Every finding on record at Onondaga Center for Rehabilitation and Nursing

Based on record review and interviews during the recertification survey conducted [DATE]-[DATE], the facility failed to provide cardiopulmonary resuscitation prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for one (1) of three (3) residents (Resident #85) reviewed. Specifically, Resident #85 had a physician order for cardiopulmonary resuscitation (chest compressions and rescue breathing when there is no pulse and/or respirations) and an advance directive for cardiopulmonary resuscitation to be attempted. On [DATE], Resident #85 was found without a pulse and was not breathing, and staff did not initiate cardiopulmonary resuscitation. The resident was pronounced deceased by Emergency Medical Services. The facility's failure to administer cardiopulmonary resuscitation resulted in Immediate Jeopardy and Substandard Quality of Care to Resident #85 and placed all 79 residents in the facility with Advance Directives at risk for serious harm, serious injury, serious impairment or death. Findings include:The facility policy Code Blue/Cardiopulmonary Resuscitation, dated [DATE], documented, in accordance with the resident's code status (e.g. full code), cardiopulmonary resuscitation would be initiated upon recognition of cardiopulmonary arrest (e.g., no pulse, no respirations, no audible blood pressure).Resident #85 had diagnoses including chronic obstructive pulmonary disease (lung disease), high blood pressure, and anxiety disorder. The [DATE] admission Minimum Data Set (a resident assessment tool), documented the resident was cognitively intact. Resident #85's baseline admission care plan did not include code status. The resident's Medical Orders for Life-Sustaining Treatment, signed by the resident on [DATE], documented the resident wished for cardiopulmonary resuscitation should they have no pulse and/or was not breathing. Physician #4's orders documented: -On [DATE], cardiopulmonary resuscitation order: attempt cardiopulmonary resuscitation.-On [DATE], please see Medical Orders for Life-Sustaining Treatment. The 07/2025 Medication Administration Record documented cardiopulmonary resuscitation order: attempt cardiopulmonary resuscitation, please see Medical Orders for Life-Sustaining Treatment. The [DATE] at 6:26 AM, Licensed Practical Nurse #7 progress note documented they entered Resident #85's room at 5:30 AM and found the resident unresponsive, cold to touch, rigid and no color, no signs of life, and no respirations or pulse. They immediately called the Director of Nursing and the on-call provider service. They last saw the resident alive and breathing around 3:20 AM when the certified nurse aide (not identified) asked for assistance to change the resident and the linen on the bed. The Assistant Nurse Manager arrived at the facility around 5:45 AM, taking charge of the situation. The Assistant Nurse Manager called 911 after arriving (no identified time) and notified the family. The on-call provider service had not called back as of 6:39 AM. The [DATE] at 6:30 AM Licensed Practical Nurse Assistant Unit Manager #6 progress note documented they were notified by the 10:00 PM - 6:00 AM nurse the resident was found with no pulse, and no response to stimuli. Emergency Medical Services and Physician #4 (previous Medical Director) were notified. Emergency Medical Services pronounced the resident deceased (no time documented). The [DATE] at 6:55 AM Licensed Practical Nurse #7 progress note documented the on-call physician returned their call at 6:50 AM. The [DATE] ambulance service Patient Care Record completed by Paramedic #16 (third party ambulance service) documented they were called for an obvious death. Upon their arrival, the supervisor (facility) stated they just arrived and called 911. The resident was last seen between 3:00 AM and 3:30 AM, sitting on the edge of the bed. Paramedic #16 assessed Resident #85's vitals and noted their jaw was stiff, and all other extremities were movable. Resident #85 was pronounced dead at 6:02 AM. The [DATE] Licensed Practical Nurse #7 Charting by Exception note documented it was an addendum to the note on [DATE]. The writer was aware of the resident's code status being a Full Code. When the writer found the resident with no pulse, no respirations, no color, cold to the touch, rigid, signs of blood pooling, and dependent lividity they knew cardiopulmonary resuscitation was futile and did not begin it. They attempted to call the on-call provider multiple times with no return call. The Assistant Unit Manager arrived and attempted to call Physician #4 (previous Medical Director), was unable to contact them, and called 911. Emergency Medical Services arrived, did not initiate cardiopulmonary resuscitation and pronounced the time of death. The unsigned [DATE] facility Investigative Summary documented an unexpected death on [DATE].-on [DATE] at approximately 5:30 AM, Licensed Practical Nurse #7 entered Resident #85's room and found them unresponsive without a pulse or respirations. They checked the Medical Orders for Life-Sustaining Treatment and noted the resident wished to have cardiopulmonary resuscitation. They noted the resident was cold, rigid, signs of blood pooling, and signs of dependent lividity were present. The licensed practical nurse stated they felt cardiopulmonary resuscitation was futile. They called the provider and 911. Emergency medical technicians and police arrived at approximately 5:45 AM. A telephone call was placed to the Director of Nursing at approximately 5:42 AM. The emergency medical technicians pronounced the resident (deceased ) at 6:02 AM.-The [DATE] at 5:53 AM statement from Certified Nurse Aide #5 documented while doing rounds (time not included) Resident #85's breathing was wet sounding, and the licensed practical nurse (unnamed) was in the room with them. The licensed practical nurse said they would let the right staff know. They left to care for other residents and Licensed Practical Nurse #7 called them back (time not documented) to the resident's room because the resident was cold and no longer breathing.-The [DATE] Licensed Practical Nurse #7 statement documented at around 5:30 AM they entered Resident #85's room and found the resident with no signs of life, no respirations, no pulse. They were last in the resident's room at 3:30 AM helping the certified nurse aide lift the resident into bed. The Director of Nursing was called immediately along with the on-call provider. No return call was received from the on-call provider.-The undated statement by Licensed Practical Nurse Assistant Unit Manager #6 documented they were notified Resident #85 was unresponsive and had passed at 5:40 AM as they were driving to the facility and was instructed to get to the room and assess. When they arrived (no time) the resident was lying in bed unresponsive, cold, pale, mouth open with their jaw to their chest, arms rigid, fluid filled forearms, and mottled lower extremities. They called 911. When Emergency Medical Services arrived, they pronounced the resident and the police took statements.-The [DATE] Certified Nurse Aide #5's clarification of their statement completed by telephone by Acting Director of Nursing #2 documented when they described the resident's breathing as wet, they meant it sounded like the resident was having trouble breathing. Licensed Practical Nurse #7 evaluated the resident and left to make a phone call.During an interview on [DATE] at 2:23 PM, Licensed Practical Nurse #7 stated they found Resident #85 unresponsive, rigid with blood pooling in their fingers, and was clearly deceased . They did not start cardiopulmonary resuscitation based on those observations. If they knew it was going to be a whole situation, they would have just done cardiopulmonary resuscitation and they would do it now. They stated when they found Resident #85, they called out for Certified Nurse Aide #5, then called Registered Nurse #17 (Director of Nursing at the time). There was no registered nurse in the building, but the Director of Nursing was on call. They were told to contact the on-call provider service. When the on-call provider did not call back, they contacted Registered Nurse #17 again. By that time, Licensed Practical Nurse Assistant Unit Manager #6 arrived and called 911. During a telephone interview on [DATE] at 11:46 AM, Certified Nurse Aide #5 stated they provided care for Resident #85 on [DATE] at 3:20 AM. They left the resident and assisted a couple of other residents and used the rest room when Licensed Practical Nurse #7 found Resident #85 unresponsive. They stated they could not recall what time it was. When they walked in the resident's room to help Licensed Practical Nurse #7, the resident was limp. Licensed Practical Nurse #7 left the room and made some phone calls. Licensed Practical Nurse #6 then came in at about 5:45 AM. They were not sure what happened after that as they returned to certified nurse aide tasks, because they were the only certified nurse aide on the unit. During a telephone interview on [DATE] at 12:41 PM, Licensed Practical Nurse Assistant Unit Manager #6 stated Resident #85 passed over the summer and was a full code and did not have cardiopulmonary resuscitation performed. Resident #85 was passed for some time when they got to the facility at about 6:00 AM on [DATE]. The resident's skin was cold, and they appeared rigid. They called 911 at that time. Licensed Practical Nurse #7 told them they made the judgement call the resident was dead, and did not start cardiopulmonary resuscitation. They stated there was no registered nurse on the overnight shift. During a telephone interview on [DATE] at 5:00 PM, Registered Nurse #17 stated if the Medical Orders for Life Saving Treatment documented full code, cardiopulmonary resuscitation should be initiated and 911 called. Emergency Medical Services could make the decision to terminate the resuscitation efforts. There was a caveat, if the resident had signs and symptoms of rigor mortis there was a possibility not to do cardiopulmonary resuscitation. They were not sure if the decision to not initiate cardiopulmonary resuscitation due to rigor was an assessment or an observation. If it was an assessment then a registered nurse would make that decision, but if it was based on observations a licensed practical nurse could make that decision. The initiation of cardiopulmonary resuscitation should occur quickly after reviewing the Medical Orders for Life Saving Treatment. They were aware Resident #85 did not have cardiopulmonary resuscitation initiated when they were listed as a full code on the Medical Orders for Life Saving Treatment. They stated they received a phone call in the early morning on [DATE] from Licensed Practical Nurse #7 stating they found Resident #85 who was clearly deceased , was cold and rigid, and they did not start cardiopulmonary resuscitation, and did not know what to do. They advised Licensed Practical Nurse #7 to call 911 and the provider, because there was no registered nurse in the building. They did not instruct them to start cardiopulmonary resuscitation. They were not aware Licensed Practical Nurse #7 did not contact 911. During a telephone interview on [DATE] at 4:47 PM, Physician #4 stated when a resident wished to be a full code the expectation was to resuscitate them. If the resident was found unresponsive, without a pulse or respiration, staff should try to resuscitate. Cardiopulmonary resuscitation should be initiated right away. Licensed practical nurses should initiate cardiopulmonary resuscitation and contact Emergency Medical Services. They were aware Resident #85 was a full-code and cardiopulmonary resuscitation was not started. They were notified the next day when they were contacted to sign the resident's death certificate. During an interview on [DATE] at 5:13 PM, the Administrator stated if a resident was found without a pulse or respirations, a Code Blue should be called, and the Medical Orders for Life Sustaining Treatment should be checked for the code status. If a resident wished to be a full code, cardiopulmonary resuscitation should be given. In the case where rigor mortis was present, cardiopulmonary resuscitation would not be started. The determination to initiate cardiopulmonary resuscitation should be made by a registered nurse assessment. At the time of Resident #85's death, there was no registered nurse in the building. The Licensed Practical Nurse found the resident stiff and called 911 and did not start cardiopulmonary resuscitation as the body was stiff. The Licensed Practical Nurse tried to get in contact with medical and nursing. The facility followed the American Heart Association guideline, if a resident had rigor mortis, they would not start cardiopulmonary resuscitation. On [DATE], 911 was called and Emergency Medical Services determined Resident #85 had passed away. 10 NYCRR 415.3(e)(2)(iii)------------------------------------------------------------------------------------------------------------------The Administrator was notified of the Immediate Jeopardy on [DATE] at 5:52 PM. The Immediate Jeopardy was removed on [DATE] prior to survey exit based on the following corrective actions taken:-On [DATE] the facility reviewed their Code Blue/ [Cardiopulmonary Resuscitation], policy and made no changes. - All staff identified for education received education by [DATE], except two staff who were not available. The two staff who did not receive education were to complete education upon their return, prior to the start of their shift.- Staff Interviews were completed on [DATE] and determined compliance with training and retention of educational content.- The Administrator was notified on [DATE] at 12:42 PM the Immediate Jeopardy was lifted.

Based on record review and interviews during the recertification survey conducted [DATE]-[DATE] the facility failed to promptly notify the ordering physician of laboratory results that fell outside of clinical reference ranges for 3 of 3 residents (Residents #41, #60 and #85) reviewed. Specifically:-Resident #85 had abnormal laboratory values on [DATE] and [DATE] that were not reviewed timely or assessed by the medical provider. -Resident #41 had a critical laboratory result on [DATE] with no documented provider notification until [DATE]. - Resident #60 had abnormal laboratory and a positive wound culture on [DATE]. The results were not reviewed until [DATE]. This resulted in the likelihood of serious injury, serious harm, or death that was Immediate Jeopardy to resident's health and safety for all residents with ordered laboratory tests.Findings include: The facility policy Lab/Test Results - Reporting, revised 9/2019, documented upon completion of the test, the lab would send written results to the facility, and communication would be via fax or electronic depending on the facility's capabilities. The nurse would call or fax the abnormal results to the physician. When the nurse called or faxed the results to the physician, the nurse would write a note with results reported, to who, and when.The electronic medical record Lab Results report documented a legend for flags included on the report. A red stop sign with an exclamation mark in the center indicated the report contained critical results (results in red text). A yellow triangle with an exclamation mark in the center indicated the report contained abnormal results (results with orange text). 1) Resident #85 had diagnoses including hypertension (high blood pressure) and chronic obstructive pulmonary disease (lung disease). The [DATE] Minimum Data Set assessment documented the resident was cognitively intact.A [DATE] physician order documented complete blood count with differential (a blood test that measures the number and size of different cells in the blood); basic metabolic panel (a blood test used to provide information about fluid balance, metabolism, and kidney function); and B-type natriuretic peptide (measures heart health) to be drawn on [DATE] for routine monitoring. The [DATE] Lab Results Report documented the results were reported [DATE] at 10:34 AM and included a yellow triangle with an exclamation mark in the center indicating the report contained abnormal results. The abnormal results included B-type natriuretic peptide (indicates heart health) 241 picograms/milliliter (reference range <125); sodium (electrolyte) 123 millimoles/liter (reference range 136-145); chloride (electrolyte) 91 millimoles/liter (reference range 98-107); blood urea nitrogen (indicates kidney function and/or fluid status) 28 milligrams/deciliter (reference range 9-23); blood urea nitrogen/creatinine ratio (provides information on kidney function) 25 (reference range 9-23); glucose (blood sugar) 156 milligrams/deciliter (reference range 70-99); red blood cells 3.65 total volume 30 microliters (reference range 4.60-6.10); hemoglobin (transports oxygen) 11.5 gram/deciliter (reference range 13.5-18.0); and hematocrit (percentage of red blood cells in total volume of blood) 34.1% (reference range 41.0-53.0). There was no signature indicating the results were reviewed when received. The report documented the labs were reviewed by Acting Director of Nursing #2 on [DATE] at 8:24 AM, over one month after receiving results. The [DATE] untimed Physician Assistant #36 progress note documented the resident was seen for an acute visit for chest congestion and pain following recent falls. There was no documented evidence the [DATE] lab results were reviewed. There were no documented nursing progress notes addressing the resident's abnormal labs on [DATE]. A [DATE] physician order documented basal metabolic panel for routine monitoring to be drawn on [DATE]. The [DATE] Lab Results Report documented the results were reported on [DATE] at 10:26 AM and included a yellow triangle with an exclamation mark in the center indicating the report contained abnormal results. The abnormal results included sodium 121 millimoles/liter (reference range 136-145); potassium (electrolyte) 5.8 millimoles/liter (reference range 3.5-5.1); chloride 90 millimoles/liter (reference range 98-107); blood urea nitrogen 42 milligrams/deciliter (reference range 9-23); and blood urea nitrogen/creatinine ratio 38.9 (reference range 9-23). There was no signature indicating the results were reviewed when received. The report documented the labs were reviewed by Licensed Practical Nurse Assistant Unit Manager #6 on [DATE] at 6:14 AM. There were no documented medical provider or nursing progress notes addressing the abnormal lab results on [DATE]. [DATE] progress notes documented the resident had falls at 2:22 PM and at 6:00 PM The resident expired on [DATE] at 6:02 AM. The Provider Communication Sheets (used to communicate medical issues to the provider) dated [DATE] to [DATE], did not document notification of the available labs for Resident #85. 2) Resident #41 had diagnoses including end stage renal (kidney) disease and dependence on renal dialysis (a treatment that filters the blood during kidney failure). The [DATE] Minimum Data Set documented the resident was cognitively intact and received dialysis. The [DATE] Comprehensive Care Plan documented:-the resident needed hemodialysis related to end stage renal disease. Interventions included to monitor, document, and report to the provider any signs or symptoms of bleeding, hemorrhage, bacteremia, septic shock, and to obtain vital signs and weight per protocol. The [DATE] Nurse Practitioner #11 progress note documented the recommendation to draw a complete blood count and basic metabolic panel for follow up and monitoring of both acute and chronic conditions. The [DATE] Lab Results Report documented the results were reported on [DATE] at 10:58 AM and included a red hexagon indicating the report contained critical results. The resident's creatinine (a waste product filtered from the blood used to assess kidney function) was 10.89 milligrams/deciliter (reference range 0.70-1.30) with a note documenting consistent with previous results. There was no signature indicating the results were reviewed when received. The report documented the labs were reviewed by Nurse Practitioner #11 on [DATE] at 12:46 PM.There was no documented nursing progress note regarding the resident's critically high creatinine level. The Provider Communication Sheets dated [DATE] to [DATE] did not document notification of the available labs for Resident #41.The [DATE] Nurse Practitioner #11 progress note documented they discussed the [DATE] laboratory results of hemoglobin of 8.3 (low) and a hematocrit of 27.9 (low) with the resident. The recommendation was to repeat the labs on the next lab draw, hold the resident's warfarin (blood thinner) for three days, and continue to monitor. It did not address the resident's critical creatinine level. 3) Resident #60 had diagnoses including right below knee amputation, methicillin resistant staphylococcus aureus (antibiotic resistant bacteria) infection, and acute kidney failure. The [DATE] Minimum Data Set documented the resident was cognitively intact, had multidrug-resistant organisms, a wound infection, and received antibiotics. The [DATE] Comprehensive Care Plan documented the resident had a colonized multi-drug-resistant organism of methicillin resistant staphylococcus aureus. Interventions included to monitor the resident for signs and symptoms of worsening infection and educate the resident, family, and visitors of precautions. The intervention added [DATE] documented the resident was on enhanced barrier precautions. The [DATE] Lab Results Report documented labs were drawn on [DATE] at 3:10 PM for a complete blood count, procalcitonin, and wound culture and sensitivity of right stump. The labs were reported on [DATE] at 9:18 A and included a yellow triangle with an exclamation mark in the center indicating the report contained abnormal results. The resident's red blood cell count was 3.0 (reference range 4.1-11.0); hemoglobin 8.9 grams/deciliter (reference range 13.5-18.0); hematocrit 28.6% (reference range 41.0-53.0); procalcitonin 0.26 nanograms/milliliter (interpretation <0.51 sepsis is not likely); and the gram stain of the right stump showed methicillin resistant staphylococcus aureus with sensitivity results (what antibiotics the organism was susceptible to). There was no signature indicating the results were reviewed when received. The report documented the labs were reviewed by Nurse Practitioner #11 on [DATE] at 9:31 PM. There were no documented nursing notes regarding the laboratory or wound culture results being reported to the provider. The Provider Communication Sheets from [DATE] to [DATE], did not include documentation the provider was notified of the available labs and wound culture. The [DATE] Nurse Practitioner #11 progress note documented on last inspection there was a stitch on the resident's right below knee amputation surgical site draining purulent drainage, it was cultured and came back as methicillin resistant staphylococcus aureus. The stump incision looked more degraded. The assessment was the resident had methicillin resistant staphylococcus aureus positive culture, and the resident was to start Bactrim DS 1 tablet every 12 hours for 10 days. During a telephone interview on [DATE] at 10:24 AM, laboratory Customer Service Representative #12 stated abnormal labs were reported to the facility via automatic fax five times a day after resulting. Critical lab values were called to the facility, and a note was added to the lab results with the person the results were reported to. Resident #85 did not have results called to the facility because they did not meet the critical value criteria. During an interview on [DATE] at 1:18 PM, Registered Nurse Unit Manager #13 stated Resident #85 had labs drawn on [DATE] and included an abnormal B-type natriuretic peptide for the heart. The level was high at 241 and should be less than 125; the sodium was 123 and should be around 136-145, Glucose was 156, should be 70-99. The provider was responsible for reviewing the labs. They did not see any documentation the labs were reviewed. There was no documentation the provider was notified. They stated the expectation was once the abnormal value was identified; notification should be immediate. A progress note could be created from the lab screen when the provider was notified, and there were no notes about provider notification Resident #85's [DATE] laboratory results. During a telephone interview on [DATE] at 3:33 PM, Licensed Practical Nurse Assistant Unit Manager #6 stated they did not read the laboratory results for Resident #85. Licensed Practical Nurse #7 did. The Electronic Medical Record documented the labs were reviewed on [DATE], but it was their job to clear the dashboard (a screen in the electronic medical record showing pending labs in one view) in the morning. They reached out to former Director of Nursing #17 and Physician Assistant #36 came to the facility the following day. During an interview on [DATE] at 3:33 PM, Nurse Practitioner #11 stated they expected to be notified of abnormal laboratory results through the provider book, by fax, or by phone. They should be notified of abnormal or critical laboratory results to follow up with the resident and put in orders if needed. During an interview on [DATE] at 3:48 PM, Physician (Previous Medical Director) #4 stated they expected to be notified of abnormal labs, including on the weekends. They could be reached at any time, and if they were not available there was always an on-call provider available. They expected there to be documentation the provider was notified. The provider was responsible for the resident, no matter what the abnormal labs where they needed to be addressed. During a follow up interview on [DATE] at 9:32 AM, Nurse Practitioner #11 stated if an abnormal or critical lab resulted over the weekend, they expected staff to follow the policy and procedure to follow up on it. Resident #41's critical lab should have been communicated to them if they were in the facility when it came through. Resident #60 was started on antibiotics due to their wound culture results. They stated with Resident #41 they did not believe anything could have happened from not receiving the results earlier and they reached out to infectious disease to see if they needed to be on antibiotics. During an interview on [DATE] at 12:53 PM, Registered Nurse #13 stated all labs should be reviewed. The laboratory called the facility with critical reports and faxed abnormal results. The lab faxed results to two difference fax machines. The Minimum Data Set Nurse, the Director of Nursing, or they checked the fax machines. On the weekends, the electronic medical record dashboards were checked for laboratory results by nurses who would notify the on-call provider. They did not recall Resident #41's critical lab results for the creatinine. They believed the provider reviewed the laboratory result but was unaware it was not reviewed until the day after it resulted. Providers should be notified immediately of critical laboratory results, and the notification should be documented. A wound culture result received over a weekend should be reviewed as soon as possible. The licensed practical nurses should check their dashboard, and the providers should be notified as soon as possible. There was no standard way of informing a provider of laboratory results; sometimes the nurses called right away and sometimes they utilized the communication book. If they used the communication book, it was not reviewed until the next time the provider came into the facility. During an interview on [DATE] at 1:28 PM, the Acting Director of Nursing stated the facility had a nurse practitioner and two physicians who oversaw the clinical side and when they were not there, there was an on-call service for medical needs. The nursing staff was responsible for letting the providers know when laboratory results were received, and the providers were responsible for reviewing the laboratory results. Critical laboratory results should be reported immediately to the providers. During an interview on [DATE] at 4:18 PM, the Administrator stated the lab identified critical values, and nursing staff should call the results to the provider immediately. Abnormal results were not the same level as critical but should still be reported to the provider as quickly as possible. Any nurse was able to call the on-call provider. They knew who to contact after hours and to contact the in-house provider during business hours. They stated notifying the provider two or three days later for an abnormal lab was too long to wait. Labs should be reported within 24 hours. During a telephone interview on [DATE] at 9:34 AM, Physician #14 stated labs should be reviewed by Nurse Practitioner #11 the day the results were available. Nurse Practitioner #11 should review labs daily and contact them with questions. They were not sure how critical labs were reported, but someone was usually called for critical labs. They were unaware of what arrangement Nurse Practitioner #11 had made with facility and if nursing called Nurse Practitioner #11 or the on-call service with laboratory results during off peak hours. Laboratory results should be reviewed the day they resulted and if it was a weekend, the nurse on-site should notify the on-call provider. Resident #41's critically high creatinine should have been addressed with at least a note by Nurse Practitioner #11 even if nothing was clinically done. A wound culture should be reviewed and the facility notified of the results timely. If a wound culture resulted on the weekend, the provider should be notified of the results. Resident #60's results should have been reported to Nurse Practitioner #11 or to the on-call the first day the results came back, and the results should have been addressed earlier. The providers should be notified of critical or abnormal laboratory results because it may not be appropriate to wait on those results and wait for the resident to be seen. A resident who had a potassium of 5.8 and a sodium of 121 could have seizures or go into a coma. The results would need to be addressed right away. During a telephone interview on [DATE] at 2:34 PM, Physician #3 stated laboratory results should be reviewed daily, particularly abnormal results. If the facility was not able to contact Nurse Practitioner #11 during the day, the facility should call them or Physician #14. Abnormal laboratory results over the weekend or afterhours should be reviewed by nursing staff and reported to the on-call service. Two days was too long for a wound culture to be reviewed, the wound culture should have been reported the day it came in. Three days was too long for an abnormal laboratory result to not be reviewed. A resident who had a high potassium of 5.8 and a low sodium of 121 could have altered mental status and there could be metabolic changes. It needed to be taken seriously. Those laboratory results were something they would hospitalize a resident over. It was important critical and abnormal laboratory results were reported to the providers so they could make the right clinical decisions for the patient such as ordering follow up labs or sending the resident to the hospital. 10 NYCRR 415.20 The facility has taken the following steps to lift the IJ in F773, issued [DATE] at 5:22 PM: The facility educated staff on reviewing labs in the dashboard and reporting requirements. Facility policy for lab reporting was reviewed without changes needed. Plan for immediacy was accepted on [DATE] at 6:53 PM. Complete IJ plan approved by team to start education on [DATE] at 12:30 PM. 100% of working staff have received stand up education as of [DATE] at 1:43 PM, with plans for ongoing education of staff prior to the start of their next shift for those not currently on the schedule. 92.3% of staff were educated based on education outline as of [DATE] at 3:34 PM. 96% of staff were educated based on the education outline as of [DATE] at 7:59 AM. Post tests reviewed; no discrepancies found in grading. Staff education sign in sheets were reviewed and compared to the current nursing staff list. 21 of 22 nursing staff and 4 of 4 medical providers were educated. Staff education was verified during an onsite visit(s) [DATE], multiple staff licensed nurses and providers were interviewed, no discrepancies identified. Staff were able to report content of education and the facility staff who presented the education. Lab dashboard reviewed on [DATE] at 9:45 AM and no labs awaiting review. Administrator was notified on [DATE] at 11:21 AM. Officially IJ lifted [DATE].

Based on observations, record review, and interviews during the recertification and extended survey conducted 09/22/2025 - 11/20/2025, the facility failed to ensure its operations were administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, administration's actions, inactions, or decisions contributed to deficient practices rising to Immediate Jeopardy in F678, Cardiopulmonary Resuscitation and F773, Laboratory Notifications. Additionally, administration failed to ensure nursing staff had appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident (F726, Competent Nursing Staff). Findings include: The undated facility Quality Assurance and Performance Improvement Plan documented the Quality Assurance and Performance Improvement committee was comprised of the Administrator, Medical Director, Director of Nursing, Assistant Director of Nursing, Facility Educator, Unit Managers, Wound Nurse, nursing and ancillary staff and all department heads. The Quality Assurance and Performance Improvement Committee would oversee implementation of the Quality Assurance and Performance Improvement Plan. The objectives of the Quality Assurance and Performance Improvement plan included:-Provide a means to identify and resolve present and potential negative outcomes related to resident care and services.-Reinforce and build upon effective systems and processes related to the delivery of quality care and services.-Provide structure and processes to correct identified quality and/or safety deficiencies.-Establish and implement plans to correct deficiencies and to monitor the effects of these plans on resident outcome.-Help departments, consultant, and ancillary services that provide direct or indirect care to residents to communicate effectively, and to delineate lines of authority, responsibility, and accountability.-Provide a means to centralize and coordinate comprehensive [Quality Assurance and Performance Improvement] activities in order to meet the needs of the residents and the facility; and-Establish systems and processes to maintain documentation related to the [Quality Assurance and Performance Improvement] Program, as a basis for demonstrating that there was an effective ongoing program.The undated job description for the Administrator of Record documented the primary purpose of the position was to direct the day-to-day functions of the facility in accordance with current Federal, State, and Local standards, guidelines, and regulations that governed skilled nursing facilities and nursing homes to assure the highest degree of quality of care was being always provided to the residents at the facility. The Administrator was responsible to direct all the facility employees in their specific roles and to ensure that each department was functioning efficiently and in accordance with all corporate policies and procedures. Essential functions included: ensure the proper function of the nursing department and the clinical staff; hire and direct a qualified and capable Director of Nursing; ensure all residents right to fair and equitable treatment, self-determination, individuality, privacy, confidentiality of information, property and civil rights including the right to lodge a complaint, were strictly enforced; and ensure all Department of Health reportable events were reported timely to the correct state or federal agency per state and federal regulations. The undated job description for the Director of Nursing documented they assumed authority, responsibility, and accountability for the delivery of nursing services in the facility. In collaboration with Administration, they allocated department resources in an efficient and economic manner to enable each resident to attain or maintain the highest practicable physical, mental and psycho-social well-being. The Director of Nursing was responsible for oversight, planning, organizing, developing, training and 24-hour management of the clinical nursing department in the Nursing Home and Rehabilitation Center and assisted with the planning, organization, development, coordination, and direction of the nursing department in its program and activities in accordance with current Federal, State, and local guidelines and regulations, accepted standards of practice. The Director of Nursing oversees and supervises development and delivery of in-service education to equip nursing staff with sufficient knowledge and skills to provide compassion, quality care, and respect for the resident rights. The 03/13/2025 Facility Assessment documented the average daily census was 75 residents. The list of current resident diagnoses included: psychiatric/mood disorders with common diagnoses of psychosis (hallucination and delusions), mental disorders, depression, bipolar disorder (mania/depression) schizophrenia, post-traumatic stress disorder, anxiety disorder, skin ulcers, urinary tract infections, infections with multi-drug-resistant organisms, diabetes, risk for bleeding or blood clots, and renal failure. The services provided by the facility were physical therapy, occupational therapy, speech therapy, medication administration, tube feeding, end of life care, and wound care (surgical, other skin wounds). Cardiopulmonary Resuscitation: Refer to the citation text under F678.On 07/22/2025, Resident #85 was found without a pulse and without respirations, and staff did not initiate cardiopulmonary resuscitation per the resident's wishes documented on their Medical Orders for Life Sustaining Treatment.This resulted in actual harm that was Immediate Jeopardy and Substandard Quality of Care to residents' health and safety.Lab Services/Physician Order/Notification of Laboratory Results: Refer to the citation text under F773.Residents #85, #60, and #41 had laboratory results that fell outside of the clinical reference range, and the ordering physician was not promptly notified of the results. This resulted in the likelihood of serious injury, serious harm, or death that was Immediate Jeopardy to residents' health and safety. Competent Nurse Staff: Refer to the citation text under F726.Licensed Practical Nurses #6, #7, #10, #27, and #29 did not have documented education or competencies completed annually in accordance with the needs identified in the Facility Assessment. Additionally, Licensed Practical Nurse #29 did not provide care to a resident with a feeding tube that met the professional standards.During an interview on 10/01/2025 at 12:38 PM, the Assistant Director of Nursing stated they were in their current role for just over two (2) months and were originally hired as a supervisor. They were part of the Administration team and were in contact with the Administrator and the Director of Nursing often. Their duties included the infection control program, education of facility staff, and anything related to nursing. They had been to some Quality Assurance and Performance Improvement committee meetings since starting in their role. Education was completed through a printed PowerPoint for different topics with posttests. Attendance was recorded by printed sign in sheets. Competencies were done through group discussions and posttests. They could not say if there had been any hands-on competencies completed. During an interview on 11/20/2025 at 12:32 PM, the Director of Nursing stated they were part of the administrative team and were part of the Quality Assurance and Performance Improvement committee. Once a concern was identified, it was discussed with the interdisciplinary team to determine if it needed a performance improvement plan. There were concerns noted with staff training prior to survey, but they could not state what or when it was identified. Education was part of the Assistant Director of Nursing's duties. There were no concerns identified regarding competency for nursing staff prior to the survey start. The registered nurses were very competent even if they did not have formal competencies documented. They were unsure what was occurring to ensure competencies were being completed upon hire and annually for staff prior to their start date. The performance improvement plan dated 09/05/2025 for the concerns identified regarding a lack of staff education was recently implemented with a skills fair in October 2025. They were unsure of what the process was for ensuring licensed staff had their cardiopulmonary resuscitation certification prior to survey entrance. The facility assessment was an interdisciplinary document the Administrator ensured was completed. The education program was supposed to outline the needs of the facility based on the facility assessment. During an interview on 11/20/2025 at 1:32 PM, the Administrator stated they had support through the nursing administration which included the Director of Nursing, unit managers, and nursing supervisors. The Assistant Director of Nursing was responsible for overseeing the completion of the cardiopulmonary resuscitation certifications with a hands-on component for the licensed staff as they oversaw education. They did not know how the facility was tracking cardiopulmonary resuscitation certifications prior to survey entrance. Licensed staff who had their cardiopulmonary resuscitation certifications were required to meet the needs of the residents in the facility. Licensed staff were supposed to have competencies associated with the Center for Medicaid and Medicare Services regulations throughout the year. The Assistant Director of Nursing was also responsible for tracking the competencies of the staff and they were unsure how they were previously tracked. They stated they were responsible for completing the facility assessment. The education programs outline should meet the needs of the facility based on that assessment. 10 NYCRR 415.26(a)

Based on observations, record review, and interviews during the recertification survey conducted 09/22/2025-11/20/2025 the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for one (1) of one (1) main kitchen and one (1) of one (1) dining room. Specifically, in the main kitchen prepared foods were not cooled properly, multiple boxes of food items were stored on the floor, food items were not dated, and areas of the kitchen were unclean; and the dining room had unclean and sticky floors, and multiple trays from the previous meal were stacked on a rolling rack.Findings included: The facility policy Rapid Cooling of Food, revised 01/2023, documented time/ temperature control for safety, food should be cooled rapidly. Time/ Temperature control for safety, food would be maintained at 135 degrees Fahrenheit or cooled to 40 degrees Fahrenheit. Food would be cooled from 135 degrees Fahrenheit to 70 degrees Fahrenheit within two hours. The procedure documented multiple steps to ensure proper cooling.The facility policy Food Storage, revised 05/10/2024, documented food items would be stored on shelves and off the floor. Food would be stored a minimum of six inches above the floor, 18 inches from the ceiling and two inches from the wall on clean racks or other clean surfaces, and would be protected from splashes, overhead pipes, or other contamination. Leftover food would be stored in covered containers or wrapped carefully and securely. Each item would be clearly labeled and dated before being refrigerated. Leftover food would be used within 24-72 hours. Meat, fish, and poultry would be stored on lower shelves, while fruits, vegetables, juices and breads should be stored on upper shelves.The undated facility policy Dining Room Cleaning Procedure, documented collect and remove all dirty dishes, utensils, and trays to the dishwashing area. Dispose of leftover food and trash into designated receptacles. Sweep or vacuum floors to remove crumbs and debris under tables, chairs, and edges. Spot mop spills immediately with disinfectant. After sweeping, damp mop the entire floor with a clean mop head and fresh solution.Dining Room:During an observation on 09/22/2025 at 6:32 AM, the main dining room had several meal trays on a rolling rack from the previous dinner meal. The floor was unclean and sticky. The surveyor's foot stuck to the floor as they walked through the dining room.Food Storage:During an observation in the main kitchen on 09/22/2025 at 6:34 AM, there were several boxes of food on the floor, including one box of crackers, two boxes of canned soup, and other various dry goods. At 6:42 AM, in the main walk-in cooler there was one metal pan of corn dated 9/17, one pan of sliced pineapple dated 9/18, and several proportioned 2-ounce plastic souffle cups unlabeled or dated. There were several undated sandwiches in a preparation cooler and unlabeled or dated 2-ounce plastic souffle cups.During an observation in the main kitchen on 09/24/2025 at 12:30 PM, there was one carton of raw eggs stored on a shelf above a bin of sliced apples, a bowl of pudding, and a container of butter chips (pickles) in the walk-in cooler.Kitchen Cleanliness:During an observation in the main kitchen on 09/22/2025 at 6:38 AM, the meat slicer was unclean with dried food debris. The hand washing sink had dried paper towels and a Band-Aid in the basin. At 7:00 AM, the dish room have several unclean dishes stacked up and the three- bay pot and pan sink had numerous stacked up unclean pots and pans.During an interview on 09/22/2025 at7:00 AM, the Food Service Director stated the dish room was a mess, as a staff member went home sick the previous evening.During an observation in the main kitchen on 09/24/2025 at 11:16 AM, the walk-in cooler shelving had areas of rust and were not smooth or easily cleanable.Improper Cooling:During an observation in the main kitchen on 09/24/2025 at 11:16 AM, the walk-in cooler had one container of vegetable soup dated 9/23. The vegetable soup measured 44 degrees Fahrenheit. When the temperature of the vegetable soup was rechecked at 11:38 AM, it remained unchanged at 44 degrees Fahrenheit.There was no documented evidence of completed food cooling logs.During an interview on 09/24/025 at 11:38 AM the Food Service Director stated the vegetable soup was from the previous dinner meal, they cooled the soup in a shallow pan and transferred it into a 3-gallon container. The soup remained in the walk-in cooler since then. They could not recall the food cooling process, and they did not measure the temperature of the soup at any time. If the soup was not cooled properly, it should be discarded.During a follow up interview on 09/24/2025 at 3:28 PM, the Food Service Director stated the facility had not received any food deliveries on Monday 09/22/2025 prior to 6:00 AM. Food products should not be stored directly on the floor, and dishes, including pots and pans should be washed after every meal. All items in the walk-in cooler and prep coolers should be labeled and dated after opening and when transferred into other containers. The meat slicer should be cleaned after each use and the surfaces in the kitchen should be smooth and cleanable. They did not see the rust on the shelves in the walk-in cooler. Raw food items should not be placed above ready to eat food items in the cooler due to the potential of cross contamination. All food items should be stored properly, cooled properly, and kitchen areas should be clean to prevent food borne illness.During an interview on 10/01/2025 at 12:52 PM, the Director of Housekeeping and Laundry Services stated housekeeping staff should clean the dining room after each meal. This included wiping down the tables, removing trash, and mopping the floor. If the dining room floor was unclean and sticky it would not be considered homelike.During an interview on 10/01/2025 at 1:19 PM Housekeeper/Laundry Service Aide #40, stated their job included completing housekeeping duties and the resident's laundry. They cleaned the dining room at the end of their shift, they only partially mopped the dining room and would spot mop as needed. They did not have a lot of time to dedicate to the dining room and did not mop the dining room floor on the evening of 09/21/2025.During a follow up interview on 10/01/2025 at 1:27 PM the Food Service Director stated on the evening of 09/21/2025 there were two food service aides, and they were the cook/supervisor that evening. It was the responsibility of the food service staff to remove the trays from the dining room. It was not homelike to have dirty dishes from the previous meal in the dining room while the residents were eating their meal. 10NYCRR 483.60(i)(1)-(2)

