchair they were not aware of, which may have been pressing against the resident's hips. She did not know when the resident's wheelchair had been changed. She stated the resident had always had a cushion in her wheelchair. She stated the resident was able to transfer herself and participated in the Walk to Dine program. She stated the resident preferred to lie on her right side and required frequent reminders to stay off that side. Registered nurse (RN) Unit Manager #2 was interviewed on 10/7/2016 at 8:45 AM. She stated that when an area of skin breakdown occurred on the resident's right hip, after one had previously occurred on the left hip, they had determined the pressure areas were likely caused by bars on the resident's wheelchair. The first wheelchair cushion had been too thin and the bar was felt through the cushion. A new cushion was obtained, as well as a new wheelchair, after the area developed on the right hip in 7/2016. Wound Care RN #3 was interviewed on 10/7/2016 at 9:10 AM. She stated initially in 5/2016 they thought the area on the left hip was an abscess. The resident was sent for a test, and the area was deemed a pressure ulcer and was located on the left trochanter (hip bone). She had recommended a PT consult for positioning and did not know why it had not been done. She stated the resident developed an identical area on the right side in 7/2016. She stated since the area on the left hip began to heal, she did not feel a more in-depth investigation was needed and the plans which were in place were working. She stated when the area on the right side developed, she determined the crossbar in the wheelchair seat was pressing on the cushion causing pressure, and immediately got a new cushion and wheelchair for the resident. During an interview with PT #4 on 10/7/2016 at 9:35 AM, she stated she had never done a positioning evaluation for the resident, and OT would have done one. She stated the resident had been on a restorative PT program until 4/2016, and was currently receiving maintenance therapy every Monday. During an interview with OT #5 on 10/7/2016 10:15 AM, she stated she had spoken with the wound care nurse regarding the resident's pressure ulcer on her right hip. They had thought it may have been caused by the bar on the wheelchair and the cushion was bottoming out. When the second area developed on the right hip, they determined the chair was not padded correctly. A thicker cushion and a new wheelchair were issued. The physician was interviewed on 10/7/2016 at 11:45 AM. He stated when the first pressure area developed on the resident's left side, he ordered a CT (computed tomography) scan to determine what type of injury it was. He stated it was deep tissue injury and was not sure what could have caused it. He stated he ordered a (physical) therapy consult for movement. He stated when the second area developed on the right side, it was determined it was likely caused by the wheelchair. 10NYCRR 415.12(c)(1-2)