Based on record review and interviews during the recertification and extended survey conducted 09/22/2025-11/20/2025, the facility did not ensure the services provided or arranged by the facility were delivered by individuals who had skills to do a particular task in accordance with each resident's written plan of care for 38 resident's with orders for cardio-pulmonary resuscitation (perform chest compressions in the absence of a heartbeat). Specifically, staff with current cardio-pulmonary resuscitation certification that met accepted national standards were not present in the building twenty-four hours per day. Findings include:The 03/13/2025 Facility Assessment Portfolio documented the services and care offered based on Resident Needs, and did not include Basic Life Saving skills or individuals requiring Cardiopulmonary Resuscitation certification.The facility job description for Licensed Practical Nurse, Registered Nurse Supervisor, Registered Nurse, and Unit Manager documented they must maintain and provide the facility with current license/certification as required by the position. Cardio-pulmonary resuscitation certification or Basic Life Saving skills were not listed within the job requirements. The revised 01/23/2015 Centers for Medicare and Medicaid Services, Memo #14-01-NH, Cardio-pulmonary Resuscitation in Nursing Homes, documented cardio-pulmonary resuscitation certified staff must be available at all times. Staff must maintain current cardio-pulmonary resuscitation certification for healthcare providers through cardio-pulmonary resuscitation training that includes hands-on practice and in-person skills assessment. Online-only certification was not acceptable. There was no documented evidence Licensed Practical Nurse #7, Licensed Practical Nurse Supervisor #26, and Licensed Practical Nurse #38 had cardio-pulmonary resuscitation certification. Licensed Practical Nurse #27 had a Cardiopulmonary Resuscitation certification from National Cardio-pulmonary Foundation issued on 7/24/2025. The National Cardio-pulmonary Foundation documented at the bottom of their training website, online training was a legal and acceptable form of training, however, in-person training was not offered. Employers or licensing boards may require in-person training for special industries. They could not guarantee the certification would be accepted in every situation. Licensed Practical Nurse #19 had a cardiopulmonary resuscitation certification from the American Health Care Academy issued on 7/23/2025. The American Health Care Academy website documented cardio-pulmonary resuscitation certification was offered online. The 07/10/2025-07/24/2025 nursing schedule documented the following nurses were the only nurses on shift:-Licensed Practical Nurse Supervisor #26 worked 6:00 PM to 6:00 AM on 07/14/2025, and Licensed Practical Nurse #27 worked 10:00 PM to 6:00 AM on 07/14/2025.-Licensed Practical Nurse #27 and Licensed Practical Nurse #38 worked 10:00 PM to 6:00 AM on 07/15/2025.-Licensed Practical Nurse Supervisor #26 worked 6:00 PM to 6:00 AM on 07/17/2025, and Licensed Practical Nurse #27 worked 10:00 PM to 6:00 AM on 07/17/2025.-Licensed Practical Nurse #7 and Licensed Practical Nurse #38 worked 10:00 PM to 6:00 AM on 07/20/2025.-Licensed Practical Nurse #7 worked 10:00 PM to 6:00 AM on 07/22/2025.-Licensed Practical Nurse Supervisor #26 worked 10:00 PM to 6:00 AM on 07/24/2025. The 09/21/2025-09/23/2025 Nursing Schedule documented the following nurses were the only nurses on shift:-Licensed Practical Nurse Supervisor #26 worked 10:00 PM to 6:00 AM on 09/22/2025.-Licensed Practical Nurse #27 worked 6:00 PM to 6:00 AM on 09/23/2025.-Licensed Practical Nurse #19 worked 7:30 PM to 6:00 AM on 09/24/2025. During an interview on 09/24/2025 at 5:30 PM, the Administrator and Corporate Director of Clinical Transformation stated they had to review the cardio-pulmonary resuscitation certifications they had for staff, as they did not know the National Cardio-pulmonary Resuscitation Foundation certifications did not include a hands-on skill evaluation. During a telephone interview on 09/24/2025 at 6:22 PM, American Health Care Academy's Customer Service was contacted with the Administrator present. The certification number for Licensed Practical Nurse #19 was provided. The customer service representative stated Licensed Practical Nurse #19 only purchased and completed the online course, and did not purchase or complete the hands-on skills portion. During an interview on 10/01/2025 at 12:38 PM, the Assistant Director of Nursing stated their role included providing nursing education and was responsible for documenting education that was provided. During an interview on 11/20/2025 at 12:32 PM, the Director of Nursing stated they were concerns about staff training prior to survey. They started at the facility in August 2025 and was not sure when the concerns about training was identified. They were not sure how much education was accomplished, but they identified training needed to be done. They did not know the process for licensed staff to complete their cardio-pulmonary resuscitation certification. They stated the normal process anywhere was people would go someplace to do the training in person, or it was provided in the facility. The interdisciplinary team had input into the Facility Assessment, the Administrator was responsible for ensuring the form was completed. The Facility Assessment was supposed to outline the education programs based on the needs of the facility. During an interview on 11/20/2025 at 1:32 PM, the Administrator stated the Assistant Director who was in charge of staff education, oversaw the completion of cardio-pulmonary resuscitation certification. Prior to the survey, they did not know who tracked cardio-pulmonary resuscitation certifications. They had previous Assistant Director of Nurses who did competencies, but they were unable to locate those specific binders. They were supposed to track the hands-on competencies for cardio-pulmonary resuscitation certifications. Cardio-pulmonary resuscitation certified individuals were required to meet the needs of the residents in the facility. 10 NYCRR 415.11(c)(3)(ii)

Based on observations, record review, and interviews during the recertification survey conducted [DATE]-[DATE], the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care person-centered care plan, and the resident's choices for one (one) of three (3) residents (Resident #85) reviewed. Specifically, Resident #85 had an unwitnessed fall on [DATE] at 6:00 PM and there was no documented evidence the resident was assessed by a qualified professional.Findings include:The facility policy Falls Management and Prevention, revised 1/2023, documented in the event a resident had fallen and/or was found on the ground, a completed head-to-toes assessment must be performed. Resident #85 had diagnoses including chronic obstructive pulmonary disease (lung disease), high blood pressure, and anxiety disorder. The [DATE] admission Minimum Data Set assessment documented the resident was cognitively intact, required partial assistance of one for toileting hygiene, supervision for toilet transfers, and had falls in the last month prior to admission. The Comprehensive Care Plan initiated [DATE] documented the resident was at risk for falls/had actual falls related to history of falls. Interventions included provide toileting assistance per resident needs and therapy recommendations. The comprehensive care plan initiated [DATE] documented the resident required assistance with self-care and mobility related to mild femoral head osteophytes (limited range of motion due to bone irregularities at the hip). Interventions included toileting hygiene and toilet transfers with partial assistance of one person. The [DATE] at 6:00 PM Licensed Practical Nurse #21 progress note documented Resident #85's roommate informed them Resident #85 was on the floor, sitting next to their bed. Vital signs were taken and were stable, range of motion was within normal limits, and there were no signs of injury at the time. The supervisor and on call medical provider were called and no return calls were received. Physician Assistant #36 was notified. There was no documented evidence the resident was assessed by a qualified individual after being found on the floor in their room. The [DATE] Accident/Incident Folder included:-on [DATE] at 6:00 PM, Certified Nurse Aide #30 documented they were assigned to Resident #85's care. The resident was found on their knees in the bathroom. The resident thought they could toilet themself. Certified Nurse Aide #30 documented the resident was sitting in their wheelchair in their room at 5:30 PM, when they cleaned them, and they did not use their call light. -on [DATE] at 6:00 PM, Certified Nurse Aide #42 documented Resident #85's roommate came out and told them about Resident #85. Resident #85 was trying to use the toilet prior to their fall. They documented they thought the resident was becoming more unsteady.-on [DATE] at 6:00 PM, Licensed Practical Nurse #21 documented they heard about the incident (fall) from Resident #85's roommate. Licensed Practical Nurse #21 went into the resident's room, checked their safety, and took vitals. They documented the resident stated they went to the bathroom, then felt dizzy and sat on the floor. They notified the supervisor (unnamed) at 6:30 PM.-on [DATE] at 6:00 PM, Licensed Practical Nurse #9 documented they heard about the incident from the staff. Staff reported the resident was in the bathroom on the floor. The supervisor (unnamed) was notified at 6:52 PM by Licensed Practical Nurse #9. Resident #85 expired on [DATE] at 6:02 AM.During an interview on [DATE] at 11:35 AM, Certified Nurse Aide #30 stated the resident had a fall on [DATE] in the evening while attempting to use the bathroom on their own. They were found on the floor in the bathroom. Resident #85 had two falls on [DATE], once in the bathroom, and another next to the bed. The resident was assessed before being assisted off the floor using a mechanical lift. They could not recall who assessed the resident. They did not have a registered nurse in the building during the 2:00 PM –10:00 PM shift, so they had to call someone for a video call. During a telephone interview on [DATE] at 2:19 PM, Licensed Practical Nurse #21 stated they did not recall any falls for Resident #85. If a resident had a fall, they checked on them, checked to see if it was safe, and checked for injury. The supervisor needed to assess the resident. The registered nurse would do the assessment. If there was no registered nurse in the building, they should call the on-call registered nurse and inform them about the fall and they could video call for the assessment. They would notify the medical providers, and document in the resident's chart about the fall and who they spoke to. During a telephone interview on [DATE] at 12:26 PM, Assistant Director of Nursing #22 stated Resident #85 experienced a couple of falls but could not recall when. If they were notified of the fall, they would review the resident's vitals, call medical, and notify family. If medical was not in the building, they could do a video call to allow them to get a visual of the resident. They could ask the resident to move limbs, view their skin, observe for bleeding, ask the nurse on site to complete a neurological assessment, and check length of limbs to see if there was a difference. They never completed a video call for Resident #85. Resident #85 had a fall prior to expiring, but they were not part of the investigation or assessment.During an interview on [DATE] at 12:32 PM, the Director of Nursing stated the process to complete an assessment if there were no registered nurses in the building was to contact telehealth with the Medical Director Services. They should call the provider, and the provider could look at them and give orders. They should contact the registered nurse and let them know. They provided education for the staff to contact the Medical Provider first. If staff contacted the Medical Provider with telehealth there would be a telehealth note in the progress notes or uploaded.10NYCRR 415.12

Based on record review and interviews during the recertification survey conducted 09/22/2025- 11/20/2025, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries for two (2) of three (3) residents (Residents #94 and #95) reviewed. Specifically, Residents #94 and #95 were discharged to home after discontinuation of Medicare Part A services and the facility did not provide the resident with the Notice of Medicare Non-Coverage (Centers for Medicare and Medicaid Services-10123) for Medicare Part A as required. Findings include:The Center for Medicare and Medicaid Services form Center for Medicare and Medicaid Services-10123 instructions documented a Medicare health provider must give an advance, completed copy of the Notice of Medicare Non-Coverage to enrollees receiving skilled nursing services, no later than two days before the termination of services. The Skilled Nursing Facility Beneficiary Protection Notification Review completed by the facility documented Resident #94 had a Medicare covered stay with a start date of 04/29/2025, and the last covered day of Part A services was 05/22/2025. The discharge was a facility-initiated discharge when benefit days were not exhausted.There was no documented evidence the Notice of Medicare Non-Coverage for Centers for Medicare and Medicaid Services-10123 letter was provided to Resident #94.Resident #95's 04/07/2025 discharge Minimum Data Set assessment documented the resident had a Medicare covered stay with a start date of 02/11/2025 and an end date of 04/07/2025. The discharge was a planned discharge with return not anticipated. There was no documented evidence the Notice of Medicare Non-Coverage for Centers for Medicare and Medicaid Services-10123 letter was provided to Resident #95.During an interview on 09/23/2025 at 3:05 PM, the Director of Rehabilitation #43 stated the Business Office Manager was responsible for issuing the Notice of Medicare Non-Coverage. They stated in the absence of the Business Office Manager and the Minimum Data Set Coordinator; they were the third person responsible for the issuing the Notice of Medicare Non-Coverage. The Notice of Medicare Non-Coverage was issued to inform residents their Medicare benefit covered services was ending. Resident #94's last coverage day was 05/22/2025 and they should have received a Notice of Medicare Non-Coverage at least two days prior. Resident #95's last covered days were 04/06/2025, they should have been issued a Notice of Medicare Non-Coverage on 04/04/2025. They were unable to locate the forms for Residents #94 and #95 in the computer system or determine if they were issues. They stated without the Notice of Medicare Non-Coverage being provided the resident would not know their services would be ending. During an interview on 09/23/2025 at 3:28 PM, Minimum Data Set Coordinator #44 stated Resident #95's Notice of Medicare Non-Coverage should have been issued by 04/04/2025 and Resident #94's Notice of Medicare Non-Coverage should have been issued on 05/20/2025, but there was no documentation they were issued. If the Notice of Medicare Non-Coverage was not provided to the resident, the facility could be liable for payment of services received by the resident. The resident could think they were eligible for services, if they remained in the facility. During an interview on 09/23/2025 at 3:50 PM, the Administrator stated the Business Office Manager was responsible for issuing the Notice of Medicare Non-Coverage. The Business Office Manager left their position at the facility in June 2025. There were gaps in the beneficiary notification process. The Administrator stated it became apparent during the survey process documentation for resident notifications were not being maintained how they should be. The Notice of Medicare Non-Coverage for Resident #95 should have been in their file, but they were not able to locate the files to confirm Resident #95 was notified as required. If the residents were not notified of non-coverage, benefits provided under Medicare would no longer be available to the resident, and the resident would not be advised of the appeal process. The residents could lose their right to appeal, and the resident could potentially be financially responsible for any Medicare non-covered services they received. 10 NYCRR 415.3(g)(2)(iii)

Based on record review and interview during the extended recertification survey conducted 09/22/2025-11/20/2025, the facility failed to ensure that licensed nurses had the appropriate competencies and skill sets necessary to provide nursing care and related services to assure residents safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident for five (5) of five (5) licensed nurses (Licensed Practical Nurses #6, #7, #10, #27, and #29) reviewed. Specifically, Licensed Practical Nurse #29 performed feeding tube care for Resident #5 that did not meet professional standards for infection control; and Licensed Practical Nurses #6, #7, #10, #27, and #29 did not have documented education or competencies completed annually in accordance with the needs identified in the Facility Assessment. Deficiencies were identified in the areas of Cardiopulmonary Resuscitation (F678) and Infection Control (F880). Findings include:The undated Facility Educator job description documented the Facility Educator was responsible for planning, organizing, developing, implementing, facilitating and evaluating all employees' education programs throughout the facility or campus, in accordance with the Company's policies and procedures current applicable federal, state, local standards, guidelines, and regulations to assure the highest degree of quality resident care could be maintained at all times. Essential functions included working in collaboration with all facility department directors in the orientation and education of staff to ensure mandatory and regulatory education requirements are met within the facility; conducted competencies in areas of nursing practice with attention to management of the medically complex patient; and regularly conducted education needs assessment for the facility to assist in identifying areas for improvement. They prepared, scheduled, and selected material, equipment, and training aides; scheduled and communicated in-services training programs according to the need of the facility; conducted regular scheduled meeting and education to all staff within the facility; facilitated training related to required certifications, and cardio-pulmonary resuscitation; and maintained attendance and documentation of in-services in accordance with regulatory guidelines and corporate policies. Monthly duties included but were not limited to: developing and posting monthly in-service calendars; developing a report for each department that addressed the evaluation of each employee's compliance to education requirements and evaluation status of each employees compliance to employee health regulations; met with each department director to discuss their department education needs; facilitated or conducted cardio-pulmonary resuscitation classes; and oversaw and provided orientation of new employees.The 3/13/2025 Facility Assessment Portfolio documented upon hiring all facility personnel would participate in general orientation and job specific orientation. The primary objectives of the facility staff training program were to provide the employees with an in-depth review of the established operation policies and procedures and evidence-based practices that would assist the employees in providing high quality care. Each facility department had job specific orientation with pertinent training topics and policy/procedures for that discipline, with the job specific curriculum and job specific competency. Ongoing monthly education curriculum would be determined based on facility needs, identified concerns, observed staff practices, regulatory requirements, or findings. All facility employees would receive mandatory education of the topics listed in the discipline chart. Nursing (Licensed Practical Nurses and Registered Nurses) had required competencies for person centered care, behavior management, medication administration, glucometer testing, handwashing, applying and removing personal protective equipment, enteral nutrition feeding, treatment competency, wound vacuum competency, tracheostomy care competency, nebulizer treatment competency, pain management, intravenous therapy, urinary catheter, and resident rights.The facility policy Staff Development and Inservice Programming, revised 01/18/2023 documented personnel should participate in in-service training to remain current in knowledge which affects the delivery of service with the facility and met Federal and State requirements. The facility conducted education to provide employees with information pertaining to their job function, regulatory, policy, procedural and safety updates, as well as evidence-based practice changes. All staff should attend a series of Mandatory Education annually and as required by state regulations. The facility educator or designee will track employee attendance to ensure required education is attended and required hours of in-service are met.The undated Licensed Practical Nurse/ Registered Nurse Competency Skills Sheet documented topics included Enteral Nutrition Feedings Competency and Personal Protective Equipment Competency.1) Resident #5 had diagnoses including stroke and dysphagia (difficulty swallowing).The 08/30/2025 Minimum Data Set documented the resident was severely cognitively impaired, was dependent for most activities of daily living, and received 26-50% of their total calories through a tube feeding.The 05/20/2025 Comprehensive Care Plan documented the resident required tube feedings for dysphagia. Interventions included to administer tube feeding and water flushes per registered dietitian's recommendation and medical provider's orders: Osmolite (tube feeding formula) 1.2 at 75 milliliters per hour every 12 hours, keep the head of the bed at 30 degrees during administration, and provide local care to the tube site as ordered and monitor for signs and symptoms of infection.The 08/29/2025 physician order documented an enteral feeding order of Osmolite 1.2 via enteral tube at a rate of 75 milliliters to begin at 6:00 PM for a total volume of 900 milliliters to be delivered every 24 hours for neurogenic dysphagia and functional/mechanical obstruction. The hook up was at 6:00 PM and was to be disconnected at 6:00 AM.During an observation on 09/22/2025 at 7:05 AM, Licensed Practical Nurse #29 disconnected the resident's tube feeding from the pole/electronic pump wearing gloves and without wearing a gown. The tube feeing formula bottle was placed in the garbage receptacle with the bottle sitting upright and still connected to the resident's tube feeding line. Licensed Practical Nurse #29 stated they removed the tube feeding so the resident did not have to hear the beeping.During an interview on 09/29/2025 at 1:50 PM, Licensed Practical Nurse #29 stated they could not recall doing any competencies. They received in-services in the facility but none when management observed them. They knew how care for tube feedings due to their experience as a nurse. When disconnecting Resident #5's tube feeding, they wore gloves, flushed the line, took down the tube feeding and threw everything out. The tube feeding bottle should not be connected to the resident when in the garbage. They did not remember taking the resident's tube feeding down on Monday, but they did remember the resident's machine beeping.During an interview on 10/01/2025 at 12:38 PM, Registered Nurse Assistant Director of Nursing #22 stated the process for disconnecting a resident's tube feeding was to put the tube feeding on hold, stop the machine, pinch the tube, cap it, and cover it. It was not acceptable for the tube feeding bottle to be in the trash can while connected to the resident.2) Education and Competencies: Nursing Personnel Education Records were reviewed with the following results:-Licensed Practical Nurse #6 did not have documented evidence of job specific orientation or licensed nurse skills competency. Electronic General Orientation for 2024 was completed 05/20/2025. Computer based cardio-pulmonary resuscitation certification was completed 07/24/2025.-Licensed Practical Nurse #7 did not have any documented education or competencies. -Licensed Practical Nurse #10 did not have any documented education or competencies. -Licensed Practical Nurse #27 did not have documented evidence of job specific orientation, licensed nurse skills competency, or General Orientation. Computer based cardio-pulmonary resuscitation certification was completed 07/24/2025. -Licensed Practical Nurse #29 did not have documented evidence of job specific orientation, licensed nurse skills competency, or General Orientation. Computer based cardio-pulmonary resuscitation certification was completed 07/26/2025.During a telephone interview on 09/23/2025 at 12:41 PM, Licensed Practical Nurse #6 stated after the passing of Resident #85, the facility reviewed staff cardio-pulmonary resuscitation certifications, and the former Director of Nursing and they were the only staff that held a cardio-pulmonary resuscitation certification. They stated they were asked to complete the online training courses and take the exams for other nursing staff and completed them two days after the incident. They completed the training and exam for themself, Licensed Practical Nurse #7, Licensed Practical Nurse #38, and two others.The 09/25/2025 electronic communication from Regional Nurse #41 documented education and competencies were not found for wound care, medication administration, tube feeding administration and care, and nephrostomy care for Licensed Practical Nurses #6, #7, #10, #27, and #29. They identified this as a problem and wrote a performance improvement plan on how to fix the issue. The 09/05/2025 Performance Improvement Summary documented an identified concern with education tracking and documentation. The Assistant Director of Nursing was educated regarding what the required education and competencies were for all new hires. General orientation was assigned to all current staff to ensure that everyone had completed it. All staff would be educated regarding the online education program and the requirements to complete the assignments monthly. Cardio-pulmonary resuscitation certification trackers would be initiated and kept current for better monitoring of staff expiration dates. A competency fair would be set up to get all nursing staff up to date on all competencies. The Learning Management System would be audited weekly to ensure monthly completion of all mandatory education. Competency tracker would be audited monthly to ensure that all new hires have completed the required competencies.There was no documented evidence of education provided to the nursing staff after the facility identified the areas of concern.On 09/29/2025 at 2:47 PM, a voicemail was left for Licensed Practical Nurse #27. They did not return the call prior to survey exit.During a telephone interview on 09/29/2025 at 3:06 PM, Licensed Practical Nurse #7 stated facility trainings were completed on the computer. They did not remember when their last nursing competency was completed. They completed wound vac training when they started employment in 2022. They did wound care training but could not recall when or who provided the training. They had a wound care observation by the corporate team during an audit, but it was over a year ago. They were observed completing a medication pass recently during an audit review of the medication cart, approximately three to six months ago. They received one on one education for tube feed administration and feeding tube care with the unit manager, last year sometime. There a was mock audit completed by corporate a little over a year ago when they were observed providing care and tube feed administration. During a telephone interview on 09/30/2025 at 11:44 AM, Licensed Practical Nurse #10 stated the last nursing competencies were completed with the medication cart audits, a few months ago. The completed wound vac competencies last year. They recently had education for wound care, because they were put on the wound care team for the facility. Audits were done by the corporate team or the Unit Manager. The Unit Manager gave feedback or discussed concerns if any were noted. Hand hygiene education was done every few months when the facility did hand hygiene audits and watched for proper hand hygiene. Tube feed administration and care education was completed when the residents changed. They saw competency checklists, but did not know what was done with them, as the leadership team was consistently changing and no one stayed working there long. During a telephone interview on 09/30/2025 at 12:44 PM, Licensed Practical Nurse #6 stated that they had not received any hands-on competency trainings and only watched videos when they were hired. They had not received any hands-on training regarding wound vacs, no one had ever watched them complete a medication pass, and no one ever observed their hand hygiene practices to ensure competency. They had never received any training/ education on tube feeding administration.During an interview on 10/01/2025 at 12:38 PM, The Assistant Director of Nursing stated they were responsible for nursing education. The education was completed with a sign in sheet, and printed documents for the topic. They read the document and discussed; some trainings had post-tests. Hands on competencies were not done as part of the training. There were competencies to be done annually, many of them were completed on the computer with videos and questions. They had not completed any hands-on competencies with the nursing staff at this time including, wound care, wound vacs, medication administration, and hand hygiene. They recently had completed tube feeding administration, but did not review tube feed dressings. They were unsure where the documented education was, and it was their responsibility to track education. They had not completed any competencies for nephrostomy tubes as they had not received it themselves. If the nursing staff had not received competencies, they could review policies and procedures in place and staff could ask questions. The facility had recently identified there was an issue regarding staff education and were working on the following topics with PowerPoints, critical/routine laboratory results and reviewing the dashboard (one view of the electronic medical record) so the staff were familiar with it.During an interview on 11/20/2025 at 12:32 PM, the Director of Nursing stated there were concerns about staff training prior to survey. They started at the facility in August 2025 and was not sure when the concerns about training were identified. They were not sure how much education was actually accomplished, but they identified training needed to be done. They asked corporate to send them information to review with staff. The interdisciplinary team had input into the Facility Assessment, the Administrator was responsible for ensuring the form was completed. The Facility Assessment was supposed to outline the education programs based on the needs of the facility. There were certain things that were the core that had to be done, and others were based on the Facility Assessment specifically. They ensured the education program met the needs of the residents based on their invitation to Resident Council. They did not think there were concerns noted for nursing competencies prior to survey. The facility had intravenous devices that were cared for by registered nurses, the nurses were very competent, even though they did not have formal competencies. They had trainings done for respiratory care and wound vacs, but did not know if anything was recorded correctly. They were not sure what the process for education was before they arrived in August, however, they found a form for teachable moments. If they kept noting the same concerns, they should do a house wide training on the topic.During an interview on 11/20/2025 at 1:32 PM, the Administrator stated the Assistant Director of Nursing was responsible for nursing education and documentation of the education. They were supposed to go through and have the competencies associated with the federal regulations throughout the year. They recently conducted a handwashing competency. The Facility Assessment was completed by them, with the assistance from the interdisciplinary team. The education program for the facility should outline the needs of the facility. They ensured the education program met the needs of the residents by completing the Facility Assessment. They reviewed what every specific resident needed and built the best plan of care, to have the best plan they needed to have the education on it.10 NYCRR 415.26(c)(1)(iv)

Based on record review and interviews during the recertification survey conducted [DATE] -[DATE], the facility did not ensure all investigations were reported to the State Survey Agency within five (5) working days of the incident for one (1) of three (3) residents (Resident #85) reviewed. Specifically, cardiopulmonary resuscitation was not initiated for Resident #85 per their Medical Orders for Life Sustaining Treatment and was not reported to the New York State Department of Health as required. Refer to F678 (Cardiopulmonary Resuscitation).Findings include: The facility policy Accident-Incidents, dated [DATE], documented the Director of Nursing and Administrator were responsible to review Incident/Investigations and conclusions to determine if incident required reporting to outside agencies such as the Department of Health.The 08/2016 New York State Department of Health Nursing Home Incident Reporting Manual documented at least one of the following elements must be present for an incident to be reportable to the [New York State Department of Health]:- Cardiopulmonary Resuscitation was not provided when it was required.- Cardiopulmonary Resuscitation was provider against a resident's wishes.- Cardiopulmonary Resuscitation was initiated and stopped when staff became aware of the resident wishes. Resident #85 had diagnoses including chronic obstructive pulmonary disease (lung disease) and high blood pressure. The [DATE] Minimum Data Set assessment documented the resident was cognitively intact. Resident #85's Medical Orders for Life-Sustaining Treatment, signed by the resident on [DATE], documented they requested cardio-pulmonary resuscitation be attempted when they had no pulse and/or was not breathing. The [DATE] physician order documented attempt cardio-pulmonary resuscitation. Resident #85's Comprehensive Care Plan did not include their wishes or orders for resuscitation. The unsigned [DATE] facility Investigative Summary documented an unexpected death on [DATE]. -on [DATE] at approximately 5:30 AM, Licensed Practical Nurse #7 entered Resident #85's room and found them unresponsive without a pulse or respirations. They checked the Medical Orders for Life-Sustaining Treatment and noted the resident wished to have cardiopulmonary resuscitation. The resident was cold, rigid, signs of blood pooling, and signs of dependent lividity were present. Licensed Practical Nurse #7 stated they felt cardiopulmonary resuscitation was futile. They call the provider and 9-1-1. Emergency Medical Technicians and police arrived at approximately 5:45 AM. A telephone call was placed to the Director of Nursing at approximately 5:42 AM. The Emergency Medical Technicians pronounced the resident deceased at 6:02 AM.-Review of the investigation was completed and there was no evidence to support any alleged resident abuse, neglect, exploitation, or mistreatment occurred. The incident was not reportable to the Department of Health. During a telephone interview on [DATE] at 5:00 PM, Registered Nurse #17 (former Director of Nursing in 07/2025) stated they were part of the investigation for the incident around Resident #85's death. The incident was not reported to the Department of Health, because they were told not to report. They were told it was not the Director of Nursing's decision to report incidents. They were advised by the Administrator not to report the incident. There were conversations with corporate staff who did not want it reported. They stated they knew it should have been reported. During an interview on [DATE] at 5:13 PM, the Administrator stated they did not report the death because they followed the American Heart Association guidelines, and it was not reportable. The incident information and investigation were gathered by Registered Nurse #17 (Former Director of Nursing). The Director of Nursing and they were responsible for reporting incidents to the New York State Department of Health. 10 NYCRR 415.4

Based on record review, observations, and interviews during the recertification and abbreviated (#2565048) surveys conducted 09/22/2025-11/20/2025, the facility did not ensure residents received adequate supervision to prevent accidents for two (2) of three (3) residents (Residents # 70 and #80) reviewed. Specifically, Resident #70's physician orders documented aspiration precautions (used to prevent food, fluids, or secretions from entering the airway) with no straws, the resident was provided a straw during meals and was not assisted with meals as care planned; Resident #80 did not have planned fall interventions in place and their call bell was not in reach. Findings include: The facility policy Aspiration Precautions, revised 12/2023, documented the resident would be offered food and liquids at a rate and portion size the resident was able to tolerate. The resident would be monitored for pocketing (holding food in mouth without swallowing) or coughing during and after intake of food and liquids. The facility policy Activities of Daily Living (ADL) Care and Support, revised 02/2025, documented activities of daily living care and support were provided for residents who were unable to carry out activities of daily living independently in accordance with the resident's assessed needs and individualized plan of care. 1) Resident #70 had diagnoses including dysphagia (difficulty swallowing), dementia, and acute respiratory failure with hypoxia (low oxygen). The 08/10/2025 Minimum Data Set assessment document the resident had severely impaired cognition, did not reject care, required supervision or touching assistance with eating, coughed or choked during meals or when swallowing medications, and received a mechanically altered diet. The Comprehensive Care Plan initiated 4/16/2020 and revised 5/12/2025, documented the resident required partial assistance with meals. The 05/09/2025-06/04/2025 Occupational Therapist #31 Discharge Summary documented the resident required minimum assistance at meals. The 08/04/2025 at 8:54 AM, Registered Nurse #24 progress note documented an interdisciplinary team referral for speech therapy due to the resident's difficulty following directions, food falling out of their mouth, and poor lip closure. The resident had noted difficulty with chewing and was coughing at times on thin liquids. The 08/04/2025 at 8:57 AM, Registered Nurse #24 progress note documented the resident had increased chewing at times and was coughing on liquids. The resident reported they were having more difficulty with certain items, their diet was downgraded, and a referral was placed for speech therapy. The 08/24/2025-08/30/2025, Speech Language Therapist #25 Speech Therapy Evaluation and Plan of Treatment documented the resident would be seen for skilled therapy to assess and determine least restrictive diet, reduce sign and symptoms of aspiration to enhance quality of life, and safely swallow without signs/symptoms of dysphagia. The 08/29/2025, physician order documented the resident was to receive a regular mechanical soft (ground) diet, nectar thick liquids, small bites and sips, and no straws related to dysphagia. The 08/31/2025-09/13/2025, Speech Language Therapist #25 Progress Report completed documented the resident continued to receive mechanical soft solids and nectar thick liquids and continued to be seen for skilled interventions. The current care instructions documented the resident required partial assistance of one person at meals and received mechanical soft solids and nectar thick liquids. During an observation on 09/24/2025 at 1:17 PM, Resident #70 was sleeping in their bed and Certified Nurse Aide #30 placed the resident's lunch tray on the over the bed table and left the room. Speech Language Pathologist #25 was seated in the hallway outside of the room working with another resident. At 1:32 PM, the resident continued to sleep in bed without assistance while Certified Nurse Aide #30 sat in a chair in the hallway. At 2:11 PM, Resident #70's meal tray remained in front of them. They consumed 0-25% of their Health Shake, 100% nectar thick juice, and 0-25% of the chicken, beets, potatoes, and pudding. During an interview on 09/24/2025 at 1:47 PM, Certified Nurse Aide #30 stated they were assigned to Resident #70 today and their shift was over at 2:00 PM. If a resident was on aspiration precautions the resident should be seated up right. Staff did not have to sit with them during meals but should check on them to make sure they were not experiencing any swallowing issues. If a resident required partial assistance at meals staff should provide verbal cues and assistance if needed. Resident #70 was at risk for aspiration and received a ground diet with nectar thick liquids. The resident at times did not like to get out of bed and staff made sure the head of the bed was upright and checked on them while they ate. The resident did need assistance with meals and staff should encourage them to eat. They did not assist the resident at the lunch meal because they thought Speech Language Pathologist #25 was going to work with the resident. During an observation on 09/24/2025 at 2:11 PM, Resident #70's meal tray remained in front of them. They consumed 0-25% of their Health Shake, 100% nectar thick juice, and 0-25% of the chicken, beets, potatoes, and pudding. At 2:12 PM, Certified Nurse Aide #30 entered Resident # 70's room with their purse and asked the resident if they were going to eat, did not assist the resident, and exited the room at 2:13 PM. At 2:16 PM, Certified Nurse Aide #32 entered the resident's room and stood next to their bed. They provided the resident with a straw for their Health shake and left the room and entered another resident's room. At 2:20 PM, the resident remained in their room with their lunch meal and a straw in their Health Shake. During an interview on 09/24/2025 at 2:20 PM, Licensed Practical Nurse #9 stated Resident #70 was on aspiration precautions should not have straws and did not need assistance with meals. During an interview on 09/24/2025 at 2:27 PM, Licensed Practical Nurse #33 stated Resident #70 was on aspiration precautions and staff should assist the resident with their meals. They were not made aware the resident was not assisted at meals and did not provide any supervision at the lunch as they were busy with another resident. During an interview on 09/24/2025 at 2:32 PM, Certified Nurse Aide #32 stated they started their shift at 2:00 PM and noticed Resident #70 still had their lunch meal in front of them. They did not look at the resident's ticket and provided the resident with a straw so they could drink their Health Shake. They did not provide any additional meal assistance to the resident as they were rounding the unit at the start of their shift. During an interview on 9/24/2025 at 2:41 PM, Speech Language Pathologist #25 stated aspiration precautions could be implemented by nursing staff when a resident had issues with swallowing. Resident #70 was currently on their caseload as they were having issues with swallowing at meals. Their recommendations were no straws, alternating solids and liquids, and their diet order was currently mechanical soft solids and nectar. The resident was a high risk for aspiration and should not have straws with their liquids. They stated they had been working another resident at breakfast and noticed Resident #70 was not being assisted and assisted the resident. They did not tell nursing staff they were going to assist the resident at lunch today. During an interview on 9/24/2025 at 4:40 PM, The Regional Director of Therapy stated occupational therapy determined the level of assistance required at meals. Resident #70's discharge recommendations included partial assistance at meals. Partial assistance included sitting with the resident, assisting them as needed, providing verbal encouragement, and cues. During an interview on 10/1/2025 at 12:38 PM, The Assistant Director of Nursing stated if a resident was on aspiration precautions staff should visually monitor the resident during meals, and ensure they were seated upright. The certified nurse aides should check the resident's care instructions to ensure they were providing the correct assistance with meals. Staff should open cartons, remove lids, and cut food up if a resident required partial assistance. Resident #70 was on aspiration precautions and required partial assistance at meals. 2) Resident #80 had diagnoses including diabetic neuropathy (nerve damage), cataracts, and obesity. The 07/29/2025 Minimum Data Set documented the resident had moderately impaired cognition, was dependent for transfers and dressing, and did not have a history of falls. The 10/10/2023 Comprehensive Care Plan documented Resident #80 was at risk for falls and has had an actual fall related to deconditioning, gait/balance problems, immobility, incontinence, bilateral lower extremity and foot ulcers with resulting pain and discomfort, right Bundle branch block, and peripheral neuropathy. Interventions included to anticipate and meet the resident's needs, be sure their call light was in reach and encourage to use, bed in the lowest position, and floor mats at bedside as indicated. The 7/28/2025 Unit Manager Quarterly Evaluation documented a fall risk assessment. The resident was on antihypertensives and nonsteroidal anti-inflammatory drugs more than three times a week, had some issues with memory and recall, had adequate vision, was totally incontinent, was confined to a chair, and was unable to independently come to a stand. The intervention initiated to decrease fall risks was to wear non-skid socks. The resident was observed at the following times: -on 09/22/2025 at 7:53 AM in bed with two fall mats folded up on the wheelchair in the corner of their room. Their bed was raised to hip height and was not in the lowest position. -on 09/23/2025 at 3:05 PM in bed with the bed at hip height. The fall mats were in the wheelchair next to the wall. The resident needed assistance, and their call light was on the floor underneath the bed. -on 09/24/2025 at 11:40 AM in bed with the bed at thigh height. The call light was under the bed cross bar and not within reach. The resident stated that they did not get help when they needed it as they were supposed to use the call light, but they could not reach it. At 2:01 PM, the resident was in bed and there was one fall mat on the floor between the bed and window. The Acting Director of Nursing was in the room to check the resident's oxygen. At 2:04 PM, the resident's call light was under the bed not within reach. -on 09/25/2025 at 11:44 AM lying in bed with their call light under the cross bar under the bed. There was no fall mat on the side between the resident's bed and their roommate's bed. The second fall mat was folded behind the resident's wheelchair. Certified Nurse Aide #28 entered the resident's room to provide care. At 12:01 PM, Certified Nurse Aide #28 left the resident's room, and the call light was on the floor underneath the resident's bed. -on 09/29/2025 at 1:43 PM in bed with only one fall mat on the floor and the other folded up. Their resident's call light was on the floor out of reach. During an interview on 09/25/2025 at 9:06 AM, Registered Nurse #24 stated the care plan or the Kardex (care instructions) contained what fall interventions a resident needed. They stated Resident #80's care plan did not specifically state how many mats they were supposed to have at the bedside, but it did have mats as in plural. The fall mats should be in place if the resident was in bed. The resident's call light should always be in reach. During an interview on 09/25/2025 at 12:01 PM, Certified Nurse Aide #28 stated they knew what fall precautions needed to be in place for a resident by the resident's care plan. If a resident's care plan documented to have fall mats in place, they should be in place. Resident #80 was supposed to have two fall mats in place. The second fall mat was likely put up to provide the resident their tray and whoever picked up the tray did not replace it. It should have been replaced after the resident was finished with their meal. They stated the resident's call light was in reach, they had just picked it up and put it on the bed as well as putting the bed in the lowest position. 10 NYCRR 415.12(h)(1)(2)

Based on observations, record review, and interviews during the recertification survey conducted 09/22/2025-11/20/2025, the facility did not ensure they established and maintained 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 three (3) of three (3) residents (Residents #5, #43, and #80) reviewed. Specifically, Resident #43's urinary catheter (drains urine from the bladder) collection bag was uncovered and laying directly on the floor without a barrier, and the resident did not have appropriate transmission-based precaution signage posted; Resident #5 was on enhanced barrier precautions and Licensed Practical Nurse #29 did not wear appropriate personal protective equipment when disconnecting the resident's tube feeding; and Certified Nurse Aide #28 did not wear appropriate personal protective equipment when providing direct care to Resident #80 who was on enhanced barrier precautions. Findings include:The facility policy Enhanced Barrier Precautions, revised 3/12/2025, documented enhanced barrier precautions was applicable for residents with a multiple drug-resistant organism (MDRO), any type of wound that required a dressing, and/or an indwelling medical device such as central lines, urinary catheter, feeding tube, or tracheostomy. Enhanced barrier precautions were intended to be in place for the duration of the residents stay or until resolution of a wound or an indwelling medical device and did not require a physician order but could be Initiated or discontinued by the infection preventionist or their designee. Signage would be placed on the door or just outside the door to indicate precautions were in place, the resident's plan of care would be updated to reflect the implementation, and the healthcare provider, staff, resident, and the resident representative were notified and provided education about enhanced barrier precautions. Enhanced barrier precautions required wearing disposable gloves and an isolation gown prior to high resident contact activities such as providing hygiene, transferring, dressing, wound care, device care or use, changing linens, and bathing/showering. The facility policy Catheter Guidelines; Urinary, revised 9/11/2023, documented urinary catheter care and management would follow current infection control prevention and control standards which included emptying the urinary drainage bag regularly to avoid pulling on the tubing and positioning the urinary drainage bag below the level of the bladder but not touching the floor.1) Resident #43 had diagnoses including paraplegia (paralysis of the lower body), osteomyelitis (bone infection) of the left foot and ankle, and an enlarged prostate (causing difficult urination). The 07/28/2025 Minimum Data Set assessment documented the resident was cognitively intact, was dependent with most activities of daily living, and had an indwelling urinary catheter.The Comprehensive Care Plan documented:-on 07/23/2025 the resident had colonized multiple drug-resistant organism. Interventions included to educate resident, family, and visitors on precautions and to monitor for worsening signs and symptoms of infection.-on 7/23/2025 the resident had an indwelling urinary catheter. Interventions included monitor for signs and symptoms of a urinary tract infection, ensure tubing was anchored to prevent pulling, and to maintain the urinary collection bag below the level of the bladder.The Comprehensive Care Plan did not include enhanced barrier precautions. The following observations were made:-on 09/22/2025 at 7:20 AM and 12:06 PM, Resident #43 had no transmission-based precaution signage posted outside their room.-on 09/24/2025 at 11:04 AM, Resident #43 had an enhanced barrier precaution sign posted outside their room. They were lying in bed and their uncovered urinary collection bag contained 1400 milliliters of tea colored urine and was resting directly on the floor. There was no barrier between the collection bag and the floor. At 2:00 PM, Resident #43 was lying in bed and their uncovered urinary collection bag contained approximately 150 milliliters of tea colored urine and was resting directly on the floor. There was no barrier between the collection bag and the floor. The Assistant Director of Nursing, Licensed Practical Nurse #33, and Certified Nurse Aide #35 were standing next to the resident's bed and talking to the resident.During an interview on 09/29/2025 at 3:09 PM, Certified Nurse Aide #35 stated they cared for Resident #43 on 09/24/2025 during the day shift. They noticed the resident's urinary collection bag contained brownish colored urine, did not have a privacy cover, and was laying directly on the floor. It should not have been on the floor because the floor was dirty with bacteria. They could not recall if anyone moved the catheter bag off the floor. During an interview on 10/01/2025 at 12:38 PM, the Assistant Director of Nursing stated they were responsible for infection control. They tracked all residents on precautions and ensured they had proper signage, and their isolation carts were full of personal protective equipment. Resident #43 was put on enhanced barrier precautions upon admission. They were unsure why they did not have signage posted outside their room on 09/22/2025 but they thought it could have been moved by another resident. Urinary collection bags should never be placed on the floor, and they did not recall seeing Resident #43's collection bag on the floor on 09/24/2025 or they would have picked it up.During an interview on 10/01/2025 at 1:02 PM, Licensed Practical Nurse #33 stated Resident #43 had a catheter. Urinary collection bags should be covered with a blue bag, kept below the level of the bladder and off the floor. They could not recall if Resident #43's urinary collection bag was on the floor because they did not work at that end of the hallway.During a follow up interview on 10/01/2025 at 1:11 PM, Certified Nurse Aide #35 stated residents with an infection or open wounds were on enhanced barrier precautions and they should have an orange precaution sign outside their room. Resident #43 had a catheter and open wounds but did not have an enhanced barrier precaution sign outside their room on 09/22/2025. On 09/23/2025, an enhanced barrier precaution sign appeared outside the resident's room because the State was there, but no one told them they had to wear a gown.2) Resident #5 had diagnoses including dysphagia (difficulty swallowing), severe malnutrition, and bleeding inside the brain. The 08/30/2025 Minimum Data Set assessment documented the resident had moderately impaired cognition, was dependent for activities of daily living, and had a feeding tube. The Comprehensive Care Plan initiated 5/21/2025 documented the resident was at risk for multiple drug-resistant organism colonization/infections related to a feeding tube (tube inserted into the stomach to provide nutrition). Interventions included enhanced barrier precautions, wear gown and gloves when providing high contact activities at bedside including dressing, changing linens, device care, providing hygiene, wound care, and may wear face protection if there was a risk of splash or spray.The 8/29/2025 physician order documented Osmolite (tube feeding formula) 1.2 via feeding tube at a rate of 75 milliliters per hour to begin at 6:00 PM for a total of 900 milliliters to be delivered. Disconnect at 6:00 AM.During an observation on 09/22/2025 at 7:05 AM, Licensed Practical Nurse #29 disconnected the resident's tube feeding from the pole/electronic pump wearing gloves. They were not wearing a gown. The bottle was placed in the garbage with the bottle sitting upright still connected to the resident's tube feeding line. Licensed Practical Nurse #29 stated they had removed the tube feeding so the resident did not have to hear the beeping.During an interview on 09/29/2025 at 1:50 PM, Licensed Practical Nurse #29 stated they could not recall if they disconnected Resident #5's tube feeding on 09/22/2025. They normally wore just wear gloves when disconnecting the tube feeding and did not wear a gown. The resident was on enhanced barrier precautions so they should have worn gloves and a gown because there was splash back when disconnecting the tube feeding and they had to protect themself. 3) Resident #80 had diagnoses including chronic ulcer of the skin and methicillin resistant staphylococcus aureus (type of bacteria resistant to many antibiotics). The 07/29/2025 Minimum Data Set assessment documented the resident had moderately impaired cognition, was dependent for most activities of daily living, had a diabetic foot ulcer, and one Stage 4 (full thickness skin loss with exposed tendon or bone) pressure ulcer. The Comprehensive Care Plan initiated 10/20/2023 documented the resident had an actual multiple drug-resistant organism infection to wounds related to community acquired methicillin resistant staphylococcus aureus. Interventions included enhanced barrier precautions, wear gown and gloves when providing high contact activities at bedside including dressing, changing linens, device care, providing hygiene, wound care, and may wear face protection if there was a risk of splash or spray.During an observation on 9/25/2025 at 11:44 AM, Resident #80 was lying in bed. There was an enhanced barrier precautions sign posted outside their room. Certified Nurse Aide #28 entered the room without wearing any personal protective equipment and was carrying a brief, a clean gown, and wash clothes. At 11:45 AM, the certified nurse aide removed the resident's top sheet, threw it on the floor before exiting the room and retrieved gloves. They reentered the room without wearing a gown and shut the door. During an interview on 9/25/2025 at 12:01 PM, Certified Nurse Aide #28 stated they knew a resident was on enhanced barrier precautions because they had a sign outside their room. They were supposed to put on personal protective equipment before they entered the room. They did not think Resident #80 was on enhanced barrier precautions and they were unsure if the enhanced barrier precaution sign outside of the resident's room was for Resident #80 or their roommate because no one told them. During an interview on 10/1/2025 at 12:38 PM, the Assistant Director of Nursing stated if a resident was on enhanced barrier precautions nursing staff was expected to wear personal protective equipment when they provided care which included handling soiled linens from a wound, disconnecting a tube feed, or providing any hands-on care.10NYCRR 415.19(a)(b)

Based on observations, record review, and interviews during the recertification survey conducted from 09/22/2025-11/20/2025, the facility did not ensure residents were informed during their stay of their rights and rules and regulations governing resident conduct and responsibilities eight (8) of ten (10) residents present at the Resident Group Meeting. Specifically, eight (8) anonymous residents in the resident meeting stated they were not aware of where information on the state complaint hotline, the ombudsman, or other pertinent State agencies were posted; they were not aware of their rights or where they were posted; and the State complaint hotline and other pertinent State agencies and advocacy groups were in small print and not posted at a resident accessible level.Findings include:The facility policy Resident Rights, revised 05/28/2024, documented Federal and state laws guaranteed certain basic rights to all residents of the facility. Residents had the right to communicate with outside agencies (e.g., local, state, or federal officials, state and federal surveyors, state long-term care ombudsman, protection or advocacy organizations, etc.) regarding any matter. Residents had the right to be informed of their rights and responsibilities in the facility. Copies of resident rights were posted throughout the facility, and a copy was provided to each employee, provider and contracted staff member. Any inquiries concerning the residents' rights were to be referred to the Director of Social Services. During an observation on 09/24/2025 at 8:10 AM the Rights as a Nursing Home Resident document was posted in a locked glass cabinet upon entrance to the north hall. The posting was above standing head height or eye/forehead level and in small print. The complaint hotline and Ombudsman number were also posted above head height. At 8:13 AM the Rights as a Nursing Home Resident, the facility advocacy information, and the ombudsman information were posted in a glass cabinet upon entrance to the south side hall. The posting was above standing head height or eye/forehead level and in small print.During a resident meeting on 09/23/2025 at 2:00 PM, seven anonymous residents stated they were unaware of where the residents' rights were posted in the facility. One anonymous resident stated they asked the Interim Director of Nursing last month about posting the resident rights on both wings and at the front door at a height that was accessible to residents in a wheelchair. Several anonymous residents were not aware of where the state complaint hotline or Ombudsman information were posted.During an interview on 09/30/2025 at 2:04 PM, the Director of Social Work stated they sat in on resident council for the last couple of months. They reviewed resident rights yesterday because a resident asked for a copy of the rights and where they were posted in the facility. The Director of Social Work stated they were unaware of who was responsible for posting the resident rights, Ombudsman information, and state complaint hotline. It was not accessible to all residents if the postings were at eye level at standing height or higher.During an interview on 09/30/2025 at 2:24 PM, the Director of Nursing stated they attended the resident council meeting in August 2025. The residents said they wanted a larger posting of the resident's rights. Resident Rights and other state agency information posted in small print at or above a standing person's eye level was not accessible to all residents; they should be in large print and varying heights. Resident Rights were provided upon admission to the facility, but the resident also received so many other documents at the same time. Resident Rights and other pertinent state contact numbers should be accessible to residents so they knew their rights and they should be able to report complaints or talk to the Ombudsman whenever they wanted to.During an interview on 11/20/2025 at 2:28 PM, the Administrator stated that Resident Rights should be reviewed on admission and yearly at Resident Council.10 NYCRR 415.3

Based on observations, record review, and interviews during the abbreviated survey (NY00364719), the facility failed to protect the resident's right to be free from physical abuse for 1 of 5 residents (Resident #1) reviewed. Specifically, Resident #1 was pushed by a staff member into a wall, causing a nosebleed and fractured nose. This resulted in harm, past noncompliance, to Resident #1 that was not Immediate Jeopardy. Findings include: The facility policy, Abuse, dated 6/1/2024, documented the facility prohibited abuse of residents and exploitation of the mentally and physically disabled resident in the facility. Abuse included willful infliction of injury, and intimidation resulting in physical harm, pain, or mental anguish. Physical abuse included hitting, slapping, pinching, scratching, spitting, holding roughly, kicking, etcetera. It also included controlling behavior through corporal punishment. Resident #1 had diagnoses including Parkinson's Disease (a progressive neurological disorder), osteopenia (bone loss), and anxiety. The 9/10/2024 Minimum Data Set assessment documented the Brief Interview for Mental Status (a cognitive function assessment, scored 0-15, with 15 indicating no impairment) was 12 (showing moderate cognitive impairment). The resident had behavioral symptoms including physical behaviors directed toward others, rejection of care, wandering which occurred one to three days, and other behavioral symptoms not directed towards others such as pacing, hitting or scratching self and/or verbal symptoms. The resident required supervision or was independent with activities of daily living including transfers and walking, had no falls, wore a wander alert device, and took antianxiety and antipsychotic medications. The Comprehensive Care Plan initiated 1/5/2024 documented: - the resident exhibited behavior symptoms (related to anxiety, dependent personality disorder, bipolar disorder, and major depressive disorder) such as mood swings, frequent verbalization of feeling anxious, verbal and physical outbursts, frequently asking when medications were due, frequently requesting something for anxiety, difficulty sleeping, intrusive wandering, restlessness, anxiety, inability to remain still, attempting to take medications from the medication cart and from the nurses' hands when they prepared medications, and going into trash containers. - Interventions included: medications as ordered, distract with preferred activities, psychiatric evaluation as needed, notify physician for new or escalating behavior, reapproach for care or other needs when more agreeable, redirect to a less stimulating environment or room, reapproach in a calm manner. - The care plan was reviewed and updated on 6/19/2024 with additional interventions including: acknowledge/encourage expression of feelings, and offer decaffeinated coffee when behaviors escalate. The Comprehensive Care Plan initiated 7/8/2024 documented: - the resident was at risk for misappropriation, neglect, abuse and/or exploitation related to intrusive wandering, agitation when redirected, repetitive approaching of staff, and physical and verbal aggression. - Interventions included: monitor for signs of abuse and report, separate from aggressor, intervene, and attempt to calm the resident when they began to display escalating behaviors. The 11/18/2024 at 7:27 PM Psychiatric Nurse Practitioner #10 progress note documented the resident was seen for a follow-up, medication management, and reported worsening anxiety symptoms. The resident reported worsening anxiety the past two weeks, affecting sleep and quality of life. Recommendations included: begin Atarax (antihistamine also used to treat anxiety and tension) 10 milligrams every 12 hours, continue melatonin (sleep aid), buspirone (anti-anxiety), olanzapine (anti-psychotic), and lithium (mood stabilizer), monitor for mood dysregulation, open blinds during the day for natural light, minimize nighttime interruptions, and follow up in one to two months or as needed. The 12/12/2024 at 10:46 AM Interdisciplinary Team high risk meeting progress note entered by Social Worker #5, documented the resident's anxiety had increased with increased aggression toward staff when the resident requested medication. The resident was to be seen by psychiatry regularly. The 12/15/2024 at 3:17 PM Licensed Practical Nurse #1 progress note documented the resident was going into other residents' rooms and approaching a family member requesting something for anxiety. The 12/15/2024 at 7:41 PM Director of Nursing progress note documented nursing became aware of an incident that occurred on 12/15/2024 at 5:37 PM. It was reported to the Director of Nursing by Certified Nursing Assistant #2 that Licensed Practical Nurse #1 had pushed Resident #1 up against the wall with the resident's face on the wall. The Director of Nursing directed Registered Nurse Supervisor #4 to suspend Licensed Practical Nurse #1 pending investigation and notified the Administrator. Registered Nurse Supervisor #4 completed an assessment. The resident had dried blood on their nose, the on-call medical provider was notified and ordered an X-ray. The police were called, and the resident's family was notified of what happened. The care plan interventions were reviewed, and implementation verified. The untimed 12/16/2024 Medical Director progress note documented the resident was seen for a report of being against the wall, hitting their face and had a small nosebleed. The on-call provider ordered an x-ray but did not order to send the resident to the hospital. The x-ray showed an acute fracture to the tip of the nasal bone. The Medical Director recommended the resident be evaluated at the hospital. The 12/16/2024 hospital record documented the resident arrived at 12:55 PM for evaluation following an alleged assault. The resident reported they were pushed by a nurse the prior evening, fell to the ground, and had a nosebleed. The resident denied hitting their head or having any pain and had no specific complaints related to the assault. The resident complained of anxiety, and stated it was a chronic problem. The physical exam did not reveal any injuries, the resident had no acute distress and did not appear anxious. They were discharged back to the facility with no new orders. The 12/16/2024 at 10:21 PM Assistant Director of Nursing progress noted documented they assessed the resident at approximately 4:30 PM (follow-up assessment after the incident). The resident denied pain and stated they were tired. Their nose was a little swollen and there was slight bruising noted. The resident was being transferred to the hospital to see an Ear, Nose, and Throat (specialist) for evaluation per an order from Physician Assistant #8. The 12/16/2024 hospital record documented the resident presented in the emergency department earlier that day due to an assault at the nursing facility. They had an outpatient x-ray done and were found to have a non-displaced nasal bone fracture. No septal hematoma was identified, and the resident was requesting discharge. The 12/15/2024 facility Incident Report and Investigation Form signed and reviewed by the Director of Nursing, Administrator, and Assistant Director of Nursing on 12/17/2024 documented: - On 12/15/2024, Certified Nurse Aide #2 reported to the Director of Nursing, they observed Resident #1 was being pressed into a wall, face first, with their nose against the wall, by Licensed Practical Nurse #1. - Certified Nurse Aide #2 reported they heard Resident #1 tell Licensed Practical Nurse #1 the nurse was going to break the resident's nose as the nurse pressed their face to the wall. - Licensed Practical Nurse #1 was suspended immediately upon the reported incident. - Local police were notified and responded to initiate an investigation. - The medical provider was notified and ordered a nasal x-ray. - Resident #1 sustained a fracture to the tip of their nose. - Certified Nurse Aide #2's statement documented, at approximately 5:05 PM, they were in the hall when Resident #1 approached Licensed Practical Nurse #1 to ask about anxiety medication. As Certified Nurse Aide #2 approached to redirect Resident #1, Licensed Practical Nurse #1 grabbed both resident's arms, turned the resident around, and shoved them into the wall face first. The aide observed the resident's face hit the wall and the resident cried and said they thought they broke their nose. Certified Nurse Aide #2 took Resident #1 to the cafe to get them a drink and comfort them and notified the Director of Nursing via phone call to report the incident. - Resident #1's statement, taken by the Administrator on 12/15/2024 at 6:10 PM, documented Licensed Practical Nurse #1 pushed them down to the ground and made their nose bleed. It happened before dinner, and the resident was asking the nurse about medication. The resident reported no pain, they felt safe at the facility, and they did not want any care provided by Licensed Practical Nurse #1 going forward. - Resident #2's statement, taken by the Administrator on 12/15/2024 at 6:15 PM, documented they were by the oxygen room and saw Licensed Practical Nurse #1 push Resident #1 into the wall face first. - Certified Nurse Aide #3's statement documented they were in the hall and heard Licensed Practical Nurse #1 telling Resident #1 they were tired of it. The aide turned to go back up front and saw Resident #1 up against the wall with Licensed Practical Nurse #1 in front of the resident. - Licensed Practical Nurse #1's statement documented on 12/15/2024 they had multiple conversations with Resident #1 about the resident obtaining anxiety medications. The resident stood behind the medication cart to ask for something for anxiety and did so as the nurse kept the cart in front of themself, so their back was to the wall, to observe the unit end to end. - The investigation conclusion documented there was reasonable cause to believe abuse occurred by Licensed Practical Nurse #1 toward Resident #1. - Licensed Practical Nurse #1 was arrested following the police investigation, remained suspended from their duties, and was not allowed on the facility premises. The 12/17/2024 police report documented on 12/15/2024, Police Officers #12 and #13 were dispatched to the facility at 7:44 PM for a report of an assault. The resident's apparent condition was mentally disordered and appeared to be physically injured but not seriously. There was dried blood in the resident's nostrils and minor marks on both knees, which the resident stated were not there before the altercation. The officers interviewed Resident #1, who reported Licensed Practical Nurse #1 grabbed them and threw them to the ground and their nose started bleeding. The resident was not sure if they hit their head on the wall or floor. The same version of the altercation was repeated several times by the resident. Additional interviews included: - Resident #2 stated Licensed Practical Nurse #1 yelled at Resident #1 saying move get out of the way and grabbed the resident by the shoulders and pushed them toward the wall where they hit the right side of their head. - Certified Nurse Aide #3, stated they saw the tail end of the altercation and saw Resident #1's head bounce off the wall. Licensed Practical Nurse #1 was in the resident's face yelling something like I'm sick of all this [expletive] or I'm sick of your [expletive]. The certified nurse aide stated they could see blood coming from the resident's nose. Certified Nurse Aide #3 turned away and walked in the opposite direction when Resident #2, who was fully alert and oriented, stopped them and asked why that licensed practical nurse pushed Resident #1 against the wall. Certified Nursing Aide #2 walked up to them, was crying and stated they saw Licensed Practical Nurse #1 push Resident #1 against the wall and yell at Resident #1. - On 12/16/2024, Police Officers #12 and #13 spoke to Licensed Practical Nurse #1 who stated there was never any altercation that took place and they never touched Resident #1. They stated the resident was always asking about their medication and they redirected them but had yelled at the resident in the past. They stated they did not see the resident fall to the ground or have a bloody nose. - Certified Nursing Aide #2 was interviewed and stated they saw Resident #1 asking Licensed Practical Nurse #1 about their medication. They walked towards the resident to redirect them from the nurse when they saw Licensed Practical Nurse #1 grab Resident #1 by the arms and turn them around. Licensed Practical Nurse #1 pushed Resident #1 from behind with both hands and the resident's face hit the wall. Certified Nursing Aide #2 was approximately two feet away from both the resident and the licensed practical nurse when the altercation took place. Certified Nurse Aide #2 took Resident #1 to the cafeteria to make sure they were okay and contacted the Director of Nursing. - The Administrator reported Resident #1's x-ray showed a fractured nose. - The Director of Nursing reported Certified Nurse Aide #2 notified them what they witnessed and heard Resident #1 say Licensed Practical Nurse #1 was going to break their nose when Licensed Practical Nurse #1 pushed them into the wall. The 12/16/2024 Arrest Report documented Licensed Practical Nurse #1 was charged with assault in the third degree and endangering the welfare of a vulnerable adult and physically disabled person in the second degree. They were taken to the Justice Center and held for arraignment. During an interview on 12/17/2024 at 4:40 PM Police Officer #12 stated witnesses and Resident #1 were interviewed with corroborating reports of the incident. The police officer observed dried blood in Resident #1's nose and redness to their knees on 12/15/2024. Licensed Practical Nurse #1 was arrested on 12/16/2024 and charged with endangering the welfare of an incompetent or physically disabled person (Class E felony) and assault in the 3rd degree (Class A misdemeanor). Upon a follow up visit on 12/17/2024, the officer learned the resident sustained a fracture to their nose. During an interview and observation on 12/18/2024 at 9:10 AM, Resident #1 stated Licensed Practical Nurse #1 was angry, touched their shoulders, grabbed them, and threw them on the ground in the hallway, and they hit their head. They had been asking for their medication. They stated that same nurse yelled at them before, and they had been pushed before in the facility but was not sure by who or when. They did not tell anyone in the facility, only their family. They continued to feel anxious and depressed as they had been for a while, but felt safe, and staff checked on them frequently. During an interview on 12/18/2024 at 10:50 AM, Resident #2 stated they saw Licensed Practical Nurse #1 abuse Resident #1 on 12/15/2024. The incident occurred at the end of the hallway by Resident #1's room, where the medication cart was. Resident #2 stated they went down that way to get a new oxygen tank before going to the dining room. Resident #1 asked for medications all the time but on that day, Licensed Practical Nurse #1 responded angrily and told the resident they did not have medication. Resident #2 got their oxygen and Resident #1 was still there asking for their medications. The nurse said, I told you it is not time, and I am sick of this [expletive]. The nurse then grabbed Resident #1 by the shirt and threw them to the wall. Resident #1 hit their head stating they were hurt. Certified Nurse Aide #2 started to cry. The Administrator was there to talk to the residents as well as the police. During an interview on 12/18/2024 at 11:31 AM, the Administrator stated Licensed Practical Nurse #1 had no prior disciplines and there were no reported resident or family complaints about care or abuse regarding Licensed Practical Nurse #1 prior to this incident. On 12/15/2024, they were notified by the Director of Nursing before 6:00 PM related to an allegation of abuse. They arrived at the facility within 15 minutes and Registered Nurse Supervisor #4 was walking Licensed Practical Nurse #1 around the corner. Licensed Practical Nurse #1 provided a written statement and then left the facility. Licensed Practical Nurse #1 denied the incident. Certified Nurse Aide #2 left the facility at 6:00 PM when their shift ended. Resident #1 and Resident #2 were interviewed first. Witnesses stated the resident went face first into the wall. The Police Department was called, and they arrived at the facility between 7:00 PM and 7:30 PM. They spent a couple of hours interviewing residents and staff. Education on abuse and neglect was started that night around 10:00 PM for 12 or 13 staff that were working. The Administrator stated they left the facility after midnight. On 12/16/2024, the Administrator completed a full house education on abuse and neglect (all staff were educated). During an interview on 12/17/2024 at 12:05 PM the Director of Nursing stated Certified Nurse Aide #2 called them on 12/15/2024 at 5:37 PM and reported Licensed Practical Nurse #1 pushed Resident #1 against the wall with the resident's nose to the wall and the resident said to that nurse you are going to break my nose. Certified Nurse Aide #2 said they immediately took the resident to the cafeteria and the resident had coffee and cookies. The Director of Nursing immediately called Registered Nurse Supervisor #4 to get a statement and then suspended Licensed Practical Nurse #1. They notified the Administrator who went into the facility to conduct the investigation at approximately 6:00 PM. The on-call physician was notified and ordered an x-ray of the nose and the resident was sent to the emergency room for evaluation on 12/16/2024. During an interview on 12/18/2024 at 1:21 PM Social Worker #5 stated they saw Resident #1 on 12/16/2024 and each day since the incident. The resident frequently and repeatedly asked for their medications as their baseline behavior. The social worker did not see any change in their psychosocial behaviors and the resident was seen by the psychiatric provider. The resident continued to participate in their daily routine with no noted changes. Following the incident, they interviewed 19 residents who were oriented, all felt safe at the facility and had no concerns related to abuse or mistreatment by staff. During an interview on 12/18/2024 at 1:35 PM, Certified Nurse Aide #2 stated on 12/15/2024, they worked from 6:00 AM to 6:00 PM. The incident happened at approximately 5:05 PM when they were going down the hall to redirect Resident #1 because they were asking for medications. They thought they would give the resident their meal tray to distract them. As they approached the resident, Licensed Practical Nurse #1 put their hands on the resident's shoulders, turned them and pushed them. They heard the resident say, I broke my nose again and the resident's eyes teared up. There was a lot of commotion at that time with other residents in the hallway and a lot of them were eating. They took the resident, who was shaken up, to the dining room for coffee and cookies to calm them down. They calmed down and the aide walked the resident back to their room where they stayed. Certified Nurse Aide #2 then contacted the Director of Nursing on the telephone and reported the incident. During an interview on 12/18/2024 at 2:09 PM Certified Nurse Aide #3 stated on 12/15/2024, before dinner, they looked down the hallway and saw Licensed Practical Nurse #1 push the resident into the wall. They could not hear well what was being said, but when the nurse pushed Resident #1, the resident hit the wall like a basketball. They could see the resident's nose bleeding from down the hallway. They thought they heard Licensed Practical Nurse #1 say I am tired of your [expletive] and the resident said, [they] hurt me. Certified Nurse Aide #2 and Resident #2 were near the resident. Certified Nurse Aide #3 thought the resident slid to the floor but was not sure. Certified Nurse Aide #2 was crying, and Certified Nurse Aide #3 was initially shocked at what they saw and did not immediately move. Certified Nurse Aide #2 approached Certified Nurse Aide #3, very upset and asked what to do. Certified Nurse Aide #3 told Certified Nurse Aide #2 they must report it. Certified Nurse Aide #2 was scared and took the resident with them to get a drink and cookies. When they returned, Certified Nurse Aide #2 notified the Director of Nursing. Both aides were afraid of retaliation and did not know who the supervisor was or where they were only that they were busy, so Certified Nurse Aide #2 called the Director of Nursing. During a phone interview on 12/18/2024 at 5:20 PM, Licensed Practical Nurse #1 stated they were unaware of what happened and was told they tripped or pushed Resident #1. They wrote a statement for the Administrator on 12/15/2024. Resident #1 asked for medication all day long, even after they receive their medications. Licensed Practical Nurse #1 stated they got along well with all the staff and had never had a problem with staff or other residents. A certified nurse aide went to a registered nurse on another unit, and no one approached Licensed Practical Nurse #1 about a nosebleed, and they never saw Resident #1 with a nosebleed. Registered Nurse Supervisor #4 went to the unit and told them they had to leave. As they were walking off the unit, the Administrator arrived, and Licensed Practical Nurse #1 went to their office to write a statement before leaving. During a phone interview on 1/03/2025 at 11:42 AM, Physician Assistant #8 stated they were notified in the evening of 12/15/2024 about Resident #1 and they saw the resident the morning of 12/17/2024 for follow up of their injury. The resident was seen by the Medical Director on 12/16/2024 and they shared with them the abuse of this resident. The physician assistant ordered an x-ray of the resident's nose and ordered the resident to go to the emergency room for an evaluation on 12/16/2024. The resident returned without paperwork, so they did not know what the hospital had done. After the x-ray results showed a fractured nasal bone, they wanted the resident to go back to the emergency room for further evaluation to see an Ears, Nose, and Throat specialist, as there may have been cosmetic concerns. When they examined the resident's nose, there was minor bruising and swelling across the bridge of the nose. The resident expressed no pain, and their injury was not severe. During an interview on 1/7/2025 at 10:49 AM the Medical Director stated they were advised of the incident and saw Resident #1 on 12/16/2024. The resident reported no pain and had no observed swelling or bruising. The Medical Director stated they were made aware the resident's nasal bone was fractured and there was some bleeding the day it occurred. 10NYCRR 415.4(b)(1)(i) Deficient practice was identified in the area of abuse that resulted in harm to Resident #1 during the Abbreviated Survey on 12/18/2024. The facility provided verification the following corrective actions were completed by 12/17/2024: - On 12/15/2024, following notification of abuse, Licensed Practical Nurse #1 was suspended from their duties and exited the facility. They were subsequently terminated. - On 12/15/2024, the Administrator responded to the facility immediately following notification of abuse and initiated a comprehensive investigation. They completed interviews with witnesses and staff who were working at the time of the incident, as well as Resident #1. - Law Enforcement was notified on 12/15/2024 and responded to the facility for an investigation. - On 12/15/2024, the facility initiated a whole house education on abuse prevention and reporting of abuse. The education was mandatory for all staff, to be completed by the directors of each department, with oversight of the Administrator, Director of Nursing, and Assistant Director of Nursing. - All staff completed education by 12/17/2024, except for staff out on leave or who had not been scheduled. Any staff who had not completed the abuse training by 12/17/2024 would not be permitted to work until completion. - On 12/17/2024, 19 residents who reside in the facility were interviewed by the social worker and reported no concerns with instances of abuse from any staff, or being fearful of any staff, including Licensed Practical Nurse #1. - Resident #1 was monitored by the social worker and continues to meet with their psychiatric provider. No changes in the resident's baseline mood or behavior have been noted. - A QAPI meeting was held on 12/16/2024 and the incident was reviewed. Random auditing of 5 vulnerable residents was initiated and will be completed weekly for 4 weeks, then monthly for 3 months, with review at the Quality Assurance and Performance Improvement meetings.

Based on observation, interview, and record review during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not maintain equipment in safe operating condition for 2 of 2 unit kitchenette refrigerators. Specifically, the unit kitchenette refrigerators did not maintain proper temperatures. Findings include: During an observation on 5/6/2024 at 7:30 AM, the South Unit kitchenette had an upright white refrigerator labeled, out of order-do not use. The refrigerator portion was empty. The thermometer inside read 65 degrees Fahrenheit. The freezer portion held some frozen food items that included ice cream bars, frozen drinks, and individual portions of ice cream. Additionally, there was a small black refrigerator that had the door left ajar a few inches. There were drinks for resident use had a measured temperature of 41.7 degrees Fahrenheit. The door hit the side of the cooler and had to be physically pushed closed for the door to seal properly. During an observation on 5/6/2024 at 7:13 AM, the North Unit kitchenette refrigerator thermometer read 58 degrees Fahrenheit. The refrigerator contained 4 cottage cheese containers, 2 brownish pureed food containers, 3 tuna sandwiches, 2 jugs of thickened water, 1 plastic carafe of honey thick juice, and an unreadable plastic carafe with undated orange drink. During an observation on 5/6/2024 at 8:53 AM, the North Unit kitchenette refrigerator thermometer read 58 degrees Fahrenheit. The thickened dairy beverage was removed from the shelf and the temperature was measured at 55 degrees Fahrenheit. The temperature log on the refrigerator was documented as 36 degrees Fahrenheit 5/6/2024 by the Food Service Director. During an interview on 5/6/2024 at 9:00 AM, the Food Service stated they checked the North Unit kitchenette refrigerator. They stated they read the internal thermometer, which was brand new, and it read 36 degrees Fahrenheit at about 7:45 AM. The thermometer was now reading 60 degrees Fahrenheit. They stated someone may have left it open. The surveyor asked them to leave the refrigerator closed for 30 minutes to have the unit rechecked to see how the temperature would adjust. They stated they would see that no one opened the refrigerator. During an observation on 5/6/2024 at 9:05 AM, staff wheeled a new refrigerator down the hall to the North Unit kitchenette. At 9:25 AM the refrigerator was replaced. During an observation on 5/7/2024 at 10:06 AM, with the Director of Housekeeping and Laundry the South 100s kitchenette small refrigerator was removed, and the existing refrigerator was no longer labeled as do not use. The thermometer in the upright refrigerator read 60 degrees Fahrenheit and was confirmed by the surveyor's thermometer and measured at 58 degrees Fahrenheit. There was no food stored in the refrigerator. The freezer portion contained ice cream bars and the thermometer read 12 degrees Fahrenheit. During an interview on 5/07/24 at 10:06 AM, the Director of Housekeeping and Laundry stated when there was an issue with facility equipment the staff should fill out a maintenance request form. They were not sure if a form was completed for the refrigerator. During an interview on 5/10/2024 at 11:18 AM the Food Service Director stated the kitchenette refrigerator temperatures were checked by the kitchen staff twice daily and recorded on the log on each refrigerator. They stated the South Unit refrigerator went down last week; they had ordered a replacement which came in the morning of 5/6/2024. When they were informed the North Unit was not holding temperature, they sent the new one there instead and did not need to see if it was just left open. They thought they had some documentation regarding the timing of the South Unit going down and ordering the new one. Documentation regarding the temperature logs and the South Unit kitchenette refrigerator were not provided by the facility when requested from the Administrator on 5/9/2024 and 5/10/2024. 10NYCRR 415.29 10NYCRR 713-2.5

49448 Based on observation, record review, and interview during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not ensure residents were treated with respect and dignity in a manner and environment that promotes maintenance or enhancement of quality of life for 6 of 11 residents (Residents #19, #36, #59, #379, and 2 anonymous residents) reviewed. Specifically, - Activities aide #7 and licensed practical nurse #2 had a verbal confrontation in front of Resident #19 after they ran out of portable oxygen during a group activity; - Certified nurse aide #8 stood over Resident #36 while assisting them with eating; - Resident #59 exhibited continuous disruptive verbal behaviors in a common area with other residents and was not removed from the space timely as planned. Additionally, the resident was transported in their wheelchair facing backwards by certified nurse aide #9; - 2 anonymous residents stated during a group meeting that staff would tell them they could not leave their rooms because portable oxygen was not available; - Certified nurse aide #10 entered Resident #379's room, who was legally blind, without announcing themself or informing the resident of care being provided. Findings include: The facility policy Resident Rights revised 2/2020 documented all employees treated residents with kindness, respect, and dignity. Residents in the facility had a right to a dignified existence, privacy and confidentiality and equal access to quality care. The facility policy Behavior Management revised 5/2020 documented residents who exhibited behavior symptoms were taken aware to a quiet controlled space. This could be a utility room, or any area that served as a time out space and the resident was given time to calm down. 1) Resident #36 was admitted to the facility with diagnoses including dementia, Parkinson's disease (a progressive neurological disorder), and dysphagia (difficulty swallowing) The 3/30/2024 Minimum Data Set assessment dated documented the resident had severely impaired cognition, was dependent for eating, and received a mechanically altered diet. The comprehensive care plan initiated 10/23/2023 and revised 3/25/2024 documented the resident had an activities of daily living deficit related to limited mobility and was dependent on 1 for eating. During observations on 5/6/2024 at 11:33 AM and on 5/8/2024 at 8:51 AM Resident #36 was observed in their reclining chair in the hallway being fed by certified nurse aide #8 who stood while they were feeding the resident. During an interview on 5/10/2024 at 9:17 AM licensed practical nurse #6 stated staff should assist residents with meals while seated next to the resident and should not stand next to them. Staff should be at eye level with the resident so chewing and swallowing were visualized. They had seen certified nurse aides stand over Resident #36 during meals and this was not appropriate. During an interview on 5/10/2024 at 10:08 AM registered nurse Unit Manager #5 stated staff should be seated and interacting with residents while they assisted with feeding. It gave the resident a sense of comfort for staff to be at eye level during feeding. During an interview on 5/10/2024 at 10:44 AM certified nurse aide #8 stated they stood while feeding Resident #36 because it was more comfortable for them than sitting. 2) Resident #59 was admitted to the facility with diagnoses including Alzheimer's disease. The 4/30/2024 Minimum Data Set assessment dated documented the resident had severely impaired cognition, had daily behavioral symptoms not directed towards others, was dependent for most activities of daily living, and used a manual wheelchair. The comprehensive care plan initiated 8/18/2023 and revised 10/26/2023 documented the resident exhibited behavior symptoms. Interventions included determine the cause of behavior and remove the resident, distract with activities of interest, redirect negative behavior as needed, use 2 caregivers when the resident exhibited behaviors. Staff would intervene to attempt to calm the resident when they displayed escalating behaviors. Resident #59 was observed: - on 5/7/2024 during a continuous observation from 11:36 AM-12:14 PM, seated in their reclining wheelchair in the hallway outside of their room. There were other residents and families in the area. The resident continued with repetitive verbal behaviors. Certified nurse aide #9 was seated next to the resident. - on 5/7/2024 at 12:14 PM, seated in their reclining chair. Certified nurse aide #9 transported the resident from the hallway to the courtyard while the resident was facing backwards. - on 5/7/2024 during a continuous observation from 12:42 PM-1:22 PM, seated in their reclining wheelchair in the hallway outside of their room. The resident exhibited repetitive verbal behaviors with other residents and families present in close proximity. Certified nurse aide #11 was seated next to the resident. - on 5/8/2024 during a continuous observation from 10:09 AM-11:46 AM, seated in their reclining wheelchair in the hallway outside of their room, exhibiting repetitive verbal behaviors with other residents and families present in close proximity. Certified nurse aide #9 was seated next to the resident. - on 5/8/2024 at 11:46 AM, seated in their reclining chair. Certified nurse aide #9 transported the resident from the hallway to the courtyard while the resident was facing backwards. During an interview on 5/9/2024 at 1:31 PM certified nurse aide #9 stated they attempted to distract Resident #59 when behaviors were exhibited. It was common the resident yelled out in the hallway. It was not respectful the resident displayed continuous verbal behaviors in the hallway with an audience. The resident should have been moved to a quiet environment timelier. They stated they should not have transported the resident backwards because it was not dignified or respectful to the resident. They should have pushed the resident in front of them for safety reasons. During an interview on 5/10/2024 at 10:20 AM licensed practical nurse #6 stated they expected the certified nurse aides to remove residents from public areas when disruptive behaviors were displayed. Resident #59 often displayed verbal behaviors and it was disruptive to other residents and often caused other residents to escalate if they had behavioral symptoms. It was not respectful or dignified the resident was not moved from the public space timely. Residents should not be transported backwards, and it could increase the chance of a fall. During an interview on 5/10/2024 at 11:20 AM registered nurse Unit Manager #5 stated Resident #59 yelled out in the hallway frequently and should have 1 on 1 care but there was not enough staff. It was not dignified, or respectful to other residents and families who witnessed the behaviors. They were not sure if it was appropriate if the resident was transported backwards. During an interview on 5/10/2024 at 12:15 PM the Director of Nursing stated if Resident #59 was not easily calmed down they should be moved to another area. It was not dignified or respectful they were kept in the hallway while others witnessed the behaviors. Staff should push, not pull, residents in their wheelchairs for safety and dignity. 3) Resident #379 was admitted to the facility with diagnoses including legal blindness. The 5/1/2024 Minimum Data Set assessment documented the resident was cognitively intact, had severely impaired vision, required partial/ moderate assistance with eating and oral/personal hygiene, substantial/maximum assistance with toileting and bathing, and was dependent for transfers. The comprehensive care plan initiated 4/21/2023 and cancelled on 4/28/2023 documented the resident was legally blind in both eyes. Interventions included knock on the resident's door before entering and introduce yourself each time when entering their room. The comprehensive care plan initiated 4/26/2024 documented the resident had impaired visual function related to blindness. Interventions included room and personal items were arranged per resident preference and the resident was told where their items were placed. On 4/21/2023 During an observation on 5/6/2024 at 8:09 AM, certified nurse aide #10 entered the resident's room without knocking. The resident asked what their name was. Certified nurse aide #10 identified themselves and proceeded to reposition the resident in bed without explaining prior to touching and moving the resident in their bed. The bed was then lowered. Resident #379 stated they wanted to be told what was being done to them since they could not see. During an interview on 5/8/2024 at 11:46 AM licensed practical nurse #2 stated they expected staff to knock and introduce themselves before entering a resident's private space. It was especially important for Resident #379 because they had a visual impairment. It was not homelike if staff did not knock before entering a resident's room. During an interview on 5/9/2024 at 1:59 PM Corporate registered nurse #1 stated they expected staff to knock and introduce themselves before entering a resident's room. Residents should know who entered their room. 10NYCRR 415.(a)

Based on observation, record review, and interview during the recertification and abbreviated (NY00312922 and NY00340114) surveys conducted 5/6/2024-5/10/2024, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 2 of 2 (North and South units) resident units and the main dining room. Specifically, on the North unit resident rooms [ROOM NUMBERS] had used incontinence briefs on the floor and nightstand; resident 209 smelled of urine; resident room [ROOM NUMBER]'s door handle was broken; and resident rooms [ROOM NUMBER] had sliding glass door restrictors that were not maintained. On the South unit resident rooms [ROOM NUMBERS] light fixtures were missing covers, had open light sockets, and exposed wiring; and there was a broken table in the main dining room. Additionally, residents received cold beverages in disposable cups at meals. Findings include: The facility policy Resident Rights revised 2/2020 documented the residents had a right to a dignified existence. The facility policy Elopement-Prevention revised 3/13/2024 documented the physical plant should be secured to minimize the risk of elopement and may include but was not limited to the following: functional alarm system or magnetic locks with egress alarms for egress and stairwells, interior courtyards, safety locks or key-pad entry that restrict access to dangerous areas, securement and/or monitoring of the main entrance or lobby, and restricted window openings. Resident Rooms The following observations were made on the North unit: - on 5/6/2024 from 7:04 AM-9:52 AM, a used brief was laying on the floor next to an occupied bed in resident room [ROOM NUMBER]. - on 5/7/2024 at 8:32 AM, resident room [ROOM NUMBER] smelled of urine. - on 5/8/2024 at 12:14 PM, resident room [ROOM NUMBER]'s door handle had sharp metal edges and the door would not open. - on 5/9/2024 at 7:57 AM, a used brief was on the bedside table of room [ROOM NUMBER]. During an interview on 5/10/2024 at 9:02 AM certified nurse aide #15 stated after staff changed a resident's brief it should be placed in a bag and brought to the soiled utility room. Used briefs should not be left on the floor or on bed side tables. It was not dignified or homelike and could lead to odors in the room. Any staff that observed used briefs left in the room should remove them. During an interview on 5/10/2024 at 9:10 AM licensed practical nurse #27 stated used briefs should be removed from the resident's room after care was provided. It was not dignified or homelike for used briefs to be left in a room. During an interview on 5/10/2024 at 10:17 AM Regional Registered Nurse #1 stated they expected staff to remove used briefs from resident rooms once care was provided. It was not dignified or homelike for the residents to have used briefs in their rooms. The following observations were made on the South unit: - on 5/7/2024 at 10:47 AM, resident room [ROOM NUMBER]'s light over the sink was missing the cover and the light did not turn on. - on 5/7/2024 at 10:50 AM, resident room [ROOM NUMBER]'s dome light over the sink and closet area were missing the covers, the lights did not work, and there were open sockets hanging by the wires a few inches below the light. - on 5/8/2024 at 12:10 PM, resident room [ROOM NUMBER]'s door handle to the sliding door was broken and the door would not open. - on 5/9/2024 at 12:20 PM, resident room [ROOM NUMBER] had tape on the window and sliding door. During an interview on 5/7/2024 at 10:47 AM Regional Director of Housekeeping and Laundry Services #23 stated lights should be covered and not exposed. During an interview on 5/9/2024 at 11:54 AM housekeeper #43 stated if they noticed broken equipment in a resident room or throughout the facility they would alert another staff member, but they would not fill out a work order form. They had not noticed any broken light fixtures or issues with door handles. During an interview on 5/10/2024 at 11:09 AM Regional Director of Housekeeping and Laundry Services #23 stated the tape on the window and sliding door in resident room [ROOM NUMBER] prevented a draft from the glass panels. A resident could not open the window if it was taped and would need staff assistance. The tape had been got 1-2 years. There was no documentation regarding the tape on the window and sliding glass door. Sliding Door Restrictors During an observation on 5/8/2024 at 11:51 AM, resident room [ROOM NUMBER] was equipped with a sliding glass door to the outside that functioned as the room's operable window. The door was tested by the Director of Housekeeping and Laundry and opened about 9 inches wide. They stated the door was equipped with a stopper which was intended to restrict the door opening to at most 6 inches, but the stopper had been moved. During an observation on 5/8/2024 at 11:53 AM, resident room [ROOM NUMBER]'s sliding glass door to the outside was tested by the Director of Housekeeping and Laundry and opened about 10 inches wide. The surveyor was able to fit their head and shoulders through the opening. The stopper was visibly moved beyond where the original hole was drilled in the window tract which was intended to restrict the width of the opening. During an observation on 5/8/2024 at 12:16 PM, the sliding door in room [ROOM NUMBER] was opened 12 inches and led to the yard that surrounded the facility. The surveyor could easily fit their head and shoulders through the door opening. During an observation on 5/8/2024 at 12:20 PM, the Regional Director of Housekeeping and Laundry moved the sliding glass door restrictor in room [ROOM NUMBER] and the door opened 6 inches. During an interview on 5/9/2024 at 1:53 PM, certified nurse aide #3 stated the staff opened the sliding glass doors in the resident rooms upon request because it was hard for the residents to open them. The lock was on the handle and each door had a restrictor on them, so they did not open all the way. They stated they had not heard or seen any resident's fit through the door opening and they thought they were only supposed to open a few inches. If the door opened too far, they would notify the nurse or the Administrator because a resident could get out without staff knowing. During an interview on 5/9/2024 at 2:11 PM, licensed practical nurse #2 stated the residents' sliding glass doors had restrictors so they would only open to a certain point. If a door opened further than the rest, they would shut the door and notify the Administrator or maintenance immediately so the resident could not get out or allow another person to get in the room. During an interview on 5/10/2024 at 12:09 PM, the Director of Housekeeping and Laundry, the Regional Director of Housekeeping and Laundry, the Regional Administrator, and the Administrator were present. The Director of Housekeeping and Laundry stated the sliding glass door to the outside was the window in the resident's rooms and those doors were supposed to be restricted to open no more than six inches. They stated the windows were supposed to be checked by the Director of Maintenance, who was unavailable during survey. The inspections were monthly and should have been documented. The Regional Administrator stated they were unable to find any documentation. The Director of Housekeeping and Laundry stated it was important to maintain the sliding doors at the appropriate width to prevent the residents from eloping. Dining The following observations were made during mealtimes: - on 5/6/2024 at 9:37 AM the North unit meal trays had cold beverages in plastic disposable cups. - on 5/8/24 at 12:51 PM the North unit had cold apple raspberry juice in plastic disposable cups. During an interview on 5/10/2024 at 10:56 AM the Food Service Director stated food and drinks should not be served using disposable dishes. Disposable dishes should only be used in an emergency. It was not homelike to receive food and drinks in disposable dishes and cups. This is something staff had been doing since they started a couple of months ago and the kitchen was short staffed. Broken Table During an observation on 5/6/2024 at 7:56 AM, there was 1 severely broken table in the corner of the main dining room by the fish tank. During an interview on 5/6/2024 at 7:56 AM the Director of Housekeeping stated staff did not remove the table after it was broken and pushed it into the corner of the dining room. During an observation on 5/9/2024 at 4:31 PM there was 1 severely broken table located in the corner of the main dining room by the fish tank. During an interview on 5/10/2024 at 12:09 PM the Administrator, the Director of Housekeeping, and Regional Director of Housekeeping and Laundry Services #23 stated if staff observed any broken items in resident rooms or throughout the facility a work order should be filled out. It was important to maintain a safe and clean environment to promote resident safety. 10 NYCRR 415.29(j)(1) 43754

48675 49448 Based on observation, record review, and interview during the recertification and abbreviated (NY00212922, NY00310702, and NY00310431) surveys conducted 5/6/2024-5/10/2024, 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 10 residents (Resident #1, #12, #35, and #37) reviewed. Specifically, Resident #1 was not assisted with dressing; Resident #12 was not assisted with bathing; Resident #35 was not assisted out of bed or supervised with meals; Resident #37 had unclean and untrimmed fingernails. Findings include: The facility policy Activities of Daily Living Care and Support revised 3/13/2024 documented residents received activities of daily living care and support in accordance with current standards of practice based on the resident's assessed needs, personal preferences, and goals of care. Care and support were provided to residents who were unable to carry out activities of daily living independently and included hygiene (bathing, dressing, grooming, and oral care), mobility, toileting, transfers, dining, and communication. The resident's bath or shower was scheduled per resident preference and was completed at a minimum of weekly. Nail care was provided as needed. The amount of assistance provided to the resident was documented in the clinical record. 1) Resident #1 was admitted to the facility with diagnoses including dementia, major depressive disorder, and glaucoma (progressive loss of vision). The 3/1/2024 Minimum Data Set assessment dated documented the resident had severely impaired cognition, required supervision for upper body dressing, and partial/ moderate assistance for lower body dressing, and did not reject care. The comprehensive care plan initiated on 10/26/2021 and revised 10/6/2023 documented the resident had an activity of daily living deficit related to dementia. Interventions included supervision, verbal cues or touching assistance of 1 for upper body dressing, and partial assistance of 1 for lower body dressing. The undated care instructions (Kardex) documented the resident received a shower/ bath on Tuesday and Friday on the day shift, received morning and evening personal hygiene care, and required assistance for dressing. Resident #1 was observed at the following times: - on 5/7/2024 at 12:19 PM sleeping in bed wearing a black nightgown with pink flowers; at 12:54 PM sitting up on the side of the bed wearing a black nightgown with pink flowers; and at 2:35 PM sleeping in bed wearing a black nightgown with pink flowers. - on 5/8/2024 at 8:55 AM sleeping in bed wearing a black nightgown with pink flowers; at 10:01 AM in the hallway asking for water wearing a black nightgown with pink flowers; at 12:02 PM sleeping in bed wearing a black nightgown with pink flowers; at 1:19 PM sitting on the side of the bed eating lunch wearing a black nightgown with pink flowers; and at 2:43 PM sleeping in bed wearing a black nightgown with pink flowers. - on 5/9/2024 at 9:11 AM sleeping in bed wearing a black nightgown with pink flowers; and at 9:24 AM walking out into the hallway asking for water wearing a black nightgown with pink flowers. The May 2024 certified nurse aide documentation for Resident #1 included: - on 5/7/2024 a bath was provided by certified nurse aide #11 at 10:00 AM. - on 5/7/2024 care was provided per Kardex by certified nurse aide #11 at 10:00 AM and at 8:19 PM. - on 5/8/2024 care was provided per Kardex by certified nurse aide #20 at 1:59 PM and by certified nurse aide #21 at 5:41 PM. - On 5/9/2024 care was provided per Kardex by certified nurse aide #20 at 11:59 AM and by certified nurse aide #9 at 3:08 PM. During an interview on 5/9/2024 at 12:43 PM certified nurse aide #11stated they gave Resident #1 a bath on 5/7/2024. They always took the resident to the shower room, and they assisted with bathing the entire body and then placed on a black nightgown with pink flowers. The resident was supposed to receive new clothing every morning or when soiled. This was charted electronically in the certified nurse aide documentation. The resident required assistance with bathing and dressing because they had poor vision. They stated certified nurse aide #20 was assigned Resident #1 today, but the resident was wearing the same nightgown they assisted with putting on after the shower a couple of days ago. During an interview on 5/9/2024 at 1:18 PM certified nurse aide #20 stated they were expected to follow the Kardex and document tasks if they were completed. If a resident refused, it was documented as a refusal. They stated the residents only got clean clothing on shower days, but they should get clean clothing every day. They were assigned Resident #1 but had not been in their room at all today because they were too busy. They were also assigned the resident yesterday and did not assist them with dressing. During an interview on 5/10/2024 at 10:10 AM licensed practical nurse #6 stated residents got clean clothes twice daily, once in the morning and once at night, or more if soiled. This was important for good hygiene and residents should get the care they needed and should feel clean. They expected all residents to be clean and dressed daily. During an interview on 5/10/2024 at 11:20 AM registered nurse Unit Manager #5 stated certified nurse aides were expected to change residents clothing daily and if it was documented, it meant it was completed. It was not appropriate for Resident #1 to be in the same nightgown for 3 days. It was not proper hygiene and put the resident at risk for infection. 2) Resident #12 had diagnoses including major depressive disorder, anxiety disorder, and chronic obstructive pulmonary disease (restrictive lung disease). The 4/28/2024 Minimum Data Set assessment documented the resident was cognitively intact, required substantial/ maximum assistance with bathing, and did not reject care. The comprehensive care plan initiated on 4/23/2024 documented the resident preferred a sponge bath. Interventions included assistance with daily routine as needed. The resident required assistance with self-care related to impaired balance and limited mobility. Interventions included shower/ bath on Tuesday and Friday evening shift. The undated care instructions (Kardex) documented the resident required substantial/ maximum assistance of 1 for bathing and the helper completed more than half of the activity. The May 2024 certified nurse aide documentation included a shower/ bath was completed by certified nurse aide #3 at the following times: - On 4/23/2024 at 9:06 PM - On 4/26/2024 at 9:59 PM - On 4/30/2024 at 8:28 PM - On 5/3/2024 at 9:20 PM. During an interview on 5/6/2024 at 11:20 AM Resident #12 they stated they had been at the facility for 3 weeks and had not been offered or received a shower until today. Certified nurse aide #3 had told them they could have a shower tomorrow. The May 2024 certified nurse aide documentation included a shower/ bath was completed by certified nurse aide #3 on 5/7/2024 at 9:02 PM. During a follow up observation and interview on 5/9/2024 at 11:47 AM, certified nurse aide #3 exited the resident's room with a bag of dirty linens. Resident #12 was lying in their bed wearing a clean hospital gown and stated they just got cleaned up in bed by the certified nurse aide. They stated they asked when their next shower day was, and the certified nurse aide stated they would let them know. They would like to get their showers in the morning and now that they received their first shower a couple of days ago (5/7/2024), they wanted to receive them regularly as they felt much better afterwards. During an interview on 5/9/2024 at 1:46 PM certified nurse aide #3 stated the Kardex provided the level of assistance needed and listed shower days. They had given Resident #12 a shower on 5/7/2024 and it was their first shower since admission. They did not think the resident had been there that long. The resident did not refuse care. They thought they had given bed baths on the other documented days, and they did not always have time to give showers as planned. Showers were important for hygiene and dignity. During an interview on 5/9/2024 at 2:21 PM licensed practical nurse #2 stated certified nurse aides were expected to reference the Kardex for shower days and showers should be given as scheduled. They were not notified of any refusals by the resident. It was dignified to receive showers and the residents felt better and deserved good hygiene. During an interview on 5/10/2024 at 10:26 AM registered nurse #1 stated the Kardex was where information regarding shower days was located. They stated showers should always be offered and if a resident refused a bed bath should be offered. It was not acceptable the resident had been offered one shower since admission as residents were scheduled for showers twice a week. All residents deserved showers for proper hygiene. 3) Resident #35 had diagnoses including protein-calorie malnutrition, major depressive disorder, and normal pressure hydrocephalus (a brain disorder). The 3/1/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, required supervision with eating, was dependent with toileting, dressing, bathing, and transfers, and did not reject care. The comprehensive care plan initiated 12/30/2022 and revised 11/29/2023 documented the resident required assistance of 2 with a mechanical lift for transfers, and required supervision, verbal cues or touching assistance of 1 for eating. The May 2024 Documentation Survey Report for activities of daily living documented care was provided per the Kardex on all shifts from 5/6/2024-5/9/2024. Resident #35 was observed at the following times: - on 5/6/2024 at 7:00 AM and at 8:46 AM lying in bed in a hospital gown - on 5/7/2024 at 9:05 AM sitting up in bed eating breakfast in a hospital gown, no staff was present in the room supervising the resident. - on 5/7/2024 at 12:02 PM lying in bed in a hospital gown. - on 5/7/2024 at 12:52 PM, sitting up in bed in a hospital gown eating lunch, no staff was present in the room to supervise the resident's lunch meal. - on 5/8/2024 at 8:51 AM sitting up in bed in a hospital gown with their breakfast on the overbed table, there was no staff present in the room to supervise the resident's meal. - On 5/8/2024 at 9:07 AM sitting up in bed in a hospital gown with breakfast tray untouched. At 9:12 AM, an unidentified certified nurse aide walked into the room and asked why they were not eating and then exited the room without providing assistance. The 5/8/2024 at 8:28 AM percentage of meals eaten documented the resident consumed 51-75% of the morning meal and 166-239 cubic centimeters of fluid. There were no documented staff name to accompany the percentages. During an interview on 5/9/2024 at 10:24 AM certified nurse aide #11 stated the level of care residents required was in the care plan. They were responsible for getting residents out of bed daily. They stated Resident #35 required supervision and verbal cues with meals and they should not have eaten alone in their room. They were not sure if they had offered to get the resident out of bed, but all residents should be offered to get up every day. During an interview on 5/10/2024 at 9:00AM licensed practical nurse #6 stated the level of care assistance residents needed was located on the care plan and included transfers, meals, and personal care. Resident #35 required supervision with meals and should not have been left alone. If the resident did not eat, the certified nurse aides should provide encouragement. The resident had eaten alone in their room this week and should not have. It was their responsibility to ensure the certified nurse aides completed the tasks as outlined in the care plan. They expected residents to get up and out of bed daily and if they refused, they should be notified, and the resident should be reapproached. During an interview on 5/10/2024 at 9:53 AM registered nurse Unit Manager #5 stated it was important that residents got out of bed to prevent pneumonia, bed sores, and it provided socialization. They stated one of the certified nurse aides informed them on 5/8/2024 that Resident #35 refused to get out of bed and the resident was not reapproached by them but should have been. The resident was also supposed to be supervised for meals and it was not appropriate they ate in their room alone. The resident needed varying levels of assistance with eating. During an interview on 5/10/2024 at 10:32 AM certified nurse aide #8 stated it was important for residents to get out of bed as it prevented decline. Resident #35 sometimes refused to get out of bed, and they would tell the nurse. They stated some days the resident could feed themselves and other days they could not. Because the resident required supervision with meals, they should not have been left alone in their room. 10NYCRR 415.12(a)(3)

Based on observation, record review, and interview during the recertification and abbreviated (NY00312922) surveys conducted 5/6/2024-5/10/2024 the facility did not ensure each resident received at least three meals daily at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests and plans of care for 2 of 2 nursing units (North unit and South unit) observed. Specifically, resident meal trays were delivered to nursing floors up to 1 hour and 25 minutes after the scheduled mealtimes. Findings include: The facility policy Meal Service revised 4/2022 documented meals would be delivered promptly to assure quality. During an interview on 5/6/2024 at 8:30 AM Resident #19 stated sometimes the meals came late due to the kitchen being short staffed. The facility's posted schedule documented the following mealtimes: Breakfast: -North Unit 8 AM. -South Unit 8:15 AM. -Dining room [ROOM NUMBER]:35 AM and 8:45 AM. Lunch: -Dining room [ROOM NUMBER]:15 PM and 12:25 PM. -North Unit 12:35 PM. -South Unit 12:45 PM. The following observations were made on the North Unit: - on 5/6/24 at 9:25 AM, the 1st breakfast cart arrived on the unit, and at 9:37 AM, the second breakfast cart arrived on the unit. - on 5/8/24 at 8:51 AM, the 1st breakfast cart arrived on the unit and the 2nd breakfast cart arrived on the unit at 9:08 AM. - on 5/9/24 at 8:21 AM, the 1st breakfast cart arrived on the unit and at 8:57 AM, the 2nd breakfast cart arrived on the unit. - on 5/10/2024 at 8:57 AM, the 1st breakfast cart arrived on the unit and at 9:24 AM the 2nd breakfast cart arrived on the unit. The following observations were made on the South Unit: - on 5/6/24 at 8:49 AM, the breakfast cart arrived on the unit. - on 5/8/2024 at 8:43 AM, the breakfast cart arrived on the unit. During an interview on 5/8/2024 at 11:46 AM licensed practical nurse #2 stated the breakfast meal trays should be delivered to the North Unit at 8:30 AM and the lunch meal trays should be delivered to the North Unit 12:15 PM-12:30 PM. The meals sometimes did not come on time as the kitchen was short staffed. The nursing units were not made aware if the meals were going to be late. During an interview on 5/8/2024 at 12:28 PM registered diet technician #13 stated 9:25 AM was late to be served breakfast as the meal was scheduled to come to the unit at 8:00 AM. Meals should be served as close as possible to the scheduled times. During an interview on 5/9/2024 at 12:46 PM registered dietitian #14 stated they worked remotely and did not come into the facility. They did not provide any oversight to the foodservice staff and meals should be served per the facility's schedule. During an interview on 5/10/2024 at 10:56 AM the Food Service Director stated the meal schedule indicated the 1st cart was to arrive to the North Unit at 8:00 AM. The kitchen had staffing issues and they were told it was ok if the North Unit was not served until 8:30 AM. They had just started at this facility a couple of months ago and had not been able to observe what time the meal carts were leaving the kitchen as they were short staffed. It was difficult to get the meals out on time if staff called in since they were already short staffed. Staff should be following the posted mealtime schedule. 10 NYCRR 415.14(f)(3)(4)

Based on observation, record review, and interview during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Specifically, the main kitchen walk-in cooler floor and door, walk-in freezer door, hood filters, the wall beside the coffee station, and the ceiling were in disrepair and there were several unclean surfaces present throughout the kitchen. Findings include: The Food Service Department policy Cleaning Policy last reviewed 1/2023 documented the nutrition and food service staff would maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. There was no documented evidence of a kitchen cleaning schedule. During an initial main kitchen tour on 5/6/2024 the following was observed: - at 6:11 AM, one filter was out of place at the right end of the hood above the flat top stove. - at 6:20 AM, the door to the walk-in freezer would not shut completely and there was notable frost inside the door. The door was broken and separated at the bottom where it hit the floor of the walk-in cooler. There was significant food debris and a small puddle of liquid on the floor on the inside of the walk-in freezer. - at 6:22 AM, the walk-in cooler floor tiles were cracked and shattered, most of the floor was covered by black rubber mats but moved freely and was loose from the broken tiles beneath the mats. There were large brown spills (mostly dried but still slightly tacky) under the back right rack. The broom and dustpan were in the middle of the cooler perched over a puddle of liquid. The door to the walk-in cooler was ajar and would not close completely. - at 6:37 AM, there was water dripping through a light fixture by the hand wash sink. There was a water leak between the tray line and the upright double door cooler coming through a light fixture. Both of those lights were not working. Both leaks were over the aisles on either end of the tray line service area. Staff walked through the puddles to get to the tray line and cook areas. During an additional tour of the kitchen on 5/7/2024 the following was observed: - at 11:37 AM, there was a hood filter at the end above the flat top that was out of place and two filters on the opposite side were broken. - at 11:39 AM, there were some loose canned goods and food debris under the shelving unit and between the equipment on the cookline. - at 11:41 AM, there were heavy coffee stains dried onto the table below the coffee machine. - at 11:43 AM, there were unfinished drywall patched areas of wall penetrations to the left of the coffee area, they were not smooth and easily cleanable. The wall behind the coffee station was soiled by brown dried on water marks that ran from the shelf to the floor. - at 11:51 AM, the walk-in cooler floor was in disrepair with numerous broken, cracked tiles, and the floor moved under foot as staff stepped across the parts that were covered by black rubber mats. The walk-in freezer floor was soiled by puddles of unknown liquid and there was food debris under the shelving. The walk-in cooler door hit the latching mechanism at the top of the door which prevented it from closing completely. The walk-in freezer door was falling apart and was unable to be closed completely. The door was split at the bottom and separated when it hit the floor of the walk-in cooler as it was opened. During an observation on 5/08/24 at 12:26 PM, there was water dripping through a light fixture by the hand wash sink. There was a water leak between the tray line and the upright double door cooler coming through a light fixture. Both of those lights were not working. Both leaks were over the aisles on either end of the tray line service area. Staff walked through the puddles to get to the tray line and cook areas. During an interview on 5/09/2024 at 4:34 PM, [NAME] Supervisor #36 stated when something was broken, or required maintenance they would verbally report that to the Food Service Director and then to the maintenance staff. They stated the walk-in cooler floor had been shattered for a couple of months which the Maintenance Director was supposed to replace. The ceiling had been leaking for at least a year and was a problem since last winter. The walk-in freezer door was scheduled to be fixed or replaced and had been broken for the last couple of months. They were not sure if there was documentation for any of the repairs that were needed in the kitchen. The kitchen was supposed to be cleaned every day, and they did not document the cleaning anywhere. During an interview on 5/10/2024 at 11:18 AM, the Food Service Director stated the walk-in cooler floor, walk-in freezer door, and ceiling leaks had been like that since they started a few months ago. They were told they were in the process for getting them fixed or replaced. They stated they had some documented emails regarding some of the repairs. They stated they were not aware of the hood filter that was out of place, or the two that were broken. It was not a safe sanitary environment with the broken equipment and leaks in the kitchen. The kitchen was supposed to be cleaned every day and that was not documented. They stated it was important for the kitchen equipment to be properly maintained and cleaned to prevent the spread of germs, cross contamination, and food borne illness. During an interview on 5/10/2024 at 5:30 PM, the Administrator stated they did not have any documentation for the repairs that were planned and needed in the kitchen. NYCRR10 415.14(h)

44838 48675 Based on observation, record review, and interview during the recertification and abbreviated (NY00312922 and NY00310431) surveys conducted 5/6/2024-5/10/2024, 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 2 of 10 residents (Residents #36 and #45) reviewed and the facility lacked a water management plan to reduce the risk of growth and spread of Legionella (a bacteria found in water systems). Specifically, staff was observed not wearing the required personal protective equipment in Resident #45's room who was on transmission-based precautions; and Resident #36 had extended-spectrum beta-lactamase (enzyme resistant to most antibiotics) in their urine with an indwelling medical device and enhanced barrier precautions were not properly maintained. Additionally, the facility did not have a water management plan that detailed their policy and procedures for reducing the risk of growth and spread of Legionella and other opportunistic pathogens. Findings include: The facility policy Enhanced Barrier Precautions reviewed 5/18/2023 documented staff was required to wear a gown and gloves while high-contact care activities were performed. Face protection might be needed if they were performing activities with a risk for splashing or spraying. Enhanced barrier precautions would be initiated for residents with any of the following: infection or colonization with a multi-drug resistant organism, indwelling medical devices including but not limited to, urinary catheters, feeding tubes, central lines, and wounds. High-contact resident activities included bathing/showering in a resident room or shared/common shower room, transfers, hygiene, dressing, changing bed linens, changing briefs, assisting with toileting, care of an indwelling medical device, and wound care. Hand hygiene was performed before and after resident contact and after removing gown and gloves within the resident's room. Initiation or discontinuation of enhanced barrier precautions did not require a physician order but would be initiated or discontinued by the infection preventionist or designee. An enhanced barrier precautions sign was placed outside the resident's room to indicate precautions were in place and personal protective equipment would be readily available near the entrance to the resident's room. The facility policy Transmission-Based Precautions revised 4/25/2024 documented transmission-based precautions was a second tier of infection control which was implemented in addition to standard precautions based upon modes of transportation (contact, droplet, airborne). Droplet precautions referred to actions designated to reduce the spread of pathogens through close respiratory or mucous membrane contact with respiratory secretions. Upon entering the room of a resident on droplet precautions, healthcare personnel and visitors would put on a face mask. Additional personal protective equipment was recommended based on anticipated risks of exposure. Hand hygiene was performed before and after resident contact and after removing personal protective equipment within the resident's room. Single resident equipment would be used if possible and shared resident equipment would be cleaned and disinfected between each resident. Transmission based precautions would be initiated or discontinued by the infection preventionist or designee. Signage was placed outside the resident's room and would provide instruction to the type of precautions implemented with guidance to healthcare personnel and visitors (hand hygiene, gown, gloves, mask, or eye protection). Personal protective equipment would be readily available near the entrance to the resident's room. 1) Resident #45 had diagnoses including pneumonia (infection in the lungs), sepsis due to methicillin susceptible staphylococcus, and end stage renal disease (kidney disease). The 4/16/2024 Minimum Data Set assessment documented the resident was cognitively intact, had intravenous access (thin tube inserted into a vein), was on intravenous antibiotics, required partial/moderate assistance with toileting hygiene, shower/bathing self, and supervision/touching assistance with personal hygiene, oral hygiene, upper body dressing, and transfers. The comprehensive care plan initiated 4/11/2024 documented Resident #45 had suspected/actual infection- pneumonia in bilateral lungs. Interventions included administer antimicrobials (medications used to treat infections) as ordered, monitor for symptoms/sepsis, applicable personal protective equipment was to be worn by staff, providers, and visitors, and maintain proper infection control precautions. The comprehensive care plan imitated on 4/11/2024 documented Resident #4 had a central line catheter. Interventions included change dressing weekly, explain purpose of intravenous therapy including infusion pump, and to monitor every shift for abnormalities. Physician orders documented: - on 4/23/2024- change central line dressing every 7 days. - on 5/1/2024- Cefazolin (antibiotic) solution 1 gram intravenously once a day for pneumonia until 5/11/2024. The orders did not include transmission-based precautions. During an observation and interview on 5/6/2024 8:53 AM, Resident #45 was seated on the edge of their bed, in their room. They stated they were admitted to the facility after being hospitalized for pneumonia and continued to get antibiotics once a day through the central line catheter on the right side of their neck. No transmission-based precaution sign or personal protective equipment was observed outside of their room. During an observation on 5/7/2024 at 9:16 AM, Resident #45's room had a green droplet precaution sign and a 3-drawer plastic container filled with gloves, gowns, eye protection, and facemasks outside of their room. The green sign had pictures of gloves, yellow gown, eye protection goggles, and a facemask. Instructions included: clean hands before entering and leaving the room, make sure eyes and mouth were fully covered before entry, remove face protection before exiting. During an observation on 5/7/2024 at 12:44 PM, a green droplet precaution sign was on the wall outside Resident #45's room. Certified nurse aide #3 entered the room carrying the resident's lunch tray. They did not perform hand hygiene, their blue facemask was below their nose, and they did not put on any additional personal protective equipment. Certified nurse aide #3 exited the room without performing hang hygiene, their mask was below their nose, and they walked to the meal cart and picked up another resident's lunch tray. During an observation on 5/7/2024 at 1:12 PM, a green droplet precaution sign was on the wall outside Resident #45's room. Licensed practical nurse #32 entered the room wearing a blue facemask and pushing a portable vital sign machine. They did not perform hand hygiene or put on any additional personal protective equipment. They obtained vital signs from Resident #45, walked over to Resident #66, and obtained vital signs without cleaning or sanitizing the machine. At 1:16 PM licensed practical nurse #32 exited Resident #45's room wearing the same blue facemask and did not perform hand hygiene. They left the vitals machine outside the door and did not disinfect it. During an observation on 5/8/2024 at 11:15 AM, a green droplet precaution sign was on the wall outside Resident #45's room. licensed practical nurse #2 entered the room wearing a blue facemask, did not perform hand hygiene, and did not put on any additional personal protective equipment. At 11:19 AM licensed practical nurse #2 exited the room wearing the same blue facemask and performed hand hygiene using the wall dispenser. During an observation on 5/9/2024 at 1:06 PM, Resident #45 did not have a droplet precaution sign or personal protective equipment outside of their room. During an interview on 5/9/2024 at 1:56 PM, certified nurse aide #3 stated they received training upon hire and yearly on infection control which included transmission-based precautions. They would know what residents were on transmission-based precautions from their morning report. There should be bins with personal protective equipment, and signs outside the resident's room telling them that what type of precautions they were on. The signs were specific and told the staff what personal protective equipment was needed to enter a resident's room. They were unsure what the difference was between enhanced barrier precautions and droplet precautions. They were unsure if they should change their facemask when they went in and out of Resident #45's room. They stated they should read the sign before they entered the room. They stated it was important to wear their mask correctly covering their nose and mouth and to wear the appropriate personal protective equipment into Resident #45's room to prevent the spread of infection. During an interview on 5/9/2024 at 2:06 PM, licensed practical nurse #2 stated they would know a resident was on transmission-based precautions by the signage on their door and they would be told in morning report. They were unsure who was responsible for placing the transmission-based precautions signage on resident's doors. They stated it was important to wear appropriate personal protective equipment into resident rooms to prevent the spread of infection. Resident #45 was not supposed to be on droplet precautions, and they were unsure who hung or removed the droplet precaution sign from Resident #45's room. They stated they received training on infection control and transmission-based precautions, but they were unsure what the difference was for contact, droplet, or enhanced barrier precautions. They would read the instructions on the signage outside the room and wear the appropriate personal protective equipment. During an interview on 5/10/2024 at 10:38 AM, regional registered nurse #1 stated the infection prevention nurse was not available and they were covering for them. There were multiple layers of staff involved in infection control so all residents should have the appropriate signage on their rooms. Annual infection control education was provided to staff and all staff were reeducated when there was any kind of outbreak within the facility. Any resident with an open wound, device, catheter, peg tube, multidrug-resistant bacteria, or intravenous catheter should be on enhanced barrier precautions. Resident #45 had a dialysis access site and an intravenous catheter, so they be on enhanced barrier precautions. They stated if staff saw a droplet precaution sign or any transmission-based precaution on a resident's door they expected staff to wear the appropriate personal protective equipment. Once the type of transmission-based precaution was verified a physician order would be put in the electronic medical record and the residents care plan would be updated. They stated all staff should stop and read the signage before entering a resident room. The signs were specific and indicated what personal protective equipment was needed to enter the room. 2) Resident #36 had diagnoses including sepsis (system wide infection) and extended-spectrum beta- lactamase resistance (a resistant enzyme found in some strains of bacteria). The 3/30/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, was dependent on staff for activities of daily living, had an indwelling catheter, and a multidrug-resistant bacteria. The comprehensive care plan initiated 10/19/2023 documented the resident was at risk for infection related to a history of urinary tract infections, urosepsis, and multidrug-resistant bacteria. Interventions included enhanced barrier precautions and applicable personal protective equipment was to be worn by staff, providers, family, and visitors. The 3/25/2024 physician orders documented contact precautions for extended-spectrum beta-lactamases in the urine. Enhanced barrier precautions every shift. During an observation on 5/6/2024 at 7:47 AM, Resident #36 had an enhanced barrier precaution sign on their door. Certified nurse aide #37 entered Resident #36's room without performing hand hygiene or putting on a gown. At 7:55 AM certified nurse aide #37 exited the room without a gown on and their facemask was below their nose, only covering their mouth. During an observation on 5/8/2024 at 12:06 PM, Resident #36 had an enhanced barrier precaution sign on their door. Certified nurse aide #37 and 2 unidentified certified nurse aides brought Resident #36 into their room for incontinence care, and they did not put on gowns. At 12:15 PM they exited the room with Resident #36, and they did not have gowns on. During an interview on 5/9/2024 at 10:43 AM, certified nurse aide #37 stated they were unsure if Resident #36 was on precautions. They stated they did not wear a gown while they provided care and it was not communicated to them that Resident #36 was on precautions. They stated they wore a facemask because they were told to, they did not have a flu shot, and sometimes the mask would fall below their nose. It was hard to breathe with the mask over their nose, but they made sure it was pulled up when they were around residents. They stated it was expected for them to always have the mask in place while on the unit and to wear gowns in precaution rooms to prevent the spread of infection. During an interview on 5/10/2024 at 10:38 AM, regional registered nurse #1 stated the infection prevention nurse was not available and they were covering for them. There were multiple layers of staff involved in infection control so all residents should have the appropriate signage on their rooms. Annual infection control education was provided to staff and all staff were reeducated when there was any kind of outbreak within the facility. Any resident with an open wound, device, catheter, peg tube, multidrug-resistant bacteria, or intravenous catheter should be on enhanced barrier precautions. They stated if staff saw a droplet precaution sign or any transmission-based precaution on a resident's door they expected staff to wear the appropriate personal protective equipment. They stated all staff should stop and read the signage before entering a resident room. The signs were specific and indicated what personal protective equipment was needed to enter the room. 3)Legionella The facility provided sample testing results for Legionella. In 2022, 14 samples were collected by the Director of Housekeeping and Laundry, with one positive result. On 9/6/2023, 14 samples were collected by the Maintenance Director and sent to the lab, but 2 samples were rejected. The chain of custody and the lab results did not identify why the two samples were rejected. One of the two samples that was not analyzed was the same location as the positive result in 2022. During an interview on 5/10/2024 at 12:18 PM, the Director of Housekeeping and Laundry stated they were not sure why all the samples sent in 2023 were not analyzed by the lab and they were told by the Maintenance Director that all the samples came back good. During an interview on 5/10/2024 at 12:18 PM, the Administrator stated the Maintenance Director was not available for interview during survey. They stated they did not find documentation for their water management plan and was unable to provide any documentation to show why not all the samples were analyzed in 2023. They stated they were unaware that one of the rejected samples was the same location as the positive sample in 2022. It would have been an important site to retest. The Administrator stated it was important that the facility maintained a proper water management plan for the health and safety of the residents and staff to prevent the spread of Legionella. 10NYCRR 415.19(a)(2)

Based on record review and interview during the abbreviated survey (NY00310562 and NY00321915), the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 3 of 4 residents (Residents #7, 9 and 10) reviewed. Specifically, , Resident #7 was admitted to the facility with a subdural hematoma (brain bleed) and there was no documentation a plan was implemented to monitor the resident for signs and s ymptoms of worsening subdural hematoma. Subsequently, Resident #7 exhibited a change in condition, was not assessed by a qualified professional, and was found unresponsive 12 hours later. The resident was sent to the hospital, diagnosed with an acute (sudden onset) left sided subdural hematoma that was larger in size, and the resident expired the next day. Resident #9 was admitted to the facility with a surgical wound (incision site) to the spine and no treatments were ordered for 2 days. Recommended follow-up with the surgeon did not occur and the resident required a surgical procedure to remove the infection that developed along with intravenous antibiotics (antibiotics given directly into the vein). Resident #10 was admitted to the facility with a right side below-the-knee amputation and no treatments were ordered for 3 days. The resident required hospitalization for the infection and debridement (surgical removal of dead tissue) of the wound. This resulted in actual harm to Residents #7 and 10 and no actual harm with potential for more than minimal harm that was not Immediate Jeopardy to Resident #9. Findings include: The ,d+[DATE] Change in Resident's Condition Policy documented the facility would promptly notify the resident, attending physician, and representative of changes in the resident's condition or status. Prior to notifying the physician, the nurse would make detailed observations and gather relevant information. Unless otherwise instructed by the resident, a nurse would notify the resident's representative when there was a significant change in the resident's status. When a consultant was needed, the consultant would perform the requested evaluation and provide a consultant's note. The attending physician would consider the recommendations relative to the resident/patient's current condition. 1) Resident #7 was admitted to the facility with diagnoses including traumatic subdural hematoma (brain bleed) with loss of consciousness and history of falls. The [DATE] Minimum Data Set assessment documented the resident's cognition was moderately impaired, they had clear speech, could express ideas and wants, and understood others. It was very important to the resident to have family or close friends involved in discussions about their care. The [DATE] comprehensive care plan documented the resident required assistance with activities of daily living related to limited mobility and a history of falls with a subdural hematoma. Interventions included extensive assistance with bed mobility and transfers. There was no documentation of signs and symptoms staff should monitor for related to the subdural hematoma as noted in the hospital discharge summary, no documentation of the follow up needed with neurosurgery, and no documentation when the medical provider should be notified of changes. The [DATE] hospital discharge summary documented the resident was hospitalized with a subdural hematoma after a fall at home. No surgical interventions were recommended, and the resident was to follow-up with neurosurgery in 2 weeks for a repeat computerized tomography (specialized x-ray). The summary also documented to notify the medical provider for nausea and vomiting, difficulty breathing, headache or visual disturbance, extreme fatigue, and weakness. The [DATE] registered nurse Manager #18's Admission Evaluation documented the resident was admitted to the facility for short term rehabilitation, their cognition was intact, range of motion was within normal limits in arms and legs, hand grasps were equal, and they could bear weight fully. The [DATE] physician's assistant #12's progress note documented prior to admission, the resident was walking in their home from the bathroom when they became dizzy and fell . A neighbor found them approximately ,d+[DATE] hours later, they were taken to the hospital, and were diagnosed with a subdural hematoma that was stable. Staff were to monitor the resident and alert medical of any changes . The [DATE] 9:41 AM, licensed practical nurse #19's progress note (entered on [DATE] at 7:48 AM) documented therapy staff alerted them there was something wrong with resident. The resident appeared disoriented, and their words were sluggish. They could not answer questions and were talking out of the left side of their mouth. They had trouble holding up their right arm and could not stick out their tongue when asked. Licensed practical nurse #19 went to get the Nurse Manager (unidentified) out of morning report to assess the resident . There was no documented evidence the resident was assessed and no documented evidence the medical provider or the resident's family were notified of the residents change in condition. The [DATE] at 9:55 PM, registered nurse Manager #18's progress note documented they were called to the resident's room because they were unresponsive. The resident was unresponsive to verbal or tactile (touch) stimulation and unresponsive to numerous sternal rubs (painful stimulus using knuckles on the center of the rib cage to elicit response). The resident also had hemorrhaging (bleeding) from their nose. The on-call medical provider was notified and ordered to send the resident to the hospital. The resident's family was notified, and the resident left facility at 9:55 PM via ambulance. On [DATE] at 10:36 PM hospital physician #35 documented the resident presented with altered mental status, a right sided nosebleed, and was ill appearing. The resident was unable to answer questions and was intermittently grunting with painful stimulation. A stroke code (rapid response to patient with symptoms of a stroke) was called and the resident was taken for a computed tomography scan. Neurology was immediately consulted and evaluated the resident. Their condition was critical. The [DATE] hospital admission physician #36's progress note documented, per the nursing facility at around 7:30 AM, the resident was found to have slurred speech which was present the whole day. At around 7:15 PM, when a certified nurse aide went into the resident's room, they were unresponsive and only able to lift their left arm to painful stimulation. The resident also had a nosebleed and dried blood over their chest. A computed tomography scan showed a subdural hematoma with midline shift (displacement of brain tissue across the center line from increased pressure) and obstructive hydrocephalus (blockage of cerebral spinal fluid in brain causing pressure that can damage brain function). The [DATE] 11:40 PM, hospital neurologist #37's progress note documented the resident required surgical intervention for the brain bleed, but the resident's family wished comfort measures (interventions that aide in the dying process) only. The hospital record documented the resident expired on [DATE] at 8:10 AM . During a telephone interview on [DATE] at 8:45 AM, the complainant stated the resident was alert and oriented and able to clearly communicate when they were home and at the facility. On [DATE] at 9:15 PM, they received a call saying the resident was being sent to the hospital and the resident expired the next day. They learned from the autopsy report that the resident was having symptoms of the brain bleed earlier that day. Nobody at the facility notified them when the resident's symptoms first started, only when they were sent to the hospital. If they had known the resident was having symptoms earlier that day, they would have insisted on sending them to the hospital. The autopsy report showed the resident died from a brain bleed. During a telephone interview on [DATE] at 10:09 AM, certified nurse aide #22 stated the resident was alert and oriented and could clearly communicate their needs. On [DATE], they worked the day and evening shifts and when they came in that morning, the resident was still in bed and that was not their normal. The resident was usually up in their wheelchair moving about the unit when the day shift started. That morning, they observed the resident confused and they did not know what day it was or where they were. They recalled going into the resident's room later, did not recall what time, and the resident had a nosebleed and was not responsive. The resident's eyes were rolled back in their head, and they went to get licensed practical nurse #19 who evaluated the resident. They thought the resident was sent to the hospital at some point and did not recall if a registered nurse assessed the resident. During a telephone interview on [DATE] at 2:45 PM, licensed practical nurse #19 stated at around 9 AM on [DATE], occupational therapist #20 told them the resident was not acting like themself. They saw the resident and they seemed sluggish. When they asked the resident their name and where they were, the resident did not answer appropriately. This behavior was a change in condition from the previous day. Licensed practical nurse #19 stated they immediately went and interrupted the nursing meeting and believed registered nurse Manager #18 did an assessment. They asked registered nurse Manager #18 if they were sending the resident to the hospital and registered nurse Manager #18 stated they were not. They did not recall the reason for not sending the resident to the hospital that morning and stated registered nurse Manager #18 instructed them to let the resident rest. They were not sure if the resident's condition was reported to a medical provider. Licensed practical nurse #19 stated they monitored the resident the rest of the shift and occupational therapist #20 was also in and out of the resident's room. Licensed practical nurse #19 reported to the oncoming shift (did not recall who) the resident's symptoms and that registered nurse Manager #18 was aware. There was no documented evidence of monitoring of the resident as stated by licensed practical nurse #19. During a telephone interview on [DATE] at 9:42 AM, former registered nurse Manager #18 stated when a resident had an acute issue, they expected an assessment to be done, the medical provider notified, and a note documented in the chart. On [DATE], they did not recall the resident's change in condition, and they probably did an assessment if licensed practical nurse #19 asked them to. They were not sure if they notified a medical provider of the resident's condition, was not sure why they did not document a progress note and was not sure why the resident was not sent to the hospital. They did not recall if they provided instruction to staff to monitor the resident. They did not recall if they saw the resident over the remaining 12 hours of the shift until staff reported the resident was unresponsive and they sent them to the hospital. They were not aware the resident had no care planned interventions for monitoring their subdural hematoma and stated they should have. They stated the resident's family should have been notified timelier of the resident's condition. During a telephone interview on [DATE] at 9:19 AM, occupational therapist #20 stated they did not work with the resident a lot as they were per diem (as needed) staff however on [DATE], the resident was acting differently than previously. On [DATE] in the morning, they went to see the resident in their room and they were not acting like themself. They had slurred speech, was unable to follow commands, and they notified licensed practical nurse #19 of the change in Resident #7's condition. Occupational therapist #20 reported the change in condition to their department and to registered nurse Manager #18. They kept an eye on the resident during the day and went to licensed practical nurse #19 multiple times because they were concerned about the resident's condition. They stated licensed practical nurse #19 assured them that everyone knew and they were working on it, which occupational therapist #20 took to mean the resident was being sent to the hospital. Occupational therapist #20 was not aware the resident was not sent to the hospital during the day shift. During a telephone interview on [DATE] at 12:46 PM, physician's assistant #12 stated if a resident was admitted to the facility with a brain bleed, they expected staff to monitor for neurological signs and symptoms such as a change in mental status, headaches and seizures and if the hospital made recommendations for signs and symptoms to monitor for, then they would hope the facility would have implemented a plan of care using those recommendations. They were not aware the facility did not implement a plan of care for monitoring the resident for signs and symptoms of the brain bleed. On [DATE], they were on call from 7 AM to 7 PM and they did not recall being notified of the resident's symptoms. If they had been notified, they would have immediately sent the resident to the hospital. The [DATE] Wound Identification and Wound Rounds Policy documented the facility would identify, assess, and manage residents with pressure injuries/skin impairment in accordance with current standards of practice. New admissions would have a complete body check on admission. Upon discovery of skin impairment, the registered nurse would complete a skin assessment, including size, depth, stage, and appearance of the skin impairment. The licensed nurse would notify the attending physician and obtain a treatment order. The registered nurse/interdisciplinary team developed the care plan. The wound nurse/designee and wound care provider were notified of pressure ulcer or skin impairment and the resident was scheduled for weekly wound rounds. The ,d+[DATE] Physician Consultations Policy documented the attending physician would indicate the appropriate time frame within which the specialist physician should see the resident and would include that in the order. 2) Resident #10 had diagnoses including amputation of right lower leg, osteomyelitis (bone infection) of the right leg and end stage kidney disease. The [DATE] Minimum Data Set assessment documented the resident's cognition was intact, they required maximum assistance rolling in bed and were dependent on staff for transfers. The resident had a surgical wound and received intravenous antibiotics. The [DATE] comprehensive care plan documented the resident osteomyelitis, a surgical wound and needed assistance with activities of daily living. Interventions included activity of daily living assistance, documentation of the location, drainage and measurements of the wound weekly, and treatments per order. The [DATE] hospital discharge summary documented the resident had osteomyelitis of the right leg and an amputation on [DATE]. The discharge summary did not document a dressing change or treatment recommended to the right lower leg amputation site (surgical site), did not document the resident had sutures (staples) to the surgical site, and recommended a follow-up with the primary care physician in 1 week. The [DATE] registered nurse #30's admission assessment documented the resident was admitted for rehabilitation and intravenous antibiotics. The resident had a surgical incision wound on the right knee that measured 18 centimeters x 1.6 centimeters x 0 centimeters with 20 sutures present to that incision. The [DATE] physician's assistant #12's admission orders did not include a treatment order for the resident's right below knee incision site. Attending physician #34's orders documented on [DATE], to the right knee, cleanse surgical wound with normal saline, cover with a bordered gauze dressing one time and on [DATE], to the right knee, cleanse surgical wound with normal saline, cover with a bordered gauze dressing every day-shift and consult with the wound provider. There was no documented evidence of a physician's order to follow up with vascular surgery. The [DATE] physician's assistant #12 progress note documented nursing reported concerns of possible wound dehiscence (opening of surgical incision) for the resident's right below-the-knee amputation. Multiple staples and sutures were present however there was an area that was about 2 centimeters x 3 centimeters of yellow stringy material and foul odor. The resident was on intravenous antibiotics and nursing was instructed to contact the resident's vascular surgeon as soon as possible to determine if they could see the resident that week or to see if the surgeon wanted them sent to the hospital. There was no documented evidence the resident's vascular surgeon was contacted. The [DATE] Infectious Disease nurse practitioner #35's consult note documented the resident had stump skin changes and staff were to call vascular surgery for follow-up. Intravenous antibiotics were to be extended until [DATE] and follow-up in 1 week. The [DATE] physician's assistant #12's order documented to the right knee, cleanse surgical wound with normal saline, apply a petroleum dressing over wound, cover with an abdominal pad and wrap with gauze wrap daily. The [DATE] Infectious Disease nurse practitioner #35's consult note documented the resident needed to follow- up with vascular surgery for the right below knee amputation stump site. There was no documented evidence the resident had follow up with vascular surgery. The [DATE] Infectious Disease nurse practitioner #35's consult note documented the resident's right below knee amputation stump was worse despite being on antibiotics. The outer and midline of the incision were dehisced with dead tissue and foul-smelling drainage. The resident was not receiving adequate wound care and despite repeated requests, the nursing facility had not followed up with the vascular surgeon. The resident was transported to the hospital for urgent surgical evaluation. The [DATE] hospital record documented the resident presented for evaluation of the right below knee amputation with concerns for infection. The resident had surgery in ,d+[DATE] and had not seen their vascular surgeon since. There were still staples intact to the site and evidence of non-recent wound dehiscence at the inner and outer margins of the wound. The smaller inner area had some fibrinous drainage (thick, yellowish fluid that forms from tissue injury or inflammation), and the larger outer area had fibrous drainage and a central area of eschar. The resident was evaluated by vascular who debrided the wound. During a telephone interview on [DATE] at 12:43 PM, registered nurse Manager #33 stated if the attending physician wanted a resident seen by an outside consultant, then registered nurse Manager #33 would enter the order in the record. Transport Coordinator #38 would make the appointment and they were not sure how Transport Coordinator #38 was notified to do so. When an outside consultant made a recommendation, the resident came back with a note documenting the recommendations. The facility's medical provider reviewed the consult note and decided whether they agreed with recommendations. If they agreed, they let nursing know to enter the orders. When physician's assistant #12 recommended to call the vascular surgeon on [DATE], they did not believe they were notified. When the resident returned from the Infectious Disease appointment on [DATE] with Infectious Disease appointment on [DATE] with recommendations to follow-up with vascular surgery, they believed an order was entered. They were not aware there was not an order entered and not aware the resident was not seen by vascular surgery. The resident was currently at the hospital after being sent there directly from the Infectious Disease appointment on [DATE]. During a telephone interview on [DATE] at 3:27 PM, licensed practical nurse #5 stated if the facility medical provider wanted a resident to see an outside consultant, the medical provider would write an order in the communication book and notify registered nurse Manager #33 to schedule the appointment. On [DATE], they left a note in the communication book for physician's assistant #12 about the resident's stump. They saw the stump that morning and it looked like the staples were attached to the scab and not the skin and it had some areas of slough (dead tissue). Physician's assistant #12 might have mentioned to them they wanted the vascular surgeon called however registered nurse Manager #33 was responsible and physician's assistant #12 would have communicated that to registered nurse Manager #33. They saw the resident's right below knee amputation incision the day prior to their Infectious Disease consult on [DATE] and the staples were embedded in eschar, and it looked like the wound was not healing. During a telephone interview on [DATE] at 2:20 PM, registered nurse #30 stated on admission, if a resident had a surgical wound with no treatments ordered they would notify the medical provider to obtain an order. When they did the resident's skin assessment on [DATE], they believed all of the admission orders were already in place and they were asked to only complete the skin assessment. The resident should have had a treatment ordered on admission and they were not sure why they did not. During a telephone interview on [DATE] at 12:46 PM, physician's assistant #12 stated on [DATE], they instructed registered nurse Manager #33 or possibly a Corporate staff who was assisting with managing the unit to call vascular surgery. They recalled being told the resident had an appointment the next day and they thought it was with the vascular surgeon. The resident had slight wound dehiscence with an increased risk of infection, even though they were on antibiotics. They thought the surgeon needed to assess the resident. They reviewed nurse practitioner #35's consults on [DATE] and [DATE] and stated they did not initial the consult notes which they did when they reviewed notes and did not recall being aware of the recommendations to follow-up with vascular surgery. They stated if they were aware of the recommendation, they would have written an order. They were not aware the resident never followed up with vascular and the vascular consult was not obtained. 3) Resident #9 had diagnoses including a fractured neck, quadriplegia (inability to move the limbs) and orthopedic after care. The [DATE] Minimum Data Set assessment documented the resident's cognition was moderately impaired, they were dependent on staff for activities of daily living and received surgical wound care. The [DATE] comprehensive care plan documented the resident was at risk for alteration in physical function related to cervical fracture. Interventions included to follow-up with the orthopedic surgeon as ordered and incision wound care to prevent infection and promote healing. The [DATE] hospital discharge summary documented the resident was driving a scooter without a helmet when they fell and sustained profound trauma of the cervical spinal cord (area of the spine in neck) and had spinal surgery that permanently joined the spine together. Recommendations included follow-up with the surgeon in 1 week for repeat imaging and for wound re-check. The [DATE] at 12:30 PM, Corporate Director of Nursing #16's Admission Evaluation documented the resident was admitted to the facility with a fractured neck with neurologic injury (an injury to the brain, spine, or nerves) and instability. The resident had a posterior (back) neck incision with 22 visible sutures (stitches), the site measured 14 centimeters x 0.5 centimeters and a clean dry dressing was in place. The [DATE] attending physician #34's admission order documented weekly skin evaluations on Monday and Thursday done by a licensed nurse. There was no documentation of a treatment for the resident's surgical incision or to follow-up with the surgeon in 1 week. The comprehensive care plan, updated [DATE], documented the resident had impaired skin integrity related to a spinal incision. Interventions included to document the location/amount of drainage weekly and monitor and report signs and symptoms of infection (green drainage, foul odor, redness and swelling). The [DATE] physician assistant #12's progress note documented the resident was a new admission who sustained profound trauma of the neck and was status post spinal fusion surgery. The resident was lying flat in bed, skin was warm and dry, and a full skin check was not performed. The resident needed to follow-up as an outpatient with the surgeon per the hospital discharge summary. The [DATE] physician assistant #12's order documented to the surgical spine incision, cover with dry non-stick dressing, and monitor for signs/symptoms of infection every evening. There was no documented evidence of a treatment being done on [DATE]. The [DATE] Treatment Administration Record documented the resident's surgical spine dressing was changed (2 days after admission). There was no documented evidence the 1 week follow up with the surgeon was ordered or occurred . The [DATE] and [DATE] Assistant Director of Nursing #10's weekly wound assessments documented the resident's spinal incision was measured, sutures were in place, and surgical follow-up was needed. The [DATE] physician's assistant #12's progress note documented they were notified to evaluate the resident via a note left in the communication book. The resident was seen with a rash and blisters on their back. There was greenish-brown drainage on the resident's pillow and sheets, the surgical dressing was soaked through, and the smell was concerning for surgical site infection. The resident was sent to the hospital. The [DATE], emergency room physician #32's progress note documented the resident presented to the emergency room for evaluation of neck drainage and there was copious (large) amounts of skin irritation including redness and skin breakdown likely from buildup of purulent (pus) fluid. Mild pus was expressed from the wound and they were having increased pain from the site. emergency room physician #32 documented they found it very unlikely the copious amounts of drainage started that day given the extensive skin breakdown on the resident's back. The [DATE] color photograph attached to the report and noted as taken in the emergency room showed the resident turned to their right side; a large area of bright red skin was noted extending from the upper to mid back, the chux pad (large washable absorbent pad) the resident was rolled from in the picture had a large amount of yellow green drainage that nearly covered the pad. The [DATE], hospital surgeon #14's progress note documented the resident reported they were doing well at the nursing facility until ,d+[DATE] days ago when they developed drainage from their incision that had increased since then. The drainage was serous (clear liquid mixed with blood) but was now green and purulent. The surgical incision had moderate redness and induration (abnormal skin hardening that could be due to infection) around the incision with a small area of breakdown of the incision at the level of the posterior neck crease. Serous fluid with purulent debris was able to be expressed. The plan included surgical debridement (removal of dead tissue) of the surgical site in the operating room. Cultures grew bacteria and the resident was given intravenous (through the vein) antibiotics and they were recommended for 6 weeks. During a telephone interview on [DATE] at 2:41 PM, licensed practical nurse #17 stated when they did a dressing change, they looked for inflammation, redness, drainage, and was supposed to write a note when something abnormal was found. They would also notify the medical provider if they found something abnormal. They stated they could not recall back to ,d+[DATE] or the condition of the resident's incision and did not recall if they were the one that left a note regarding the incision in the physician communication book. During a telephone interview on [DATE] at 8:55 AM, emergency room physician #32 stated they evaluated the resident on [DATE]. The resident had a cervical spinal incision with sutures in place and they were covered from the suture line all the way to their hip in a cloudy thick greenish drainage. The bedding under the resident was soaked in greenish drainage. The resident had skin breakdown that suggested they had been sitting in the soaked bedding for a while and there was no way someone could get that amount of drainage over the course of a shift. The resident was taken to the operating room where they re-opened the cervical incision and flushed out the site with a goal to get infected material out of the site. They stated they had never seen sutures intact in a cervical spine incision for over a month. During a telephone interview on [DATE] at 12:14 PM, former corporate Director of Nursing #16 stated when they did an admission assessment and a resident had no recommendations for a treatment for their surgical wound, they would notify the medical provider and obtain an order. If the hospital discharge summary documented follow up appointments were needed, they would obtain orders from the medical provider and schedule the appointment. On [DATE], they did the resident's admission assessment and assumed another nurse obtains orders for a treatment and the treatment order was not obtained timely. If an order was not found for a follow up appointment with the resident's surgeon, they were not sure what happened, not sure why it was not ordered and it was not done timely. They stated sutures typically were removed after 14 days though the resident's surgeon would have made that determination. On [DATE] and [DATE], surgeon #14 was not reached in an interview. During a telephone interview on [DATE] at 12:46 PM, physician's assistant #12 stated they evaluated the resident on [DATE] for a rash they observed on the right upper arm and thought it was from yeast. As they were getting ready to write notes, they noticed some discoloration on the resident's pillowcase near their head and shoulders and it was wet. When the resident sat up so they could assess, they observed their dressing and pillowcase was soaked with drainage and it smelled so bad. They did not remove the dressing because they did not have gloves on and they had not assessed the resident's surgical site since they were admitted . They did not observe the skin on the resident's back so was not sure if there was any skin breakdown. They immediately sent the resident to the hospital. If the resident's dressing was changed the prior evening, it did not seem likely they would have that much drainage over that course of time. They stated they were upset when they assessed the resident that day and it was not every day you saw something like that. 10 NYCRR 415.12

Based on interview and record review during the abbreviated survey (NY 354), the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individuals' condition demonstrates that they were unavaoidable and failed to ensure a resident with pressure ulcers receives the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 1 of 2 residents (Resident #8) reviewed. Specifically, Resident #8: - was admitted with an unstageable pressure ulcer on the dorsum (top) of left foot and a deep tissue injury (DTI) on the left heel and treatments were not ordered until 3 days after admission. - The resident developed a pressure ulcer on the ball of the left foot that was not assessed or treated timely. - Treatment orders recommended by the wound consultant were not implemented timely on 3 occasions. - The orthopedic surgery consult recommended for evaluation of a CAM (controlled ankle motion) boot (used to limit foot and ankle movement after a fracture) was not arranged timely by the facility and the resident developed additional pressure ulcers as a result of the CAM boot. This resulted in actual harm to Resident #8 of 3 unstageable pressure ulcers that was not Immediate Jeopardy. Findings include: The 4/2019 Wound Ulcer policy documented: - Licensed staff would perform a head-to-toe assessment admission and document findings. - Wounds were to be measured weekly by licensed staff. - At the time a skin issue is discovered, it must be measured. - Wound care was to be consulted when appropriate. - Treatments were determined based on tissue type and drainage; all orders must be approved by a physician within 24 hours of discovering the open area or change in treatment. Resident #8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 11/4/21 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance for most activities of daily living (ADL), and had an unstageable pressure ulcer on admission. Interventions included pressure reducing devices for the chair and bed and pressure ulcer care. The 10/28/21 Hospital Discharge Summary documented: - the resident had a left leg boot to treat lower leg fractures. - On 10/22/21, it was noted in the hospital the resident had multiple pressure ulcers as a result of the boot. - Discharge medications included Santyl (to remove dead tissue) and to follow directions on the change dressing nursing order. - An orthopedic surgery follow-up was recommended in 2 weeks and the facility was to schedule. The 10/28/21 Director of Nursing's (DON) admission progress note documented: - Left heel deep tissue injury (DTI), measuring 4 by 4 and not open. - Dorsum (top) of the left foot, wound measured 4 by 1. There was no staging or depth documented. - Multiple pressure injuries/ulcers were documented on the resident's discharge paperwork. - The resident's Braden score (measures risk for developing pressure ulcers) was 13, meaning they were at moderate risk for developing pressure ulcers. There were no physician's orders for treatments for the skin impairments documented in the admission assessment. The 10/31/21 (3 days after admission) physician's order documented: - cleanse the wound (no location identified) with normal saline, may apply Sureprep (skin protectant) rapid dry to peri wound and allow to dry; apply Santyl and calcium alginate AG (highly absorbent and antimicrobial dressing), cover with border dressing; change daily and as needed. - Apply skin prep to the left heel (DTI) twice a day. - T-scope brace (knee immobilizer) to the left leg at all times and check each shift for skin integrity. - Short CAM (controlled ankle movement) boot to left foot at all times and check each shift for skin integrity. There was no documentation for the orthopedic surgery consult in 2 weeks as recommended in the hospital Discharge Summary. The 10/31/21 comprehensive care plan (CCP) documented the resident had impaired skin integrity related to an ulceration on the left leg. Interventions included treatments per order; document the location, drainage, peri-wound area, pain, [CONDITION(S)], and measurements of wounds. Document progress in wound healing on an ongoing basis; monitor/document/report any signs and symptoms of infection to the physician as needed and refer to the appropriate medical. The resident also had a fracture and a brace or immobilizer was to be applied as ordered. The 11/3/21 Wound Consult by Wound Advanced Practice Nurse (APN) #56 documented: - dorsum (top) of the left foot, full thickness ulcer, which was unstageable, measuring 3.8 centimeters (cm) by 2.1 cm x 0 cm. The wound base was 100% slough (moist, dead tissue) with non-odorous serous (thin, clear) drainage. The wound edges were adherent to the wound base. - The treatment recommended was to cleanse the site with normal saline, apply [MEDICATION(S)] gel (used to treat open wounds and prevent infection) to wound base daily and as needed. If present, gently pack any cavity or undermining with normal saline moistened gauze. Apply skin protectant to the periwound prior to applying secondary dressing. Cover with gauze or bordered dressing. - Off-load pressure to affected areas and continue repositioning in accordance to assessed needs. - There was no documentation APN #56 assessed the DTI on the resident's left heel. The 11/3/21 Wound Documentation progress note by the DON documented the wounds assessed by APN #56 and the recommended treatment. The 11/5/21 physician's order documented cleanse the left dorsal foot with normal saline, apply [MEDICATION(S)] gel-nickel thickness to the wound base, apply skin prep to periwound and cover with bordered dressing; complete daily and as needed. The physician order was dated 2 days after the recommendation by APN #56. The skin prep to the resident's left heel DTI continued. The 11/11/21 licensed practical nurse (LPN) #29's progress note documented the resident had a deep dark purple area on the ball on their left foot and the left toe had a reddened area. There was no documentation this area was assessed by a registered nurse (RN) or that medical was notified. During an interview on 3/29/22 at 7:26 AM, LPN #29 stated they worked with the resident one time and when they went to do the resident's treatment, they opened the resident's boot and what they saw was different than the ordered treatment. LPN #29 stated it was bad and they notified an agency Supervisor and another staff member but could not identify them. LPN #29 could not recall what treatment was ordered at that time and they thought the ball of the resident's foot was black and blue. LPN #29 stated the Supervisors were not concerned, so the LPN documented what they saw in a progress note. LPN #29 stated they did not receive instructions on how to remove the CAM boot, but they had worked with them in the past. They did not think they removed the CAM boot all the way; they opened it to do the treatment and closed it afterwards. The 11/17/21 Wound Consult by APN #56 documented: - left dorsal (top) foot, full thickness ulceration that was unstageable, measuring 3.0 cm by 2.1 cm by 0 cm. The wound base was 100% slough with scant non-odorous serous drainage. Wound edges were adherent to the wound base. - The treatment recommended was Santyl to wound base daily and as needed. If present, gently pack any cavity or undermining with normal saline moistened gauze. Apply skin protectant to the periwound prior to applying secondary dressing, cover with gauze or bordered dressing. - Offload pressure to affected area and continue repositioning in accordance to assessed needs. - There was no documentation related to the left heel DTI or the deep purple area on the ball of the left foot that was noted by LPN #29 on 11/11/21. The 11/17/21 Wound Documentation progress note by the DON documented the wounds assessed by APN #56 and the recommended treatment. The 11/19/21 Weekly Wound Assessment by Registered Nurse (RN) #64 documented additional padding was added to the resident's leg brace. There were no orders for additional padding or updates to the CCP related to padding the leg brace. The 11/19/21 physician's order (2 days after recommended by APN #56) documented to cleanse area (location of wound not specified) with normal saline, apply skin prep to surrounding area, apply nickel-thick layer of Santyl to wound bed, and cover with [MEDICATION(S)] daily and as needed for pressure ulcer. The skin prep to the left heel DTI continued. The 11/24/21 Wound Consult by Wound APN #56 documented: - left dorsal (top) foot, full thickness ulceration that was unstageable, measuring 3.0 cm x 2.1 cm by 0 cm. The wound base had 100% slough with scant non-odorous serious drainage. APN #56 recommended the Santyl treatment to continue. - Left plantar (ball of the foot), deep red tissue/purplish discoloration measuring 3.5 cm by 5 cm with the epithelium intact and slight surface induration noted. - Left heel, deep red tissue/purplish discoloration measuring 5.5 cm by 5 cm. The epithelium was intact. - Left plantar foot and heel, unstageable pressure ulcer of the left foot and heel due to deep tissue injury. The treatment was to cleanse the affected areas with normal saline or wound cleanser, apply skin prep to affected area each shift and as needed. The staff were to monitor site for signs and symptoms of infection, bogginess, drainage or [CONDITION(S)]. - APN #56 documented to evaluate current orthopedic boot as it appeared to be the source of the pressure. The 11/24/21 Wound Documentation progress note by the DON documented the wounds assessed by APN #56 and the recommended treatments. There was no documentation of an orthopedic appointment being made for the resident. The 11/26/21 physician's order documented to cleanse the left outer ankle with wound cleanser or normal saline, apply alginate to wound bed (cut to size), cover with [MEDICATION(S)] daily and as needed. The 11/19/21 physician order to cleanse area and apply Santyl remained active. Skin prep to the left heel continued. There was no prior documentation regarding the area on the left outer ankle noted in the 11/26/21 physician's orders. The 11/30/21 (former) Assistant Director of Nursing (ADON) #55's progress note documented a team meeting was held and the resident was at high risk for developing skin issues. Interventions included requesting in house medical provider to assess, placing pillow boots on bilateral feet, placing the resident on a pressure reducing mattress, full head to toe skin assessment, therapy evaluation for a new/alternate brace, moisturize dry skin areas, and Doppler studies of the bilateral lower extremities to rule out PVD ([CONDITION(S)], poor circulation). There was no documentation physical therapy (PT) was contacted to evaluate the leg brace after the 11/30/21 meeting. During an interview on 3/30/22 at 10:37 AM, former ADON #55 stated: - the bedside nurse was responsible for removing CAM boots and braces as per the physician's orders and if they saw a new skin alteration, they should report up the chain of command and a RN should evaluate. If no RN was available, the resident should be assessed the next time a RN was working. - The resident had a knee immobilizer and a CAM boot and was seen by Wound APN #56 and should have been seen weekly. - The resident had a pressure ulcer on their heel, maybe on their toe, and on the top of the foot where the boot crossed over. The pressure ulcers occurred on the foot with the boot, and they were strange. The resident's pressure ulcers seemed worse than a boot issue, which prompted the Doppler study to rule out a vascular aspect. - The facility utilized paper orders, which occasionally caused a delay in order entry after the APN recommended a treatment. The 12/3/21 and 12/8/21 Wound Consult by APN #56 documented: - the resident had three unstageable ulcerations of the left foot on the dorsal (top), plantar, and heel. - It was recommended to evaluate the current orthopedic boot as it appeared to be the source of pressure. The 12/3/21 Ultrasonography report documented a bilateral lower extremity venous duplex color Doppler was performed. The left leg was somewhat difficult technically due to fracture with a cast, but the major veins were visualized. No thrombus (clot) was seen and there was good flow and augmentation. The 12/5/21 attending physician's progress note documented the resident had ongoing wound care to the ulcer of the left lateral foot. The venous Doppler showed good blood flow and good venous augmentation. The wound of left lower extremity was stable without signs of infection and with appropriate orders in place as well as appropriate wound care follow-up scheduled. The 12/8/21 RN Unit Manager #1's progress note documented a left dorsal (top of foot) pressure ulcer with treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 4/15/22 at 10:34 AM, RN Unit Manager #1 stated they had been assisting with pressure ulcer treatments when they wrote the progress note on 12/8/21. They were not working at the facility when the resident was admitted . They stated outpatient consults were scheduled by the Unit Managers. They could not recall the resident or who was responsible for taking off the resident's brace or CAM boot. The 12/8/21 physician's order documented the resident had an orthopedic appointment on 12/14/21 (over 6 weeks after admission). The 12/14/21 Orthopedic Consult documented the resident's left foot revealed multiple dressings on the resident's heel, lateral malleolus (ankle), and dorsum (top) of the foot from their previous partial-thickness sores that were pre-existing to the hospitalization . With regards to the foot, wound care team needs to continue aggressive treatment to the foot; it was outside the physician's expertise, and it was a chronic problem. During an interview on 3/31/22 at 10:07 AM, a receptionist at the orthopedic office stated the resident was seen on 12/14/21. The facility called for an appointment on 12/8/21 at 1:14 PM; there was no other record the facility called regarding the CAM boot or for an earlier appointment. The resident left the facility Against Medical Advice (AMA) on 12/14/21. During an interview on 4/15/22 at 11:06 AM, physical therapist (PT) #63 stated the resident had a boot and immobilizer and they deferred to the orthopedic physicians for those orders. The CAM boot was to be worn with transfers and was not to be worn in bed; the PT stated they would don (apply) the CAM boot when providing therapy and would remove the boot at the end of the session when the resident was in bed. The resident was admitted with pressure ulcers on their lower legs. PT #63 reported that they asked the Unit Manager about follow up with Orthopedics at least once; they could not recall who the Unit Manager was at the time. They stated they thought the resident saw Orthopedics once during their stay and then left the facility shortly thereafter. The PT stated they had not been asked about recommendations for the boot due to the resident's pressure ulcers on the lower leg. During an interview on 3/29/22 at 1:00 PM, LPN #34 stated LPNs were responsible to check skin under braces or boots as a part of the skin check. Certified nurse aides (CNA) would also report any skin alterations they saw. They could vaguely remember the brace and CAM boot. During an interview on 3/29/22 at 3:04 PM, LPN #24 stated if the resident had a treatment ordered, the LPNs were responsible to remove braces and CAM boots. For the resident's CAM brace, the LPNs were responsible to remove it and check the skin underneath for any open areas and pad as needed. If the resident needed padding, it would be documented on the Treatment Administration Record (TAR). The orders on the TAR should be specific as to treatment location; if the area needed clarification, the LPNs should ask the Supervisor where the treatment needed to go before going any further and for the order to be reentered. It was important for the location to be specific on the orders so the LPN could easily locate the pressure ulcer to provide the correct treatment. When completing skin checks, the LPNs only documented a progress note if a new area was identified; if there was no progress note at the time of the skin check, then no new areas were identified. During an interview on 3/31/22 at 9:23 AM, Wound APN #56 stated: - residents were seen weekly once they were on their list. - They communicated order recommendations verbally and sent them to the facility at the end of the day. - They expected recommended orders to be entered the same day or the next morning. - If orders were not implemented timely, it affected care because when they saw the resident the following week, they would not know the resident missed 2 days of the recommended treatment making it difficult to assess whether the recommendations were effective. - The resident's wounds were caused by the CAM boot and they recommended the facility consult Orthopedics to evaluate the boot as it seemed to be the cause of the pressure. The Orthopedic Surgeon would be the best discipline to evaluate the boot. - On admission, the facility physician was responsible for ordering wound treatments as recommended by the hospital and 3 days was too long for a resident to go without a treatment ordered. - Treatment orders should document the specific location; residents could have different wounds with different etiologies requiring different treatments; documenting a specific location would ensure the nurse was not putting the wrong treatment on an area. - The resident's pressure ulcers deteriorated while at the facility which they attributed to the boot. During an interview on 4/15/22 at 11:32 AM, the DON stated: - skin was assessed on admission by a RN and then followed weekly during wound rounds. - If a resident had a wound on admission, they would follow the hospital orders and facility protocol for wound care. Orders for treatments should be entered on admission. - The DON assessed the resident on admission and the resident had an immobilizer and a CAM boot. - On admission, the resident had a DTI to the left heel and an ulcer on the dorsum (top) of their foot from the brace. The hospital documentation stated the resident had multiple areas and the DON believed those were the only pressure ulcers found when they removed the braces and performed a full body check. - The DON was unsure why the resident's admission treatment orders were not implemented until 10/31/21 as they should have been implemented on admission. - The CAM boot was to be worn at all times, which was documented in the hospital paperwork. - The DON stated the resident's DTI on the left heel should have been tracked and they expected weekly tracking. - The DON stated if APN #56 recommended an Orthopedic consult on 11/24/21, the Unit Manager should have called for an appointment. - If the hospital discharge paperwork documented to call for an Orthopedic appointment in 2 weeks, it should have happened. The DON did not know why Orthopedics had not been called until 12/8/21 for an appointment on 12/4/21. - If the resident had any additional padding to the brace or the boot, it should have been documented on the CCP and they did not know why RN #64 documented additional padding was added. - LPN #29's progress note from 11/11/21 should have been followed up by a RN; if a LPN saw an area on the ball of the foot, the DON expected RN documentation that the area was visualized. - Treatment orders should document a location; the LPNs should have been communicating that the treatment orders were not clear and the order should have been clarified. It was important to document the location as best as could be described for accurate treatments. During an interview on 4/18/22 at 9:48 AM with nurse practitioner (NP) #34 (the NP who had been following the resident), they stated: - treatment orders for residents should be entered within a few hours of admission if the wound was known on admission. - Discharge summaries or after visit summaries would document the expected follow up for orthopedics; if the summary documented to call within 2 weeks for a follow up appointment, the order should have been entered on admission to follow up and it should have been done. - If APN #56 recommended to follow up with Orthopedics on 11/24, the facility staff should not have waited until 12/8/21 to call for a follow up appointment. - If the facility was having a hard time obtaining a consult and the resident had things in question such as the CAM brace, the NP would call the office themselves to see what the delay was or what could be done in the meantime. The NP had not called, which likely meant they were not notified of the resident's issues. - The NP expected the resident to have an order to remove the CAM boot in bed if the discharge summary documented to do so. - The NP stated Wound APN #56's orders should have gone in the day of their visit; they were unsure the APN's order process and the facility liked handwritten orders. If the Wound APN provided verbal orders, the person taking the verbal should have entered the order. During an interview on 4/18/22 at 2:44 PM, the attending physician stated: - residents admitted with pressure ulcers should be added to the wound care list. - If a resident had a wound identified on admission and had orders from the hospital, treatment orders should go in at the time of admission. If the resident went from 10/28/21 to 10/31/21 without treatment orders, that was terrible; it was a delay and the orders needed to be entered timely. Residents who had pressure ulcers had deteriorating skin, were very sick, and the facility needed to be aggressive and on top of wound care to promote healing. - If Wound APN #56 saw a resident on 11/3/21 and made order recommendations, the orders should go in immediately by the nurse rounding with APN #56; waiting until 11/5/21 to enter orders would be too long and it was not optimal. - Follow up Orthopedic consults should be ordered as per the discharge summary; if the discharge summary documented to follow up within 2 weeks, the resident should have had an appointment within 2 weeks. To go from 10/28/21 to 12/14/21, that was potentially the time frame of an entire admission and discharge, which would not be timely. If APN #56 requested an Orthopedic consult, it should have been completed. Wound monitoring should be done weekly at minimum; if the resident had a deep tissue injury identified on admission, it should have been documented on and followed up on before 11/24/21. - The system was broken and everybody dropped the ball with the resident. With the delay in admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . - The physician stated they had requested better communication on residents with wounds, and the nutrition team should also be included with the communication as it was an integral part of wound care. 10NYCRR 415.12(c)(2)

Based on observation, interview, and record review during the abbreviated survey (NY 626) conducted on 8/25/21, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety affecting the entire facility. Specifically, the facility is using the inadequately-sanitized kitchen for preparation of food and drink for residents although sewage or liquid waste has not been properly cleaned and disposed of in an approved and sanitary manner. The kitchen walk-in cooler continues to have wastewater seeping up through the seams of the floor in the cooler. Wet footprints were observed tracking through the cooler and main kitchen area. Food products in the walk-in cooler have not been properly evaluated for contamination as evidenced by open boxes of raw vegetables that have been exposed to a contaminated environment have not been discarded. The facility intended to serve take-out foods out of the kitchen for lunch on 8/18/21 and is currently preparing food in the kitchen to serve residents for dinner. The facility's failure to properly address wastewater clean-up following a sewage flood in the kitchen resulted in Immediate Jeopardy to Health and Safety for the facility's 75 residents that is Immediate Jeopardy. Findings include: The facility's Food and Nutrition Services Sanitization policy, revised 2/2021, documents the food service area shall be maintained in a clean and sanitary manner. All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish, and protected from rodents, roaches, flies, and other insects. The facility's Food and Nutrition Services Food Safety policy, revised 8/2021, documents food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. Critical factors implicated in food borne illness include contaminated equipment and unsafe food sources. On 8/18/21 at 9:02 AM, breakfast on the North wing was observed. Nursing staff provided residents with breakfast sandwiches from a fast-food restaurant and donuts from a grocery store. Director of Social Services #20 was present on the unit and stated in an interview at that time, the facility had provided take-out food for meals since the previous day because the kitchen service was down. On 8/18/21 at 9:30 AM, breakfast on the South wing was observed. Residents were served breakfast sandwiches from a fast-food restaurant and donuts from a grocery store. On 8/18/21 at 10:30 AM, the dining room was observed. The room was connected to the facility's kitchen. There were multiple items on the tables in the dining room including condiments, bread, utensils, and other kitchen ware. Dietary aides #16 and 20 were in the dining room at that time and were moving the kitchen items from the dining room into the kitchen. They stated in an immediate interview, the items in the dining room were from the kitchen and were moved out because the kitchen flooded. They stated they were moving items back into the kitchen. During an observation on 8/18/21 at 11:02 AM with housekeepers #7 and #17, the walk-in cooler floor had three diamond plate panels. While walking on the floor, brown water began coming up through the seams of the diamond plates and on to the cooler floor. The cooler was stocked with food including heads of lettuce, tomatoes in a box open to air. The housekeepers stated they had heard the back-up came from the grease trap in the dish room, which was a brown box under the sink area. On 8/18/21 at 11:59 AM, the kitchen was observed with maintenance worker #5. Housekeeper #7 was present and stated in an immediate interview, the sensor for the box that put the chemicals into the grease trap was flashing low battery that morning. Housekeeper #5 stated it was possible the grease trap affected the flooding and housekeeper #5 had not been in the kitchen before that day and did not know if that box was flashing low battery prior to that day. At 12:03 PM, Food Service Director #6 joined the interview and stated they did not know the last time the grease trap was cleaned or maintained, did not know the last time the chemical company was at the facility, and kitchen staff had no responsibility over checking the light for the grease trap chemical machine. During an observation of the walk-in cooler on 8/18/21 at 12:05 PM with housekeepers #7 and 17, water was coming up from the seams of the cooler floor when walking on the floor. The housekeepers stated they planned on taking the cooler floor off. Food Service Director #6 entered the cooler and stated they were told by the Administrator to put items back in the kitchen and to begin using the kitchen again. Food Service Director #6 stated the shelves had not been cleaned or sanitized. There was a box of tomatoes and lettuce that had been open to the air and they stated the food had been there two days ago when the leak started, and was not instructed to discard the food in the walk-in cooler. The Food Service Director stated the facility ordered pizza for lunch and they would be serving the pizza from the kitchen. There was a rack of drinks in the walk-in cooler (milk and juice in plastic cups with lids) which the Director stated were placed there that morning and stored in the walk-in cooler to be served at lunch time today. On 8/18/21 at 12:16 PM, registered dietetic technician (DTR) #4 was observed arriving at the facility with pizza. At 12:19 PM, the Food Service Director #6 met DTR #4 at the front door to get the pizza. At 12:20 PM, Food Service Director #6 was wheeling a cart with pizza boxes into the kitchen. The surveyor asked the Director to not bring the pizza into the kitchen and the Director stated they had been told the kitchen could open. The Food Service Director stated they had intended to plate and serve the pizza from the kitchen. The Food Service Director brought the pizza into the activity room where the meal was served from. During an observation on 8/18/21 at 2:19 PM, the shelves of the cooler had areas of black mold. The cooler door was open, and the maintenance and housekeeping staff were pulling up the floor. On 8/18/21, the following was observed in the kitchen between 2:34 PM to 2:52 PM: - The walk-in cooler floor was pulled off with visible rust, brown dirt, and mud. There was a fan blowing into the cooler area from the kitchen. There was not a partition or divider in place separating the cooler area from the rest of the kitchen. In the back of the kitchen, there was a pan of baked potatoes on the counter next to a box of bananas. There was a rack of dry storage products including bags of flour with a sweatshirt thrown on the top shelf. - Soup was observed on the stove with the stove off. The Food Service Director stated they had started making the soup for lunch and they needed to throw it away. - Wet footprints were observed on the kitchen floor coming from the wet floor of the cooler. During an observation on 8/18/21 at 3:30 PM, cooked pork loins were observed on the counter near the walk-in cooler. The Food Service Director stated they had cooked baked potatoes because they were about to go bad. There were frozen cookies on a tray that were to be baked for dessert. During an observation on 8/19/21 at 11:37 AM, there was debris on canned goods in the kitchen, toasters were soiled with food debris, the back wall of the kitchen has food splatters and the back heater had food debris present on top. There was an opened box of wax paper, individual packets of salt, pepper, and sugar that were exposed. During an interview on 8/18/21 at 10:35 AM, dietary aide #16 stated on the evening of 8/16/21, water started to come out of the drains in the kitchen. The dietary aide stated the water was sewage and had a foul odor. The dietary aide stated the dietary staff returned to work in the morning of 8/17/21, the kitchen looked clean and the staff began to prepare breakfast. After breakfast was prepared, someone in management shut down the kitchen and the facility had been ordering food for the residents ever since. During an interview on 8/18/21 at 10:40 AM, the Food Service Director stated water began coming out of the drains in the kitchen at around 7:30 PM on 8/16/21. The floor of the dish room was initially covered with water and then water covered the whole kitchen. The Food Service Director stated the water was sewage. The dietary staff called the Food Service Director, and the dietary staff were directed to leave the facility. Maintenance took over cleaning the kitchen. The Food Service Director stated they came in around 6:30 AM on 8/17/21 and the kitchen looked cleaned, so staff began preparing breakfast until Corporate Clinical Staff #19 told them to stop. On 8/17/21, the facility obtained fast-food breakfast sandwiches for breakfast, ordered pizza for lunch and for dinner, the residents received turkey sandwiches. At the time of the interview with the Food Service Director, the dish room floor was observed to be very wet with standing water. There were 2 housekeepers in the kitchen cleaning and dietary staff walking between the dining room and the kitchen. During an interview on 8/18/21 at 10:50 AM, dietary aide #10 stated the kitchen started flooding on 8/16/21 at night with black water coming up through the drains. The dietary aide noticed this first in the pot room and told the staff to stop washing dishes. The drains under the food stations in the kitchen were also flooding. The water from the drains by the dishwasher smelled bad and maintenance thought it could be toxic, so the food service staff left the facility. The dietary aide stated on the morning of 8/17/21, the kitchen looked clean so the dietary staff began to cook breakfast until Corporate Clinical Staff #19 came into the kitchen and told them to stop cooking. The dietary aide stated the facility obtained outside food for the residents. At some point in the morning on 8/17/21, the dietary staff resumed washing the pots and dishes from the previous night and water came up from the drains again, so they were told not to use the kitchen. During an interview on 8/18/21 at 11:45 AM, maintenance worker #5 stated: - they were notified on 8/17/21 at 7 AM when arriving for work that there was a water back-up in the kitchen on 8/16/21. Maintenance worker #5 was not called the night the kitchen flooded and there was no maintenance staff present in the building at the time. Maintenance worker #5 stated they thought the night housekeeper addressed the flooding on 8/16/21. - In the morning of 8/17/21, maintenance worker #5 snaked 2 drains in the kitchen and then someone came and shut the kitchen down. The drains that were backed up were the 2 drains in the pot room and the one by the steamer in the kitchen. - A plumbing company came in and flushed the drains on 8/17/21. - The grease trap could have contributed to the problem, there was a bunch of grease build-up which could have made the drains back up. Maintenance worker #5 stated they worked at the facility for 8 years and never emptied the grease trap. There was a little box next to the grease trap that put in a chemical that helped keep the water moving and that box was not working. The chemical was provided by the chemical company and maintenance worker #5 thought it may have been overlooked the last time the company was at the facility. - The housekeepers were cleaning the kitchen at that time including scrubbing the walls, counters, shelves, and coolers with chemicals and with bleach. - Maintenance worker #5 was not typically involved in the kitchen unless something was broken or the drains needed to be snaked. - Maintenance worker #5 was aware there was water coming up from the seams of the walk-in cooler and the housekeepers had tried to vacuum it up and were scrubbing the floor. Maintenance worker #5 stated the housekeepers would continue to vacuum the water out, could possibly pull up the floor, or put blankets down but they thought that would be a tripping hazard. Maintenance worker #5 stated they had not been asked for recommendations on how to address this issue. The 8/17/21 plumbing service invoice documented the plumbing service was at the facility from 11:30 AM to 4:30 PM. The invoice documented the service cleaned and flushed the main pipe serving the building and removed heavy pipe debris. The drains serviced included the floor drain and main sanitary sewer drain. The facility declined full cleaning and inspection and opted for cleaning and treatment of the pipe only. The 8/17/21 Septic and Sewer Work Estimate documented the interior grease trap in the kitchen needed to be pumped and cleaned and the grease trap was recommended to be replaced and pumped every 6 months. During an interview on 8/18/21 at 2:16 PM, the Food Service Director stated at that time, they thought the kitchen was clean. The Director was cooking pork loin that had been in a vacuum sealed package in the walk-in cooler. The Director was making instant mashed potatoes and using frozen vegetables for dinner. The Food Service Director stated if the food was sealed, they thought it was usable. The Food Service Director sated they discarded anything that was opened. During an interview with maintenance staff person #25 on 8/23/21 at 11:40 AM, they stated the drain problems had been ongoing for the past 2 or 3 months and back-ups were happening constantly in the kitchen, the men's bathroom/locker room, and the back spray room. Maintenance worker #25 stated they had been instructed to just keep snaking the drains to fix the problem. Maintenance staff person #25 suggested to the department manager, and to the previous Administrator, to have an outside company come in, but nothing was done, and the maintenance staff just kept having to snake the drains. The maintenance worker said the grease trap was also a concern and was reported to maintenance staff, management, and the Food Service Director. During an interview on 8/18/21 at 1:20 PM, the Administrator stated: - On 8/16/21 in the evening, the dietary staff noticed water coming up from the drains. The water started coming out while they were doing pot washing, the dietary staff stopped, and the water went back down. Staff cleaned the kitchen at that time. - The dietary staff arrived before maintenance staff on the morning of 8/17/21 and started prepping for breakfast. Water began coming out of the drains again and the maintenance staff snaked it out. The kitchen was shut down and a company was brought in to check the drains. - An emergency plumbing company came in on 8/17/21 and stated the back-up was due to grease build up, they jetted the lines, pumped out the grease trap, and said the kitchen was all clear. The plumber suggested they get the grease trap cleaned or it would happen again. The water backup only occurred from the drains and not the sinks. - The plumbers left at 4:30 PM on 8/17/21 and the facility had a crew of three clean and sanitize the kitchen. The facility staff called their chemical company to ask which chemicals to use. The cleaning crew worked until 12:00 AM. - On the evening of 8/17/21, the staff moved the necessary kitchen equipment into the dining room and the plan was to keep the kitchen closed for breakfast on 8/18/21. - The cleaning process took longer than expected and the facility decided to order out for lunch on 8/18/21. The Administrator stated at that time, they thought the facility was where they should be, and the hope was for the kitchen to be up and running for dinner that day. - The Administrator stated they were aware there was still water coming out of the seams of the cooler floor and staff were working on it. They used bleach on the cooler floor to make sure it was sanitized. - The Administrator stated they ordered lunch on 8/18/21 and left the decision to open the kitchen for lunch that day up to the Food Service Director and DTR and they felt it should be opened since everywhere outside of the cooler had been cleaned. The Administrator stated they were notified that the Food Service Director was advised not to serve out of the kitchen since there was still water in there. - The plan at that time was to give the cleaning crew until 2:30 PM and if the kitchen was not cleaned, the management staff would reach out to corporate to go to their emergency supply of food or purchase food again. - The Administrator stated the maintenance staff was unscrewing the metal floor at that time to clean, scrub and bleach the sub floor. - Prior to the last Maintenance Director leaving, the Administrator stated they reviewed all the maintenance logs and noted the grease trap had been maintained and cleaned regularly and was not aware of any issues. The Administrator stated the company that had been onsite that day had not serviced the grease trap in the past and the Administrator did not know if the grease trap had been cleaned previously by an outside vendor. During the interview, the Administrator provided the following: The Grease Trap Log starting 3/18/18 documented the grease traps were cleaned and checked quarterly, with monthly checks starting on 1/4/21. A leak was repaired on 1/4/21 by former Maintenance Director #23. The sign off sheet was signed by the former Maintenance Director each time except for 6/3/21 which was signed by maintenance worker #5. During a follow-up interview with maintenance worker #5 on 8/19/21 at 2:00 PM, the maintenance worker stated although their initials were on the facility log as cleaning the grease trap, they had never cleaned the grease trap before. During an interview with former Maintenance Director #23 on 8/23/21 at 1:00 PM, Maintenance Director #23 stated the grease trap was something that needed to be cleaned by an outside vendor and they were not aware of a company coming and completing that in a while. Maintenance Director #23 stated the last time they recalled the grease trap being maintained was in 2018. Maintenance Director #23 stated when they initialed the Grease Trap log that meant they checked to make sure the seal was good and that it was not leaking. They did not do any cleaning of the grease trap or emptying of it. During a follow-up interview with the Administrator on 8/23/21 at 2:57 PM, the Administrator stated they were not aware of any previous issues regarding the plumbing in the facility. The Maintenance Director ran the maintenance side of things and would have dealt with the problem, so the Administrator may have never known. During an interview with the Regional Administrator on 8/19/21 at 11:37 AM, they stated that the kitchen contents had been cleaned and sanitized. Floors, walls, ceilings, equipment, and tables had also been cleaned and sanitized and canned goods present in the kitchen were cleaned. ------- Immediate Jeopardy was identified, and the facility Administrator was notified on 8/18/21 at 3:55 PM. The Immediate Jeopardy was removed on 8/18/21 at 9:20 PM based upon the following corrective actions taken: -Contracted plumbing service cleared the pipes on 8/17/21 to prevent back up into the kitchen and pumped the grease trap on 8/18/21 -All opened items in the kitchen were immediately discarded including prepared dinner items for 8/18/21. -All usable food items located in the kitchen were removed and placed in the dining room. The kitchen was closed until a full sanitization was completed. -Dinner on 8/18/18 and subsequent meals until the kitchen is properly sanitized, will be served from either the emergency disaster menu or ordered from outside vendors as needed. -The dining and activity rooms were cleaned, and all furniture sanitized and will be used as clean prep area for food service until the kitchen can be reopened. -Usable sealed plastic or metal containers of food will be cleaned with sanitizing wipes. -The freezer which is accessible through the cooler will be evaluated for contamination. -Any needed food service equipment will be cleaned and sanitized in the 3-bay sink system which will be set up in the clean food prep area. -the kitchen will be deep cleaned including floors, shelving, walls and equipment before the kitchen workspace is opened. 10NYCRR 415.14(h)

Based on observation, record review, and interview conducted during the partially extended abbreviated survey (NY 752 and NY 701), the facility failed to implement elopement policies and procedures to ensure residents received adequate supervision to prevent accidents for 2 (Residents #1 and 2) of 5 residents reviewed for accidents. Specifically, staff failed to follow policies and procedures to search for a possible missing resident, and account for the presence of all residents in the facility when the exterior door and/or the wander alert device alarm sounded. Subsequently, Resident #1 left the facility undetected when staff did not respond to, then turned off the exterior door and wander alert device alarms, and was found by a member of the community approximately 45 minutes later, one-half mile away from the facility. Additionally, Resident #2 left the facility undetected when the wander alert device alarm sounded and staff did not respond to the alarm. The resident was found outside, behind the facility approximately 30 minutes later by a maintenance worker. This resulted in Immediate Jeopardy and Substandard Quality of Care to Resident #1's health and safety, and no actual harm with potential for more than minimal harm that was not immediate jeopardy for Resident #2. This had the potential to affect 16 residents who were identified by the facility to be at risk for elopement. Findings include: The facility's Elopement, Risk Prevention and the Management of Missing Residents policy, revised 9/2016, documented if a resident with a wander alert device exited the facility. It was the responsibility of all staff to respond to activated alarms and to return residents to their units. If a resident was noted to be missing, the facility was to implement a code gray which the policy documented was the facility's code for a missing resident. A code gray included searching for the missing resident and accounting for all residents in the facility. 1) Resident #1 was admitted to the facility on [DATE] and had a [DIAGNOSES REDACTED]. The elopement and wandering risk assessment initiated on 8/3/2018 and completed on 8/8/2018 by registered nurse (RN) Manager #17 documented the resident was at risk for elopement related to poor cognition, agitation after family visits, history of opening the doors to the outside, and being independently mobile. The resident was to wear a wander alert device. The 8/19/2018 at 9:15 PM, Accident/Incident Report documented the resident left the facility unsupervised. An attached statement from activities aide #11, written by the Administrator, documented on 8/19/2018 at 9:30 PM, the activities aide was out with friends and saw the resident walking down the road in front of a baseball field. The resident got into activity aide #11's car and was returned to the facility. The investigation documented the resident was last seen at 8 PM, wandering on the unit. Prior to the resident exiting, visitors held the door for 15 seconds, activated the delayed egress, and used the door. A few minutes later, the resident exited the front door. The wander alert device alarm sounded and a staff member turned off the alarm. The resident was returned to the facility at around 8:45 PM, unharmed. The Assistant Director of Nursing (ADON) returned to the facility and assessed the resident. The administrator stated on 8/23/2018 at 8:45 AM there was surveillance video of Resident #1 leaving the facility on 8/19/2018. The time stamp on the video was one hour behind the actual time and the date was one day ahead of the actual date. A memo written by the Administrator, dated 8/23/2018, documented the date on the video surveillance footage was one day ahead and the time on the video surveillance was one hour behind the actual time. The video surveillance footage from a camera located in the lobby, pointed at the main entrance, on 8/19/2018 (video stamp date 8/20/2018) was reviewed. The documented times reflect the video stamp times with corresponding actual times indicated. - At 7:29 PM (actual 8:29 PM), a visitor activated the delayed egress function on the front door and used the front door. - At 7:46 PM (actual 8:46 PM) the resident pushed on the front door, the door opened, and she exited the facility. - At 7:50 PM (actual 8:50 PM), certified nurse aide (CNA) #4 walked into the facility and turned off the alarm using the key pad near the front door. - At 8:22 PM (actual 9:22 PM), activity aide #11 entered the facility alone. - At 8:26 PM (actual 9:26 PM), CNA #4 walked the resident into the front door of the facility. On 8/24/2018 at 9:58 AM, the Director of Maintenance stated in an interview, he reviewed the surveillance footage from the resident's elopement and determined a family member held the delayed egress on the front door for 15 seconds, released the front door and the resident came up a few minutes later and exited through the unlocked front door. He stated the wander alert device alarm sounded and he could tell this by watching the video surveillance and seeing which lights were lit up on the keypad near the front door. He stated when the wander alert device alarm sounded, if a resident was not seen, staff should have implemented a code gray and ensured all residents were accounted for. He stated when the delayed egress was activated, a local alarm sounded and the door remained unlocked until someone re-set the lock by putting a code into the key pad near the front door. On 8/24/2018 at 10:15 AM, an observation of the front door's functioning was made with the Director of Maintenance. The Director of Maintenance tested the functioning of the door and alarms with and without a wander alert device and the door functioned as described by the Director of Maintenance. On 8/27/2018 at 9:32 AM, activities aide #11 stated in an interview, she was off duty and out with her friends between 9 and 9:30 PM on 8/19/2018 and saw someone walking out of the cemetery. She asked her friends to turn around so she could see who it was and she realized it was the resident. She stated the resident had crossed the street and was standing on the shoulder of the road. Her friends stopped the car, she got out and helped the resident cross the street and assisted her into the car. She stated the resident smelled of feces and urine and the bottom of the back of her shirt was wet and had brown smears on it. She stated the resident left a wet stain in the car where she was sitting. Activities aide #11 stated when she got to the facility, she walked in alone and had the resident wait in the car with her friends. She went to the nursing unit, never saw a nurse and was told there was not a Supervisor in the building. She stated CNA #4 came to the car and walked the resident back into the facility. On 8/27/2018 at 3:25 PM CNA #4 stated in an interview, on 8/19/2018, she left the facility at around 8:10 PM and went to break and when she returned through the front door, she heard the wander alert device alarm sounding. She did not see anyone and she turned the alarm off. Later on she heard activities aide #11 brought the resident back to the facility. On 8/24/2018 at 12:33 PM, CNA #1 stated in an interview, she worked the night the resident eloped. She last saw the resident at 8 PM wandering near the front lounge. She stated that night, the alarms sounded constantly and when the wander alert device alarm sounded, she heard it, she looked at the monitor on the unit and did not see a resident so she continued working. She stated no staff left the unit and went to the front door bevause when they looked at the video monitor, they did not see anyone near the front door. On 8/24/2018 at 2:30 PM, licensed practical nurse (LPN) Supervisor #9 stated in an interview, she was the Supervisor the night the resident eloped. She stated when the wander alert device alarm sounded, she was on the other unit. She looked at the monitor and did not see anyone in the lobby area near the front door. She walked up front and did not see anyone and went back to work. She stated later on, someone came and said the activities aide #11 brought the resident back to the facility. She called the ADON, she did not see the resident, and she told the staff to start statements. Video surveillance footage did not show LPN #9 in the front lobby by the front doors during the 4 minute time period the wander alert device was alarming. On 8/28/2018 at 9:45 AM, the Director of Nursing (DON) stated in an interview, if staff hear the wander alert device alarm, and do not see a resident, they should do a headcount and ensure all residents were present at the facility. She stated if they were missing a resident, they should implement a missing resident code. On 8/28/2018 at 11:55 AM, the Administrator stated in an interview, if the staff hear the front door alarms sound, they should look for a resident outside of the facility and then go back inside and do a head count. If there was a missing resident, they should get the facility's team together and start a search. He stated since the 2 recent elopements, the facility had started doing staff education on the elopement policy and procedure. On 8/28/2018 at 2:10 PM, CNA #6 stated in an interview he heard the wander alert device alarm sound the night the resident eloped. He stated he was with a nurse, they looked at the monitor and did not see anyone and so they continued working. On 8/28/2018 at 3:35 PM, the ADON stated in an interview, she did education with staff on 8/20/2018 regarding the elopement policy. When an alarm sounds staff should ensure there is no resident in the area of the alarm before turning the alarm off. The immediate area should be checked and doors opened to see if someone was outside. She reviewed the sign in sheet and stated CNA #4 was not present at the training. On 8/28/2018 at 4:32 PM CNA #19 stated the alarms go off at least 4-5 times per evening shift and the sound was ear piercing. She would look at the monitor when the alarm sounded, to see if someone was there. If someone was seen on the monitor she would go get them if there was no receptionist. If no one was seen on the monitor she would do nothing. On 8/28/2018 at 4:40 PM CNA #20 stated she had heard the alarm go off once in awhile when she worked the evening shift and it was very loud. She stated she would look at the camera first and if she did not see anyone she would go to the front door to check outside and then turn the alarm off. 2) Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment and required supervision for locomotion off the unit. A nursing progress note dated 5/31/2018 at 6:12 PM, documented a wander alert device was placed on the resident's left ankle by the RN (registered nurse) Supervisor. The comprehensive care plan (CCP) effective 5/31/18, documented the resident was at risk for elopement related to verbalizations of intent to leave the building. An intervention included the use of a wander alert device. An elopement and wandering risk assessment completed on 6/29/2018 documented the resident was at risk for elopement due to being cognitively impaired with poor decision-making skills, alert but non-compliant with facility protocols regarding leaving the unit, exhibiting behavior with potential to trigger wandering/elopement including anger/resentment and making statements she was leaving or seeking to find someone/something. Neither Continue to Care Plan nor Do Not Care Plan was checked on the assessment. A facility investigation form dated 8/16/18 documented the Director of Maintenance saw the resident outside behind the building and he notified the receptionist who in turn notified staff who went to bring the resident back into the building. The resident was immediately placed on 1:1 supervision (direct supervision from one person) while awake. Activity Aide #11 was at the reception desk at the time and did not see the resident leave, however shut off the alarm. She was educated on the elopement policy. The plan of correction to prevent recurrence included education on the elopement policy; the receptionist was educated on the elopement policy; signs were placed at the reception desk and on the doors stating residents wearing wander alert devices were not to be let outside without a family or employee escort, and the facility planned continued education of all new staff members on the elopement policy. The administrator stated on 8/23/2018 at 8:45 AM there was surveillance video of Resident #2 leaving the facility on 8/16/2018. The time stamp on the video was one hour behind the actual time and the date was one day ahead of the actual date. A memo written by the Administrator, dated 8/23/2018, documented the date on the video surveillance footage was one day ahead and the time on the video surveillance was one hour behind actual time. The video surveillance footage from a camera located in the lobby, pointed at the main entrance, on 8/16/2018 (video stamp date 8/17/2018) was reviewed. The documented times reflect the video stamp times with corresponding actual times indicated. - At 12:45 PM (actual 1:45 PM), a visitor exited the building and did not engage the delayed egress on the door. - At 12:45 PM (actual 1:45 PM), activities aide #11 punched a code into the keypad near the front door. - At 12:48 PM (actual 1:48 PM), the resident pressed on the door for a few seconds (less than 15 seconds) and released then pressed the door again, the door opened and she exited the front door in her wheelchair. - At 12:49 PM (actual 1:49 PM), activities aide #11 punched a code into the key pad near the font door. The resident was exiting the second door of the facility at that time. During interviews with the Director of Maintenance on 8/24/2018 at 9:57 AM and 8/29/2018 at 12:55 PM, he stated he was doing yard work with another maintenance worker out back on the other side of the courtyard fence, at around 1:00 PM on 8/16/2018 when he saw the resident in her wheelchair on the other side of the fence. He had the maintenance worker stay with the resident while he went to get a staff member. He stated the resident was wearing a wander alert device and she had pushed the hold bar on the front door, engaged the delayed egress, and exited the building. He reviewed the surveillance video and stated both the door alarm and the wander alert device alarms sounded and he knew this from the lights that were lit up on the keypad near the front door. The door alarm had a different sound than the wander alert device alarm. He stated when the alarms sounded it was for a reason and someone should have checked for a resident before disengaging the alarm. The surveyors observed both the door alarm and the wander alert device alarm activation with the Director of Maintenance. The wander alert device alarm began to make a chirping sound as the wander alert device approached the front door and alarmed loudly when the wander alert device exited thought the doors. The Director of Maintenance stated the wander alert device alarm could be heard loudly and clearly on both nursing units. Activity Aide #11 was interviewed on 8/27/18 at 9:33 AM, and stated at times, she covered the receptionist desk during breakfast ands lunches. On 8/16/18, she was covering the receptionist desk at approximately 12:00 PM and felt very sick and overwhelmed with phone calls, visitors and activity. She stated she let a visitor out with the button under the desk and Resident #2 must have followed the visitor out. She did remember the alarm going off, it was a beeping and not a loud alarm. There was no one near the desk so she turned off the alarm and went back to the desk. She stated she did not check outside at that time for a resident. She stated she should have checked outside before she turned off the alarm. On 8/28/18 at 9:30 AM the resident's wheelchair was observed with a wander alert device attached to a bar underneath the seat. The Director of Nursing (DON) was interviewed on 8/28/2018 at 11:25 AM and stated her expectation was if the wander alert device alarm was sounding staff should be checking the door. If there was no one near the door, they should go outside and check. If no resident was seen, they should do a head count to make sure all residents were accounted for. When the resident exited the building, the wander alert device alarm sounded and was deactivated by the person covering for the receptionist. On 8/28/2018 at 11:55 AM, the Administrator stated in an interview, if the staff hear the front door alarms sound, they should look for a resident outside of the facility and then go back inside and do a head count. If there was a missing resident, they should get the facility's team together and start a search. He stated since the 2 recent elopements, the facility had started doing staff education on the elopement policy and procedure. On 8/28/2018 at 3:35 PM, the ADON stated in an interview when an alarm sounds staff should ensure there is no resident in the area of the alarm before turning the alarm off. The immediate area should be checked and doors opened to see if someone was outside. ______________________________________________________________________________________ Immediate Jeopardy was removed on 8/31/2018 prior to exit based on the following corrective actions taken. The facility: - Posted a staff member at the front door 24 hours a day until education and modifications to the door alarm were made. - Made modifications to the door alarms including an alarm that would sound on the units when a delayed egress was initiated on the front door and installed a louder alarm that would sound when a person with a wander alert device exited the facility. - Developed and implemented staff education on wandering, elopements, and the facility system for elopement prevention. 10NYCRR 415.12(h)

Based on record review, and interview conducted during the abbreviated survey (NY 274) the facility did not ensure that 3 of 4 residents (Residents #1, 2, and 9) reviewed for quality of care received treatment and care in accordance with professional standards of practice. Specifically, Resident #2 was not assessed by a qualified person immediately after the fall nor was there a follow up assessment by a qualified person. Resident #1 fell and was placed back to bed before a thorough assessment was completed to rule out injury. In addition the resident complained of pain that was consistent of a fracture shortly after the fall and the registered nurse (RN) and physician were not updated timely of the resident's fall and pain. When the resident was assessed by an RN the resident was diagnosed with [REDACTED].#9 was not assessed timely after exhibiting a change in condition and later expired. This resulted in actual harm to Resident #1 and 9 that is not immediate jeopardy. Findings include: Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The [DATE] Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired and he required extensive assistance for all activities daily living (ADLs). The comprehensive care plan (CCP) dated [DATE] documented the resident was at risk for falls and interventions included floor mats on each side of bed and call light within reach. The undated certified nurse aide (CNA) care card documented the resident required 2 assist and a slide board for transfers. An incident/accident report dated [DATE] at 3:35 PM documented he was found on the floor in the bathroom. Registered nurse (RN) #4 documented on the report the resident had no apparent injuries. On [DATE] at 3:34 PM RN #4 documented on [DATE] staff called a code blue due to resident fall. She assessed the resident at the time of the fall, no injuries were noted and he denied pain. The resident was placed back into his chair after the assessment, without issue and was laughing and joking with staff at the time. An incident/accident report completed by LPN #21 dated [DATE] at 10:30 PM documented the resident was found on the floor lying on his left side. It appeared as if the resident attempted to self-transfer and he fell . The report also documented the resident did not have any apparent injuries, the physician and the resident's family member were notified at 5:00 AM. There was no documented evidence the resident was assessed by an RN or that an RN was notified when the resident fell to assist with the assessment. On [DATE] at 5:24 AM LPN #21 documented at 10:30 PM the resident was found on the floor lying on his left side and he did not have any apparent injuries and did not complain of any pain or discomfort. About 2 hours later resident had complained of left lower extremity pain. The resident stated the pain was not from the fall but was a muscle spasm that happens every once in a while. He was medicated with Tylenol and he was currently in bed asleep and appears to be resting comfortably. The facility on-call provider was called and stated to this writer, if there is a fall without injury, wait until 0600 to call. The resident's family member had also been notified. The ,[DATE] medication administration record (MAR) documented the resident was administered 1000 milligrams (mg) of Tylenol on [DATE] at 10:57 PM for pain 6 on the pain numeric scale (pain ,[DATE]) and a follow up pain assessment was completed at 4:51 AM and his pain was documented as an 8. The MAR also documented the resident was not administered Tylenol again until [DATE] at 9:57 AM. In a typed statement dated [DATE] completed by LPN #21 documented she rendered frequent visual checks on the resident throughout the night post fall every ,[DATE] minutes. At no time was the resident heard yelling out in pain with any other complaints voiced. Asleep with each visual check. Observed turn and position in which he did not yell out in pain. Resident checked at shift change and he was resting comfortably. The evening shift RN supervisor was in the building at the time of the fall and was notified by this writer. RN #10 on [DATE] at 12:05 PM documented she was asked to see the resident around 9:15 AM for complaints of left leg pain. Upon assessment resident was lying in bed complaining of pain and the left extremity was flexed and he complained of pain with extension. The left leg was palpated and was painful. The staff were instructed to medicate the resident for pain, the on-call provider was notified and new order for an x-ray of the right hip was obtained. On [DATE] at 2:57 PM RN #10 documented the x-ray results of the left leg were received at 2:15 PM and a new order was obtained to send the resident to the emergency room for evaluation. A nursing progress note dated [DATE] documented the resident was readmitted to the facility after a hospital stay for a left femoral fracture. A change in condition policy and all policies pertaining to nursing assessments was requested from the Director of Nursing (DON) on [DATE] at 11:58 AM. At 1:10 PM a second request from the surveyor was made. The DON stated she was looking and could not find one. She provided the surveyor with a copy of a document that was hanging on the bullentin board of the North unit. The document gave the direction of when to call the on call nurse. The document stated when an LPN was a nursing supervisor they were to call the on call RN for a fall before moving resident. During an interview with RN #4 on [DATE] at 2:15 PM she stated if there was a resident fall LPN's were not allowed to assess, they were to call a code blue, so the RN could respond and conduct an assessment. It was the responsibility of the nursing supervisor to fill out an accident/incident report with any incident. She was not sure what the protocol was for LPN's if a resident fell and there was not an RN in the facility. She had worked the evening shift of [DATE], she was the only RN in the building and her shift hours were 2:00 PM - 10:00 PM. She had stayed late the evening of [DATE] as she was performing a procedure on another resident. Resident #1 had fallen shortly after the start of her shift around 3:30 PM. A code blue had been called, she responded and found the resident on the floor. At that time the resident stated he was trying to go to the bathroom. She did an assessment which included checking the resident's range of motion (ROM) to all his extremities, asking about pain and checking for other injuries. The resident could move all his extremities without difficulty and he did not complain of any pain when he was assisted to a standing position after the assessment. She was not aware the resident had a second fall until the next day when she came in for the evening shift and she was asked by Director of Nursing (DON) to write a progress note regarding her assessment for the [DATE] 3:30 PM fall. The DON had asked her if she knew anything about the resident having a second fall and she stated she had not been notified the resident had a second fall and had not assessed him after the initial fall at 3:30 PM. Certified nurse aide (CNA) #3 was interviewed on [DATE] at 10:55 AM and stated she had responded to the resident yelling out around 10:30 PM the night of [DATE] and she found the resident on the floor. The nursing supervisor, LPN #21, had also responded to the resident yelling out and had come into the room. The nursing supervisor did her assessment in which she asked the resident if he had pain, asked him to squeeze her hands and she asked him to move his feet. The resident denied pain at that time. She stated the only time the nursing supervisor left the room was to get the Hoyer lift and that was only for a few seconds and at no point did she recall the nursing supervisor using the phone. The resident was placed back into bed via the Hoyer lift. Around 12:00 AM she heard the resident yelling out again and when she went into his room he was complaining of left hip pain. She notified LPN #21 who went in the resident's room and gave him pain medication. The resident was quiet for about 20 minutes after he received the medication and then started yelling out again that his hip hurt. She again notified LPN #21 and she went back into the room and told the resident she could not give him any more medication that it was not time. The resident yelled consistently for about an hour after that and then on and off for the next couple of hours. There was no documented evidence the RN or the physician were notified of the resident's complaints of pain during the night. During an interview with the Assistant Director of Nursing (ADON) on [DATE] at 7:45 AM she stated every resident who fell should not be moved until they had been assessed by an RN to ensure they did not have any injuries and were safe to be moved. LPN's were not allowed to make the determination if a resident was safe to be moved after a fall. When an LPN was supervising and there was no RN in the facility the LPN was to call the DON or the ADON on call before moving the resident and that RN would walk them through an assessment on the phone or the LPN could call 911. The LPN should document on the incident/accident report what RN was contacted and what she was told to do. The RN should follow up with documentation of an assessment and what she had instructed the LPN to do as well as assess the resident when she arrived at the facility. She stated she had not been notified of Resident #1 falling on [DATE] and had not assisted LPN #21 with conducting an assessment. After a resident falls the incident reports are reviewed by the team, including herself and interventions were discussed. There had been no issues identified with the resident's fall on [DATE] at 10:30 PM. If the resident had complained of pain during the night the LPN should have called an RN or the physician as the resident had fell earlier and the LPN was not able to determine whether or not he had an injury. The resident was not a reliable historian. During an interview with RN #10 on [DATE] at 11:55 AM she stated she was the DON at the time of the resident's fall on [DATE] and part of her responsibilities included being on call. If a resident had a fall and there was no RN in the facility the LPN was to call the DON or the ADON and they would direct the assessment. She was not notified until around 5:30 AM Resident #1 had a fall at 10:30 PM the previous evening and it was reported to her the resident had no injuries. She was under the understanding another RN was in the facility at the time of the fall and she did not know if that RN assessed Resident #1 after his second fall. When the resident developed pain after the fall the LPN should have notified the physician or the RN for further direction and she did not think the LPN had done that. She did not question the LPN supervisor further regarding the incident and did not question the RN that was reported to be in the facility at the time of the incident to ensure a complete and thorough assessment was done. An RN assessment was important as assessing is outside the scope of an LPN and there could be a possibility an LPN could miss an injury. After receiving the phone call from the LPN in the early AM she had to be in the facility for another matter and she was told by one of the day nurses the resident was complaining of pain. She went in to assess the resident and he had complained of pain to the left hip, the leg was flexed and he had pain upon palpation. She notified the on call physician who ordered an x-ray. The family was in the facility at the time she assessed the resident and they were upset the nurse had waited until 5:00 AM to notify them. During an interview with LPN #21 on [DATE] at 6:05 AM she stated she had worked for the facility for about 2 months and was originally hired to work on the unit and was then put in the position of nursing supervisor. She had not received any training in supervising by the facility and had worked as a nursing supervisor at other facilities under the direction of RN #10. Her supervising responsibilities including monitoring staff and responding to any codes called. When she arrived for her shift she would also get a verbal report from the previous shift RN or supervisor. There was not always an RN in the facility however there was always an RN oncall and available by telephone if an incident such as a fall occurred. She was not to move a resident if there was an injury and was to call the RN for direction. If there was no apparent injury she would get an LPN assessment which included moving the resident's arms and legs and check for any pain. She would ask the resident if they had any pain. She would then call the RN and notify them of her findings and the RN would give permission to move the resident. She was supposed to document who she called and what the RN's direction was in the nursing progress notes. She stated Resident #1 fell on [DATE] at around 10:30 PM. She stated she had responded to a code call and entered the resident's room to find him lying on the floor. The resident had stated he just sat down on the floor. She stated RN #4 was in the facility at the time of the resident's fall and she thought the RN had assessed the resident. She has assumed RN #4 completed the resident's assessment and the RN did not communicate or give her report before leaving the facility and she had not attempted to follow up with the RN. She stated she had provided a statement that documented the RN in the facility was notified and she did not know if the RN had assessed the resident and who had gotten the resident back into bed. Later in the shift she was notified by staff on the unit the resident was yelling out in pain. She went in to assess the resident and he was sitting up, not yelling out and did not appear to be in any pain but he did state he was having an muscle spasm. She went and reviewed the resident's record and determined he did not have any medication for muscle spasms and that he was confused and not a reliable historian. She stated she had called the DON, physician and family around 5:00 AM and did not know why she waited that long. She did not call an RN or the physician after she was notified of the resident complaining of pain as he appeared comfortable. She reported to the physician, family and DON that morning the resident had no injuries as she did not think he did. During an interview with RN #24 on [DATE] at 12:10 PM she stated was currently the acting DON, had been filling in for the past several weeks until a new DON started, which was the next day. RN #10 was the DON when the resident had fallen on [DATE] however she had been working in the facility and overseeing operations. She was out for a few days when the incident with Resident #1 occurred and upon her return she was notified of the incident that the resident fell and he fractured his hip. She was the DON of the facility when the DOH arrived on ,[DATE] and then she reviewed the resident's incident report again and then questioned if the resident had an RN assessment. She requested further clarification from RN #10 at the time as to what happened and she had then called the RN that was reported to her to be in the facility at the time of the fall. She did not get a written statement from the RN but the RN told her she was not aware of the fall and she did not assess the resident. She did not do any further investigation or plan of correction and did not question if LPN did the assessment or determine if the resident was treated timely. She did not identify the LPN did not call the physician, DON and family until 5:00 AM and the LPN should have called the RN to direct her assessment of the resident as well as contacted someone when the resident developed pain in his hip. She reviewed the resident's MAR and stated she had not reviewed it as part of her investigation when more questions regarding the incident arose. She stated the resident's pain was a ,[DATE] at the time of Tylenol administration and appeared to not be effective as the resident's pain level at 4:10 AM was an ,[DATE] and the physician should have been notified for further orders. During an interview with the facilities Medical Director on [DATE] at 2:05 PM he stated if a resident fell the RN would assess the resident to determine if an injury was sustained and then fill out an incident/accident report and notify the physician. The on-call provider was available at any hours as the nurses are told they are not alone out there. If there was no RN in the facility at the time of the fall the LPN should call the RN on the phone, or the medical provider or 911 to assist with the resident' assessment. If the resident developed pain after a fall the nurse would use her nursing judgement to determine root cause of the pain and give pain medication. If no effect from the pain medication the on-call provider would be contacted for additional pain medication and possible x-ray in the morning. He was not aware of any specific information on Resident #1 and his fall on [DATE]. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment, required extensive assistance of two persons with transfers and walking, and extensive assistance of one for hygiene and eating and limited assistance for bed mobility. The resident did not have shortness of breath and did not use oxygen. The comprehensive care plan (CCP) effective [DATE] documented the resident had potential for alteration in respiratory and cardiac function related to [MEDICAL CONDITION]. There were no documented goals, interventions or notes for this focus. A licensed practical nurse (LPN) #2 progress note dated [DATE] at 2:19 PM documented the resident had a brief episode of unresponsiveness in the dining room during lunch. Respirations were erratic, color dusky. O2 (oxygen) via nasal cannula applied upon return to unit by LPN. Vital signs were temperature 96.1, heart rate 92, respirations 24, blood pressure ,[DATE] and oxygen saturation was 94%. The nursing supervisor was aware of the episode and on the unit to assess. Next shift to monitor. There was no documented evidence the resident was assessed by a registered nurse (RN) at the time of the unresponsive episode and there was no documented evidence the resident was monitored until the next morning. RN #10's documentaton on [DATE] included: - At 7:35 AM she observed the resident sitting in the hall visibly labored, rapid respirations, skin cool dusky, denied pain or discomfort, on 2 liters O2, lungs diminished throughout. Staff reported the resident had this issue all weekend. Call placed to on call medical provider, no response, message left, await call back. - At 8:28 AM no response from the oncall physician was received a second call was made with no answer. The resident's attending physician #11 was called and updated and a new order for chest x-ray was obtained and to continue to monitor. -At 9:33 AM physician #11 ordered [MEDICATION NAME] 20 mg IM x 2 days, BMP and BNP in the AM. -At 12:42 PM the on call physician was called x 2 and his voice message box was full. Physician #11 notified and updated the resident had recieved the [MEDICATION NAME] at 10:00 AM, x-ray results were pending and the resident's breathing remained labored, she appeared uncomfortable, moaning and groaning. -At 2:15 AM, able to get a hold of on call physician. X-ray results showed [MEDICAL CONDITIONS] with [MEDICAL CONDITIONS] and pneumonia. The result reviewed with the physician and he ordered [MEDICATION NAME] ([MEDICATION NAME]) as need for shortness of breath and Levoquin (antibiotic). A physician assistant (PA) progress note dated [DATE] documented he was asked to review the resident's chest X-ray and evaluate her for [MEDICAL CONDITION] versus pneumonia. The resident had crackles (lung sounds) of the right lower lung lobe and intercostal retractions (chest muscles pull sharply inward). The plan was to initiate [MEDICATION NAME] nebulizer and reassess her in one week. Any changes should be brought to his attention by the nursing staff. A nursing note dated [DATE] at 2:02 PM documented the resident expired. During an interview with RN #10 on [DATE] at 3:10 PM she stated she had noted the resident was short of breath on the morning of [DATE], her color was gray and she complained of not feeling well. She was told by an LPN on the unit the resident had been like that all weekend. She notified the physician the change in the resident's condition and he ordered [MEDICATION NAME], chest x-ray and labs. During an interview with the Director of Nursing (DON) on [DATE] at 3:35 PM she stated if a resident had a change in condition they were consistently monitored and the 24 hour report was used for shift to shift report and was generated from nursing progress notes. RN #10 was interviewed a second time on [DATE] and stated shift to shift report was done utilizing 24 hour report that was generated from nursing progress notes and resident's change in condition should have been documented to ensure she was monitored. She had not been notified in morning report about the resident having a change in condition and when she saw the resident she noticed she was short of breath and that was when one of the LPN's told her she had been like that all weekend. She reviewed the resident's progress notes and noticed that she had an episode of unresponsiveness over the weekend and she had spoken to RN #7 about it and he reported to her the resident's vital signs had been stable. She called the resident's family to report the resident's condition and it was decided the resident would be made comfort care. The resident was placed on [MEDICATION NAME] based on her x-ray results which showed pneumonia. During an interview with physician #11 on [DATE] at 5:30 PM he stated he was not familiar with the resident and had not previously evaluated her. The nurse had called him and told him the resident had a history of [REDACTED]. He had ordered a chest x-ray and labs to determine what her electrolytes were and what her kidney function was as well as a BNP to determine if she was in heart failure. He had wanted the labs done that day or at the latest the next day and would have dictated treatment. He had not been called with the results and was not aware they were not done until today. He was not aware the resident had expired. He would prefer the labs to have been done when he ordered them however did not feel it would have changed her outcome. During an interview with RN #7 on [DATE] at 11:15 AM he stated if a resident had a change in condition such as an episode of unresponsiveness he would assess the resident, check their vital signs and then notify the physician. He would document his assessment in the medical record and the physician notification and what the physician wanted done. Ongoing monitoring of the resident would be done by the following shifts and they would know about the resident's change in condition from 24 hour report that was generated from progress notes. He stated he was not told the resident had an episode of unresponsiveness and if he had he would have assessed the resident and called the physician as she has had a similar episode related to her [MEDICAL CONDITION] in the past and she would have been treated more timely. During an interview with LPN #2 on [DATE] at 11:30 AM she stated if a resident had a change in condition she would notify the RN so the resident can be assessed and the physician notified. When Resident #9 had an episode of unresponsiveness in the dining room the RN supervisor was notified and assessed the resident and directed her to monitor the resident. Those directions were verbally passed onto the next shift and does not recall having used computer generated progress notes for shift to shift report. During an interview with the acting DON #24 on [DATE] at 12:10 PM she stated if a resident had a change in condition and there was an RN available she would expect an RN to complete an assessment of the resident, document and call the physician for orders and direction. Ongoing monitoring of the resident would be done by verbal report and documentation in progress notes. During an interview with the facility's Medical Director on [DATE] at 2:05 PM he stated if there is a change in the resident's condition and RN would assess the resident, document and notify the physician for treatment orders. Ongoing monitoring and assessment would be warranted to ensure the resident's condition was stable. This could possibly change the resident's outcome and was difficult to determine if treatment imitated earlier would have been helpful. During a second interview with physician #11 on [DATE] he stated if a resident had a change in condition he would expect the RN to assess the resident and notify the on call provider so treatment can be initiated and ongoing monitor. He would want to be notified as soon as possible to treat as conditions come up. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DATE] Minimum Data Set (MDS) assessment documented the resident's cognition was intact and he required limited assistance with transfers and personal hygiene and extensive assistance with toileting. The comprehensive care plan (CCP) dated [DATE] documented the resident was at risk to fall and interventions included to evaluate for risk factors that may contribute to falls and keep environment free of potential hazards. An incident/accident report dated [DATE] at 9:00 PM, completed by LPN #15 documented when she entered the resident's room he was sitting on the floor with his back up against the bed. The resident stated he was trying to go to the bathroom. The fall was unwitnessed. The resident did not have any apparent injuries. The LPN documented she was the nursing supervisor that shift so she had called out into the hallway for assistance from the certified nurse aides (CNA) for help getting the resident back into bed. The report documented the physician and the resident's family were notified of the fall at 9:50 PM. There was no documented evidence neuro checks were initiated for this resident after an unwitnessed fall. There was also no documented evidence a qualified person was notified to assist the LPN with the assessment of the resident after a fall and there was no documented evidence the resident was followed up with by a qualified person. During an interview with LPN #15 on [DATE] at 2:10 PM she stated she would occasionally work as the nursing supervisor. If a resident fell and there was no RN in the facility she would ask the resident if anything hurt, move their extremities and if there was no apparent injury they would get the resident back into bed and then notify the RN and physician about the fall. If there was an injury she would not move the resident and call the RN for direction. During an interview with RN #10 on [DATE] at 11:55 AM she stated if a resident had a fall and there was no RN in the facility the LPNs were instructed to call the DON or the ADON and they would direct the assessment over the telephone. If an RN directed the LPN in the assessment after a fall by telephone there was no need for a follow up RN assessment if there was no injury. RN's should document the directions and she did not know if that was taking place. 10NYCRR 415.12

Based on record review and interviews during the recertification and abbreviated surveys (NY 763, NY 404 and NY 425) the facility did not ensure residents were free of significant medication errors for 4 of 13 residents (Residents #26, 61, 466 and 514) reviewed for medications. Specifically, Resident #26 had 5 doses of [MEDICATION NAME] (narcotic pain reliever) omitted due to unavailability and there was no documented evidence the physician was notified of the omissions; Resident #61 had physician orders [REDACTED].#466 had multiple omitted medications, including insulin, and there was no documented evidence the omissions were communicated to the physician; Resident # 514 had a physician order [REDACTED]. This resulted in actual harm to Resident #61 that was not immediate jeopardy. Findings include: 1)Resident #61 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 12/27/2017 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment and all activities of daily living (ADLs) occurred only once or twice in the 7-day reference date. The resident received insulin 7 of the last 7 days and the physician had changed the insulin order twice in the last 7 days or since admission. Physician orders [REDACTED]. A physician order [REDACTED]. A physician order [REDACTED]. A 12/14/2017 nurse practitioner (NP) progress note documented the resident's blood sugars continued with fluctuation ranging from 76-403 (normal fasting range for adults with diabetes per American Diabetes Association 80-130 mg/dl). The plan was to add Humalog coverage per sliding scale three times per day and follow up for recheck in one week. An NP progress note dated 12/26/2017 documented the resident had fluctuating blood sugars ranging from 67-497. The plan was to change [MEDICATION NAME] to 20 units and continue Humalog sliding scale. A physician order [REDACTED]. A pharmacy urgent non-covered medication sheet dated 1/16/2018 documented Humalog was not paid for by the resident's insurance plan and an alternative option was listed as [MEDICATION NAME]. The NP signed the sheet on 1/25/2018 authorizing the order to be changed as indicated by pharmacy. An NP progress note dated 1/30/2018 documented the resident was on [MEDICATION NAME] 20 units and Humalog coverage per sliding scale. The pharmacy was requesting consideration of changing Humalog to [MEDICATION NAME] and she would approve per request. Continue current sliding scale coverage and frequency. There was no nursing documentation on 1/30 or 1/31 referencing the change in insulin from Humalog to [MEDICATION NAME]. The (MONTH) (YEAR) medication administration record (MAR) documented the resident had an order for [REDACTED]. The boxes for administration from 1/30 at 5:00 PM and all of 1/31 had x in the boxes without nursing initials, indicating the medication was not provided. Fingersticks were documented on 1/30 as 106 at 7:30 AM, 285 at 11:30 AM, 343 at 5:00 PM, and 343 at 9:00 PM. On 1/31 fingersticks were documented as 268 at 7:30 AM, 179 at 11:30 AM, 400 at 5:00 PM and 353 at 9:00 PM. There was no documentation Humalog sliding scale was administered after the 6 units was administered on 1/30 at 11:30 AM. Review of the MAR revealed there was no order for [MEDICATION NAME] sliding scale coverage. Fingersticks were completed with no indication the resident was receiving insulin coverage as planned. The (MONTH) (YEAR) MAR documented Humalog sliding scale at 7:30 AM, 11:30 AM, 5:00 PM and 9:00 PM with a start date of 2/1/18 at 12:44 PM. On 2/1 there was an X in the boxes for 7:30 AM and 11:30 AM. Fingersticks were documented on 2/1 as 511 at 7:30 AM only. An NP progress note dated 2/1/2018 documented the resident was seen due to elevated blood sugar. Nursing had reported the fingerstick was 511 at 7:00 AM. An order was given for 12 units of regular insulin per sliding scale coverage. The NP was called to the resident's room at 12:00 PM with reports of unreadable blood sugar. A verbal order was given to administer 10 units of regular insulin and repeat blood sugar in one hour. At that time the resident's family member informed the NP that [MEDICATION NAME] did not work for treatment of [REDACTED]. Allergy to [MEDICATION NAME] was added to the resident's medical record. A nursing progress note dated 2/1/2018 at 6:38 PM documented the NP was notified of the resident's fingerstick reading of 511 that morning. A new order was received to administer the resident's [MEDICATION NAME] and recheck in one hour. When the fingerstick was rechecked the machine result was HI. The NP was notified with a new order to administer 10 units of [MEDICATION NAME] and recheck in 1 hour. The [MEDICATION NAME] was administered and when the fingerstick was rechecked it again read HI. The NP assessed the resident at that time and the resident's family member requested he be sent to the ER for evaluation. A hospital discharge summary dated 2/5/2018 documented the resident was admitted to the hospital with [REDACTED]. The NP was interviewed on 2/7/2018 at 1:33 PM. She stated pharmacy sent a recommendation to consider changing to [MEDICATION NAME] and she changed it. When she was dictating her progress note she noticed the Humalog was still in the computer and she discontinued the Humalog fearing he would get both insulins. She did not realize the [MEDICATION NAME] order had never been put in the computer. She had changed the insulin to [MEDICATION NAME] with a handwritten order as well as the pharmacy sheet she had signed. At no time did she discontinue blood sugar testing and she thought the medication nurse would have noticed the resident was having fingersticks done and did not have sliding scale insulin coverage. On the day his fingerstick was 511 she was not aware he had not been receiving his insulin coverage and there was no insulin order and she confirmed he had received his [MEDICATION NAME]. RN #14 was interviewed on 02/09/18 at 11:40 AM and stated she was on the medication cart on Thursday 2/1 during the day. She tested the resident's fingerstick and it was 501. The NP was on the unit and was told to give [MEDICATION NAME] and sliding scale coverage. There was no longer a sliding scale in the MAR, she did not know where it went. She stated the licensed practical nurse (LPN) who was on the cart more frequently should have alerted her as she knew what the resident usually gets. He did not have any signs or symptoms of [MEDICAL CONDITION]. She then received an order for [REDACTED]. The family member was in the room and the fingerstick still would not register. The NP went in and the family member wanted him sent to the hospital and 911 was called. When pharmacy makes recommendations on the sheet she places it in the communication book for the NP or physician and she rarely looked at them. The NP would usually look at them and change it in the electronic MAR or write the order on paper. Medical providers could discontinue orders in the electronic MAR. 2) Resident #466 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 12/22/2017 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired and she required extensive assistance for most activities of daily living (ADLs). The comprehensive care plan (CCP) dated 11/20/2017 documented the resident had diabetes and interventions included to monitor blood glucose levels per physician orders. The Medication Administration Record (MAR) on 12/24/2018 documented a dash (the MAR legend documented a dash meant not documented) in the administration box and no staff initials for: -Fingerstick due at 7:30 AM and again at 11:30 AM -[MEDICATION NAME] (long acting insulin) 14 units due 8:00 AM -[MEDICATION NAME] 1,000 milligrams (mg) due at 8:00 AM -Aspirin 81 mg due at 8:00 AM -[MEDICATION NAME] 75 mg due at 8:00 AM -[MEDICATION NAME] 20 mg due at 8:00 AM. The resident's fingerstick was documented as completed on 12/24/2018 at 5:00 PM with results of 426 milligrams per deciliter (mg/dl). There was no documented evidence the elevated glucose or the omitted medications on 12/24/2018 in the morning was communicated to the physician. The MAR on 1/13/2018 documented a dash in the administration box and no staff initials for: -Fingerstick due at 7:30 AM and again at 11:30 AM -[MEDICATION NAME] 1,000 milligrams (mg) due at 8:00 AM -Aspirin 81 mg due at 8:00 AM -[MEDICATION NAME] 75 mg due at 8:00 AM -[MEDICATION NAME] 20 mg due at 8:00 AM The resident's fingerstick was documented as completed on 12/24/2018 at 5:00 PM with results of 356 mg/dl. There was no documented evidence the omitted medications on 1/13/2018 were communicated to the physician. During an interview with registered nurse (RN) #8 on 2/8/2018 at 10:38 PM he stated he was the weekend supervisor, however would frequently also have to take a medication cart. Sometimes he was the second nurse on the unit and other times he was the only nurse on the unit passing medications and would have to do that on top of his supervisory responsibilities. He stated there was a dashboard on the computer that would show what medications had not been done or signed for. He stated he did not have time to review the dashboard before he was on to his next task. He did not know what happened on 12/24/17 and 1/13/18. During an interview with the NP on 2/7/2018 at 1:35 PM she stated she was not notified the resident did not receive her medications on those days and would expect to have been notified. She stated the facility was frequently short staffed and there were ongoing issues with orders not being carried out as there was staffing shortages and a lot of the nurses working were agency nurses who were not familiar with the residents and their needs. 3) Resident #514 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact, required extensive to total assistance with most activities of daily living (ADLs) and frequently had pain with the worst pain at 6 on a 0-10 scale. A hospital history and physical dated 3/15/2017 documented the resident had a [DIAGNOSES REDACTED]. Hospital discharge orders dated 3/16/2017 documented to continue taking Aubagio 14 milligrams (mg). The last dose given in the hospital was 3/16/2017 at 8:33 AM. Physician orders [REDACTED]. A nurse practitioner admission progress note dated 3/17/2017 documented the resident had MS and was receiving Aubagio. A physician admission history and physical dated 3/19/2017 documented current medications included Aubagio 14 milligrams (mg) once daily. The assessment included exacerbation of MS with severe weakness of her legs. Medication administration records documented; -March (YEAR) Aubagio was not administered from 3/17-3/31, not available; -April (YEAR) Aubagio was not administered on 4/1-4/3, not available. A physician order [REDACTED]. The order for Aubagio 14 mg once daily was renewed on 4/12/2017 at 12:28 PM. Nursing progress notes were reviewed from 3/16-4/20/17, when the resident was discharged to home. On 4/2/2017 a licensed practical nurse (LPN) documented Aubagio 14 mg not available from pharmacy, supervisor notified. There no documented evidence prior to 4/2/2017 the Aubagio was not available, the medical providers were notified or action was taken regarding unavailability. An Accident and Incident investigation summary dated 5/16/17 documented 4 LPNs who did not administer the Aubagio all stated they believed the medication had been ordered and pharmacy had been informed by another licensed nursing staff member. There was no documented evidence of communication to nursing supervisor, medical provider or pharmacy that the medication was not being administered as ordered from 03/17/2017 through date of discovery of error 04/02/2017 and no medication variance forms completed by those staff members. Facility Pharmacist interviewed 02/05/2017 at 03:20 PM stated the resident's medication was a specialty medication that needed to be ordered from the pharmacy's own specialty pharmacy. He said that the facility had been called by a pharmacist on 03/17/2017 and on 03/21/2017 to inform them that the medication required an ok for special order from the facility for the medication to be obtained by the pharmacy. The Director of nursing (DON) was interviewed on 2/1/2017 at 11:00 AM. He stated the e-refill system would identify if an order had been accepted. If the medication was not available for the next dose the medication nurse should notify the supervisor and fill in a medication variance form. There was no medication variance form completed by any of the nurses who documented the medication was not available. All staff received education about medication variance during orientation. He stated the pharmacy would call the facility with any refill problems or discrepancies with orders and he heard from them daily. He stated the nurse practitioner (NP) at the time was not informed of the incident and the medical communication book did not reference the issue with the Aubagio until 4/5/2017. He stated the NP was in the facility many days a week including weekends. Registered nurse #15 Assistant Director of Nursing (ADON) was interviewed on 2/1/2018 at 2:18 PM. She stated if a medication variance was discovered the nurse should call the physician, obtain a new order or direction and write a progress note. RN #8 was interviewed on 2/5/2018 at 10:15 AM. He stated he had filled in the medication variance for the unavailable Aubagio. When a medication was not available it should be documented on the front and back of the MAR and in nursing progress notes. The physician should be notified and a variance form filled in at that time. 10NYCRR 415.12(m)(2)

Based on observations, record reviews, and interviews conducted during the recertification and abbreviated surveys (NY 101), the facility did not ensure 7 of 20 residents (Residents #33, 36, 38, 48, 165, 167, and 373) reviewed for pressure ulcers received care and services to promote healing and to prevent new pressure ulcers from developing. Specifically: - Resident #36 was seen at the wound care center for a pressure ulcer and recommendations were not communicated to the provider. The treatments were not done consistently and the resident was not provided with a Roho cushion. - Resident #373 developed pressure ulcers on her heels and treatments and interventions were not done in a timely manner. - Resident #38 was reported as having a healed pressure ulcer in December, and treatments not being done resulting in a worsened pressure ulcer. - Resident #165 was admitted with pressure ulcers on his heel, developed a new pressure ulcer on his coccyx. Interventions including floating the heels and an alternating pressure mattress were not implemented, and the treatments for his heels and coccyx were not done as ordered. - Resident #167 developed pressure ulcers after admission that were not assessed timely by a qualified professional, and unlicensed staff were observed applying a cream to the open areas that was not ordered. - Residents #33 and 48 had treatments that were not done as ordered. This resulted in actual harm to Resident #373 that is not immediate jeopardy. Findings include: 1) Resident #373 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's cognition was impaired, she required extensive assistance with bed mobility and she had a pressure ulcer. The facility's undated Skin Care Protocol documented all new admissions scoring high risk on a skin assessment will be reviewed during the weekly team meeting, current interventions will be discussed and the care plan/care card will be revised a s indicated. The admission nursing assessment will be brought to the next morning meeting following a resident's admission to allow for IDT discussion on preventative/treatment skin care planning interventions. A hospital discharge summary dated 1/19/2018 documented the resident had a Stage III pressure ulcer on her coccyx and a skin ulcer on the right lower leg. The resident was at high risk for further skin breakdown. The admission nursing assessment dated [DATE] documented the resident had a Stage III pressure ulcer on the left buttock that measured 1-centimeter (cm) x 2 cm x 0.1 cm. The admission assessment also documented the resident was only a mild risk for developing further pressure ulcers. The 1/19/2017 comprehensive care plan (CCP) documented the resident was incontinent of bowel and bladder and she had a Foley catheter (tube that drains urine). The resident also had a Stage III pressure ulcer and an alteration in mobility. Interventions included a check and change scheduled every 2-3 hours, extensive assistance of 2 for bed mobility, position changes every 1-2 hours when out of bed and every 2-3 hours when in bed. She required a pressure reducing mattress/cushion and heels elevated in bed. A nurse practitioner (NP) progress note dated 1/19/2018 documented the resident had Stage III pressure ulcer on the left buttock that measured 1 cm x 2 cm x 0.1 cm and the wound bed was 100% red. A NP progress note dated 1/23/2018 documented the resident was incontinent of bowel and bladder and it was noted the resident socks were saturated. Daughter reported the resident was incontinent of bladder. The resident's heels were examined and the following was observed: -Unstageable pressure ulcer on the left heel that measured 1.2 cm x 2 cm x 0.1 cm and the area contained a deroofed blister. -Deep tissue injury of the right heel that measured 2.5 cm x 3 cm. -The pressure ulcer on the coccyx measured 1.2 cm x 2 cm x 0.1 cm Physician orders [REDACTED]. - to apply an alternating air mattress to the resident's bed, -blue booties to heels while in bed -Foley catheter for urinary incontinence and worsening wound -[MEDICATION NAME], ABD pad and kerlix to both heels to be changed twice daily. -Turn and reposition every 2 hours -Roho cushion in wheelchair During an interview with CNA #17 on 1/24/2018 at 08:12 AM she stated most day shifts they would work with only 3 CNA's for 35- 40 residents and typically only 1-2 CNA's for the evening shift. They were not able to get resident's up in the morning and they would have to wait to get up late, showers did not get done as there was not enough time, turning and positioning and they were not able to get resident's toileted at times or not timely. Resident #373 was observed on 1/24/2018 at 10:00 AM in her wheelchair in the hallway in front of TV. Kerlix dressings were on both feet, she wore pink socks and both feet were resting directly on the metal foot rests. The resident was sitting on a blue gel cushion and no Roho cushion was observed. During an interview with CNA #7 on 1/24/2018 at 2:15 PM she stated she would know by the CNA care card how often a resident was to be toileted or repositioned or if they need any special pressure relief interventions. On 1/24/2018 at 2:21 PM the resident's family member, Unit Manager and a licensed practical nurse (LPN) were in the resident's room with a Hoyer lift putting the resident back to bed. The daughter stated she had been asking for the resident to be put back to bed as she had been up in the wheelchair all day. The resident's wheelchair was observed and she had a blue gel cushion, no Roho cushion. On 1/24/2018 at 2:38 PM the registered nurse (RN) #14 Unit Manager stated the resident was gotten up that morning in her wheelchair so they could place the alternating air mattress on the bed and they were just getting to put her back to bed. They were going to put the Foley catheter in now as it was ordered yesterday and she had not had time to do it yet. Her treatment had not been completed yet as she had been in the hallway all day and she was supposed to be going home as her shift ended at 2:00 PM. On 1/24/2018 at 2:45 PM the resident's wheelchair contained a Roho cushion in place of the blue cushion. The Nurse Manager stated Physical Therapy had just brought the cushion in. She had not put the Foley catheter in yet as she had not had time to do it or her treatment, she just couldn't get to it. During an interview with the Rehabilitation Director on 1/24/2018 at 2:50 PM she stated she was just notified that the resident required a Roho cushion and she had just brought it down to her room and placed in her wheelchair. The resident had been issued the standard blue gel cushion upon her admission and a Roho cushion was only used for residents with skin breakdown on their bottoms. She was not aware the resident was admitted with a pressure ulcer and had she known she would have issued the Roho cushion rather than the standard blue gel cushion. During a follow-up interview with CNA #7 on 1/24/2018 at 3:00 PM she stated she had gotten the resident up and put it in her wheelchair at 9:30 AM and she had not provided any further care to the resident as she did not have time before the end of her shift at 2:00 PM. She was still here as she was still finishing her documentation. During an interview with the Registered Dietitian (RD) on 1/24/2018 at 3:15 PM she stated the resident had not yet been weighed by the staff and she was no able to accurately complete a nutritional assessment. She was not aware the resident had a pressure ulcer and she would need the resident's weight and skin condition to accurately assess what her calorie, hydration and protein needs would be. During an observation on 1/24/2017 at 3:08 PM, the resident was in bed with no booties on her feet and no booties observed in the room. During a skin observation on 1/24/2018 at 3:30 PM the resident did not have any booties on her feet. There was a deep tissue injury to the bottom and back of the right heel with various color of red and dark purple. The to the bottom and back of left heel there was a deep tissue injury with various colors of bright, dark red and blackened skin to the lower aspect. There was a large intact blister to the inner aspect of the heel. The resident had a Stage III pressure ulcer to the right buttock and a red intact area on the left buttock and the Nurse Manager stated that was from her sitting on her bottom all day. The resident was observed on 1/25/2018 at 7:25 AM lying in bed on her back, she did not have any blue booties in place. During an interview with the NP on 1/25/2018 at 10:00 AM she stated there was a lack of reporting to providers and worsening resident conditions as there was not enough nursing staff. She was not being informed of changes or worsening of resident's condition and her orders were not being followed and she was not being notified of that. The resident was admitted to the facility with a Stage III pressure ulcer and when she evaluated her on the day of admission the resident did not have any pressure ulcers on her heels. The next evaluation she noticed the resident did not have any pressure relief on her heels when she looked the resident deep tissue injuries to both heels and had not been notified of the pressure ulcers prior to her exam. The resident was a high risk for developing further pressure ulcers and preventive pressure relief measures were not initiated for the resident and she developed further pressure ulcers. That was the responsibility of the Nurse Manager to initiate those preventative measures and she was frequently passing medications on her unit as there was no other nurses to do it. She had ordered the resident a Foley catheter as it was a concern she was not being toileted to ensure healing of the pressure ulcer on her buttock and had not been notified of the Foley catheter was not placed until yesterday and she was would want to be notified if not able to place it in a timely manner. 2) Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognition was intact and she required extensive assistance with bed mobility, transfers, dressing, toilet use, hygiene, and bathing. She had open [MEDICAL CONDITION], surgical wounds, and a Stage II pressure ulcer present on admission. Skin and ulcer treatments included: pressure reducing device for the chair and bed, nutrition or hydration intervention, pressure ulcer care, and surgical wound care. The MDS did not document turning and positioning program as an intervention. The nursing progress note dated 10/19/2017 documented the resident had a Stage II pressure ulcer on her coccyx and measured 1-centimeter (cm) x 1 cm x 0.5 cm (length x width x depth); it was covered with Allevyn (absorbent water-proof protective dressing). A nurse practitioner's (NP) progress note and order dated 10/25/2017 at 7:35 AM, documented the resident had an unstageable sacral pressure ulcer that measured 0.7 cm x 0.5 cm x 1.5 cm and the wound bed was 100 % slough (dead tissue). The ordered treatment was to gently irrigate the sacral wound with normal saline (NS), apply Santyl (ointment to remove dead tissue) to the wound bed, pack with [MEDICATION NAME] Ag (silver impregnated antimicrobial dressing), and cover with Allevyn daily and as needed. The NP progress noted dated 10/31/2017, documented the resident was seen for examination of an unstageable pressure ulcer on the sacrum. The wound measured 1 cm x 0.5 cm x 1.7 cm, the wound bed was 100 % slough, and there was a moderate amount of tan drainage. The plan was to refer the resident to the wound care center for management of the pressure ulcer to the sacrum. The same treatment was continued. The NP's order dated 10/31/2017, documented to send the resident to the wound care center for an unstageable pressure ulcer on the sacrum and for the open abdomen wound. The NP note 11/14/2017, documented the sacral wound measured 4 cm x 2 cm x 1 cm and was increased in size due to maceration of the sacrum associated with bowel incontinence. The wound bed was 60 % red and 40 % slough with a small amount of serosanguineous (blood tinged serum) to tan drainage. The treatment was unchanged. There was no documented evidence the resident's sacral wound was assessed by a qualified professional from 11/1/2017 through 11/13/2017. A nursing note dated 11/30/2017 at 4:29 PM, documented the resident returned from the wound care clinic with an order to implement an air mattress and a notation that her wounds were clean and granulating well. The discharge instructions from the wound care center dated 11/30/2017 documented: - Follow-up appointment in 1 month. - Change dressing to the sacrum every day or as needed for excessive drainage; - cleanse the sacrum with mild soap and water prior to applying a clean dressing; - cut [MEDICATION NAME] Ag (or [MEDICATION NAME] Ag) to size and apply to wound bed; and - cover sacrum with [MEDICATION NAME] gentle (absorbent water-proof dressing with gentle adhesive). - Off-Loading: Roho cushion (specialized air cushion to redistribute pressure) for the wheelchair; turn and reposition every 2 hours; and stay off the buttocks as much as possible. There was no documented evidence the physician or NP were notified of the discharge instructions from the wound care center and no documented evidence the resident's sacral wound was assessed by a qualified professional from 11/15/2017 through 11/30/2017. The dietary note dated 11/21/2017 at 6:54 PM, documented the resident had an unstageable wound on the coccyx and the resident absolutely declined trying or adding any protein containing supplements. The resident received 128 grams of protein per day which was 110% of her estimated needs. The NP's progress note dated 12/5/2017, documented to continue wound treatment as recommended by the wound care center. The resident's sacral wound was treated with NS and Santyl, then packed with [MEDICATION NAME] Ag, covered with Allevyn, and changed daily as needed. The NP progress note dated 12/13/2017 at 11:21 AM, documented the resident's sacral wound was a Stage IV, it measured 0.5 cm x 0.5 cm x 0.4 cm and the area appeared improved since last seen by her. The wound was irrigated with NS and Santyl, then packed with [MEDICATION NAME] Ag, covered with Allevyn, and changed daily as needed. The resident was concerned that her ROHO cushion appeared deflated and the previously ordered APM mattress was not on the bed. The NP recommended the resident continue with weekly wound center visits. The NP progress note dated 12/19/17, documented the resident's Stage IV pressure ulcer on the sacrum appeared closed. There were no changes made to the resident's treatment order for the sacral wound. The treatment administration record (TAR) dated 12/1 - 12/31/2017, documented the treatment to the sacral wound was to irrigate with NS, apply Santyl to wound bed, pack with [MEDICATION NAME] Ag, and cover with Allevyn. The treatment was documented as being done only 18 of 31 days. The consult sheet and discharge instructions from the wound care center dated 1/4/2018 documented: - The Stage IV sacral wound was debrided, she had [MEDICAL CONDITION] and was prescribed [MEDICATION NAME] 875 milligrams (mg) twice a day for 14 days. - Change dressing to the sacrum every day or as needed for excessive drainage; - cleanse the sacrum with mild soap and water prior to applying a clean dressing; - cut [MEDICATION NAME] Ag (or [MEDICATION NAME] Ag) to size and apply to wound bed; and - cover sacrum with [MEDICATION NAME] gentle (absorbent water-proof dressing with gentle adhesive). - Roho cushion for the wheelchair, a prescription was given at the last visit, please call if further information was needed to obtain Roho. - Follow-up appointment in 1 month. The consult did not document the location of the resident's [MEDICAL CONDITION]. The nursing progress note dated 1/4/18, documented the NP was notified resident returned from the wound care center with orders including a Roho cushion for the Stage IV pressure ulcer on sacrum. The sacral wound was debrided and to start [MEDICATION NAME] for 14 days for [MEDICAL CONDITION]. The note documented the Roho was in place. There was no documented evidence the resident's sacral wound was assessed by a qualified professional from 12/20/2017 through 1/3/2018. The dietary note dated 1/11/2017 at 1:55 PM, documented the resident's sacrum had reopened to a Stage IV and 1 ounce of Prostat (high protein supplement) would be trialed twice daily. During a dressing change observation on 01/30/18 at 9:08 AM, licensed practical nurse (LPN) #6 removed the prior dressing with a moderate amount of serosanguinous (blood tinged serum) drainage and cleansed the open area on coccyx with normal saline (NS). She patted it dry with a piece of gauze and applied Santyl with a cotton swab to the base of the wound. She then tore a piece of [MEDICATION NAME] Ag and used a cotton swab to pack it in, and covered the site with an [MEDICATION NAME] dressing. She then proceeded to do the resident's abdominal dressings. A gel cushion was observed in the wheel chair. The resident's care card (care instructions) printed on 1/31/2018 documented the resident had a gel foam cushion for the wheelchair with a blue dycem on top of the cushion and required position changes every 2-3 hours. The card also documented she required extensive assistance with 2 staff members for bed mobility, toilet use, dressing, bathing, and transfer which also required a mechanical lift. During an interview with the resident and a family member on 1/31/18 at 4:39 PM, the resident stated the dressing on her sacrum was not changed every day and if LPN #6 was not working, her treatments were not done. She stated she was supposed to have a Roho cushion and they gave her a different type. She stated she was going to the wound care center tomorrow and went monthly. The resident had a gel cushion in her chair. The TAR dated 1/1/18 - 1/31/18, documented to gently irrigate the sacral wound with NS then apply Santyl to the wound bed, pack with [MEDICATION NAME] AG, cover with Allevyn, and change daily and as needed. The treatment was documented as done on 17 of 31 days. The resident was observed on 2/1/18 at 2:30 PM sitting in her wheelchair in the hall. The resident stated she returned from the wound care center little while ago. She pointed to the medication cart and stated the wound care report was in the envelope on top of the cart. She had a gel cushion in the wheelchair. The discharge instructions from the wound care center dated 2/1/2018 documented: - The resident needed a Roho cushion for the wheelchair. - 3 pieces of [MEDICATION NAME] Ag strips were packed into the wound. - MAY CHANGE OUTER DRESSING ONLY. LEAVE PACKING ALONE. KEEP IT INTACT UNTIL SEEN NEXT WEEK. - Outer dressing instructions were to cover the sacrum with [MEDICATION NAME] gentle. - Follow-up appointment in 1 week on 2/8/2018. There were no nursing progress notes or orders for 2/1/2018 regarding new instructions from the wound care center. The resident was observed on 2/5/2018 at 4:22 PM in her wheelchair with the same cushion that was observed on 2/1/2018. During an interview on 02/06/18 at 2:25 PM, LPN #6 stated she changed the resident's dressings as ordered and on the TAR. She stated when the resident returned from an appointment at the wound care center, the supervisor or RN Manager called the NP to get orders for any new recommendations. She stated if the instructions were not clear they called the wound care center. She stated the NP looked at the resident's wounds once a week or more often if there was a worsening. She stated either the Supervisor or RN Manager was responsible for calling the NP with any changes. She stated there were no changes in the resident's dressing since she started treatment at the wound care center. She stated if there were changes to the orders, she would have changed the TAR. She stated the resident had a Roho cushion in the wheelchair it was left at the hospital when she went for a blood transfusion on 2/2/2018. There was no documented evidence the resident's ROHO cushion was reordered after it was left at the hospital. The (MONTH) (YEAR) TAR, documented LPN #6 irrigated the sacral wound with NS, applied Santyl to the wound base, packed with [MEDICATION NAME] Ag, and covered with Allevyn on 2/3, 2/4, and 2/7/2018. On 2/8/2018 at 8:10 AM, the resident was observed in bed. She had a smaller foam cushion in the wheelchair. On 2/08/18 at 11:13 AM, the resident was observed and interviewed sitting in her wheelchair in the hall. The resident stated she returned from the wound care center and the physician was upset that she still did not have a Roho cushion. The discharge instructions from the wound care center dated 2/8/2018 documented: - The resident needed a Roho cushion for the wheelchair. - Cut [MEDICATION NAME] Ag to size and apply to wound bed. MAY CHANGE OUTER DRESSING ONLY. LEAVE PACKING ALONE. - Follow-up appointment in 1 week. During an interview on 2/08/18 at 11:20 AM, RN Supervisor #8, stated when a resident came back from a consult, the LPN on the medication cart was responsible for looking at consult reports. If there were orders, the nurse notified the Supervisor and the Supervisor called the NP or physician to get orders for the consultant's recommendations. RN Supervisor #8 looked at the resident's consult sheet from the wound care center and stated they wanted the resident to have a Roho cushion. He stated he would go to the therapy department and fill out a request. He stated he would also write a progress note and call the physician for an order. He looked in the envelope and reviewed the wound instructions stating he would compare it to the current order to see if the order had changed. He checked the order in the computer and stated there was no change for the sacral wound, they were still using [MEDICATION NAME] Ag. When asked to read the current physician's orders [REDACTED]. He stated he would call the physician, read the recommendation and get an order. He was unaware the same recommendations were written the week before. During an interview on 2/8/18 at 11:55 AM, the wound care physician stated he expected the resident to get the treatments he prescribed. He stated he could not understand why it was so difficult to get a Roho cushion and every time she came to the clinic, he sent her back with the recommendation. He stated he even wrote a script one time and thought that would solve the problem. He stated the Roho cushion was the major thing she needed. He was unaware that Santyl was being used and stated he would never order Santyl and [MEDICATION NAME] Ag to be used together. He stated Santyl would inactivate the silver (Ag) and at this point the antimicrobial dressing was more important. He stated Santyl should not be used on any of her wounds. He stated due to her immobility and obesity, her wounds were difficult to heal and could become chronic. He stated the least they could do would be to get her a Roho cushion. During an interview on 2/8/18 at 12:20 PM, the Director of Rehabilitation services stated she did not know the resident had a pressure ulcer until today when she got a request for a Roho. She stated they just gave her one and had she known the resident needed one before, she would have got it. She stated if there was not one available, she could order one and have it expedited. During an interview on 2/8/18 at 12:45 PM, the NP stated the resident was being seen by the wound care center and she was unsure the last time she saw any of the resident's wounds including the sacral pressure ulcer. She stated if there were changes recommended for the treatments, she expected nursing staff to call and put the new orders in to start right away. She stated if she was not called she assumed the treatment recommendation was unchanged. She stated she read and initialed the consults when she made rounds and after the last one, she wrote an order for [REDACTED]. 3) Resident #38 was admitted [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact, required extensive assist with transfer, toileting, and dressing, limited assist with personal hygiene, and fed self after set up; and his skin was intact. The comprehensive care plan (CCP) updated 9/1/2017 documented the resident had a pressure ulcer on the left lateral foot that required wound care. Interventions included to treat per physician's orders [REDACTED].>Physician orders [REDACTED]. Cover left foot wound with [MEDICATION NAME] Ag (a silver impregnated dressing) and Kling every day. Clinical communication updates from the Wound Care Center documented: -8/17/2017 the resident had a Stage III pressure ulcer on his left lateral foot. Orders were [MEDICATION NAME] Ag every other day and to offload boot at all times. -8/31/2017 the ulcer was debrided and a culture was sent for [MEDICAL CONDITION]. Recommendations included to start on [MEDICATION NAME] (antibiotic) 500 milligrams (mg) twice daily for 2 weeks. -9/14/2017 the wound was improved, continue dressing daily of Puracol Ag (a silver dressing), continue off-loading boot at all times. -9/28/2017 the ulcer was improving, Puracol Ag dressing every other day and continue off-loading boot at all times. -10/12/2017 the ulcer was improving and was debrided (dead tissue removed). Continue Puracol Ag dressings and off-loading, could he get a new offloading boot and wear socks?. -10/26/2017 the ulcer was improving and was debrided. Continue same dressing changes, off-loading. -11/30/2017 the ulcer was healed, ok to go back into sneakers and check the foot daily. The resident was discharged from the wound care clinic and the facility could call as needed. The 12/9/2017 physician's assistant (PA) progress notes documented the staff reported no skin issues and the left foot wound was reportedly healed. Physician orders [REDACTED]. Assess bilateral heels for any open areas every day. The 1/2018 electronic treatment administration record (eTAR) documented the resident was to have skin prep (liquid skin protectant) applied to the left lateral foot every shift. There were multiple missing electronic signatures on the 1/2018 eTAR. The treatment was documented as being completed every shift on 18 of 31 days. On 2/5/2018 at 4:43 PM licensed practical nurse (LPN) #19 documented a certified nurse aide (CNA) observed a circular moist area on the resident's left outer foot. The nurse cleansed the area with normal saline (NS) and covered the area with a coversite (a type of dressing), left a note in the NP communication book, and informed the resident's family. There was no documented evidence the area was assessed by qualified staff the day the open area was discovered. On 2/6/2018 at 11:44 AM registered nurse (RN) #8 documented new orders for [MEDICATION NAME] (antibiotic), [MEDICATION NAME] AG (a type of absorbent dressing containing silver), and wound care consult were obtained. On 2/6/2018 at 1:03 PM PA #43 documented the resident had a stage III (wound extending through the dermis and into the fatty subcutaneous tissue) nickel sized open area left lateral foot with slough, [DIAGNOSES REDACTED], and tenderness. Treatments included [MEDICATION NAME] AG daily after cleansing the area with NS, refer to the wound clinic, and [MEDICATION NAME] 100 mg twice a day for 10 days for [MEDICAL CONDITION] (skin infection). A physician order [REDACTED]. During an interview on 01/25/18 at 11:45 AM RN #15 stated she was the only nurse on 1/22/2018 and was on a med cart for 40 residents. One LPN was on other side by herself. She stated there should be two RNs in the building available to do admissions and any assessments for falls or changes in condition. There have been 2-3 new admissions daily even when they were short staffed. Medications were often late and some treatments were not being done on plenty of days. Sometimes there was one CNA on evenings so toileting was not getting done. One family member witnessed a Hoyer transfer with one CNA when there should be two. She stated she had voiced her concerns to administration. During an interview on 1/27/2018 at 7:00 PM, LPN #16 stated she worked every weekend from 6:00 PM to 6:00 AM as a Baylor. She stated the floor was often short staffed and she worked by herself as the only LPN on most weekends. She could usually get all her medications passed but sometimes treatments were not done. She did not receive any breaks and was frequently reprimanded by Human Resources if she had extra time and would often work off the clock. RN #15 was interviewed again on 2/7/2018 at 1:00 PM. Stated it was physically impossible to pass medications to 40 residents and to complete all the treatments as well. When she was the only RN she was also responsible for assessing residents who fell or had any changes in condition and taking physician orders. She would often stay into the next shift to complete treatments but there were treatments that were not being completed. 10NYCRR 415.12(c)(1)

Based on observation, record review, and interview during the recertification and abbreviated surveys (NY 404, 101 and 763) the facility did not ensure residents maintained acceptable parameters of nutritional status or were offered sufficient fluid intake to maintain proper hydration and health for 4 of 15 residents (Residents #41, 61, 466 and 465) reviewed for nutrition and hydration. Specifically, Resident #61 did not have adequate monitoring of fluid intake and was offered clysis (administration of fluids under the skin), the facility was unable to provide clysis due to lack of proficient licensed nursing staff and the resident was hospitalized for [REDACTED].#41 and 466 did not have adequate monitoring of weights and food/fluid intake to accurately assess nutrition and hydration status; and Resident #465 did not have adequate monitoring of fluid intake while on pudding thick liquids and was diagnosed with [REDACTED].#465 and 61 that is not immediate jeopardy. Findings include: 1)Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive deficits, required supervision for eating and had received subcutaneous (under the skin) fluids. A nutrition assessment dated [DATE] documented the resident's estimated fluid needs as 2604 cubic centimeters (cc) per day (30 cc per kilogram of actual weight). The comprehensive care plan (CCP) effective 11/30/2017 documented the resident had potential for alteration in hydration status related to decreased mobility and would be well hydrated and would consume greater than 90% of fluids offered via meal plan and medication passes. Interventions included to follow intake and output recordings, observe for signs and symptoms of dehydration, hydration mug at 10:30 AM, 3:00 PM and at hour of sleep. Resident certified nurse aide (CNA) documentation records did not have fluid intake documented from 6:00 AM-10 AM, 10:00 AM-2:00 PM, 2:00 PM-7:00 PM, 7:00 PM-10:00 PM and 10:00 PM-6:00AM: -November (YEAR), 2 of 2 days; -December (YEAR), 21 of 31 days; -January (YEAR), 20 of 31 days; and A physician order [REDACTED]. A nursing progress note dated 12/12/2017 at 5:51 AM documented the resident was receiving clysis and was tolerating well. A nutrition progress note dated 12/13/2018 at 12:23 PM documented the resident was receiving 2520 cc of fluids via meal plan plus hydration mugs (hydration mugs are filled with 22 ounces of water in the morning in the kitchen and delivered to the unit for nursing to pass out) at 10:30 AM and 3:00 PM. A nursing hydration status review dated 12/14/2017 at 10:26 PM documented the resident's minimum intake was not met (minimum intake amount was not documented) and the resident had left sided weakness and was unable to retrieve fluids easily. The resident did not show signs or symptoms of dehydration at that time. A nursing progress note dated 12/20/2018 at 2:20 PM documented the resident became flaccid during transfer and was lowered to the floor. A nursing hydration status review dated 12/20/2017 at 4:38 PM documented the resident's minimum intake was not met (minimum intake amount was not documented), needed to be provided the nourishment as he was too unsteady to get on his own and had increased fatigue/weakness. The resident did not show signs or symptoms of dehydration at that time and drinking fluids probably not all recorded. A nursing progress note dated 12/27/2017 at 1:23 PM documented a telephone call received regarding critical serum potassium level of 6.5 mmol/L (millimole per liter, normal 3.6-5.2 mmol/L). The nurse practitioner was called and new orders given. The family member was called and gave permission to continue with IV fluids (clysis) and new orders obtained. A 12/27/2017 physician order [REDACTED]. A 12/27/2017 at 11:11 PM registered nurse (RN) progress note documented clysis was started on right lower back. A 12/28/17 nurse practitioner (NP) order documented clysis therapy 0.45% NS at 30 cc per hour x 24 hours. A 1/3/2018 NP progress note documented the resident's family member wished continued trial of IV fluids (clysis). Clysis will be attempted once again x 24 hours with 1.5 liters of NS at 30 cc per hour. There was no documentation clysis was attempted. A NP progress note dated 2/1/2018 documented the resident was seen initially due to elevated blood sugar. Clysis was offered the previous day, however, facility unable to perform. The family member was requesting clysis during the visit and again, facility today is unable to provide this. At that time the family member requested the resident be sent to the emergency room . A nursing progress note dated 2/1/2017 at 6:38 PM documented the resident was sent to the hospital for evaluation of [MEDICAL CONDITION] (high blood sugar). A physician progress notes [REDACTED]. He was sent to the hospital for dehydration and [MEDICAL CONDITION] and was treated for [REDACTED]. The registered dietitian (RD) was interviewed on 01/24/18 at 12:00 PM. She stated the CNAs are not documenting fluid intakes due to not having enough time. If there are no intakes it is difficult for her to do an accurate nutritional assessment. Hydration mugs are filled with 22 ounces of water in the morning in the kitchen and delivered to the unit for nursing to pass out and are picked up before the residents go to bed. She stated the mugs may not have been consistently passed out to the resident. CNA #17 was interviewed on 1/24/2018 at 1:51 PM. She stated she could not document on resident's fluid intake because they were always short staffed and she could not physically chart on residents due to not having enough time. She had worked all by herself once and was not even able to provide fluids to residents on that day because she had spent the entire shift getting people up. CNA #9 was interviewed on 1/24/2018 at 3:00 PM and stated she was always working short and did not document anything about residents including fluid intake. Dietary aide #33 was interviewed on 1/25/2018 at 9:44 AM. She stated the meals tickets are returned to the kitchen with the percentage consumed written on them and nursing staff was responsible for keeping track and documenting. When the tickets came back to the kitchen they were thrown away because nursing would have already documented the intake. RN #15 was interviewed by telephone on 2/7/2018 at 1:00 PM. She stated LPNs can perform clysis in the facility and they should have all been trained. She was not aware clysis could not be performed on the resident due to unavailability of proficient staff. The Director of Nursing (DON) was interviewed on 02/08/18 01:45PM. He stated licensed practical nurses (LPN) can do clysis but they don't do it often enough so an RN would usually have to do. Up until about a week ago there was an RN in facility 24 hours a day. I always tried to have an RN in the building for procedures such as clysis. He stated it was difficult to get the CNAs to document when they were the only one on the floor. All CNAs had received orientation on documentation. RN #14 was interviewed by telephone on 2/9/2018 at 11:40 AM. She stated she was constantly on the medication cart when she worked and orders would have to wait. She knew the CNAs were not documenting any of their ADLs (activities of daily living) and she would tell them every day they had to document and she could not provide supervision and oversight as she was always on the medication cart and had to concentrate on that. She was not aware the clysis for the resident could not be performed. The NP was interviewed on 2/7/2018 at 1:33 PM and stated on the day before transfer to the hospital the resident needed rehydration and the family member did not want him sent out and requested IV hydration in the facility and decided to try clysis again. The facility was not able to provide clysis or IV as there was no RN available. She stated it is important to keep track of all residents input to avoid dehydration. 2)Resident #465 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 1/9/2018 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired and she required extensive assistance for bathing and dressing and supervision for eating. She was occasionally incontinent of bladder and on a mechanically altered diet. The comprehensive care plan (CCP) dated 1/2/2018 documented the resident had potential for alteration in hydration status and interventions included to monitor hydration status and monitor for signs and symptoms of dehydration. A physician order [REDACTED]. Resident certified nurse aide (CNA) documentation records from 1/2/2018 -1/18/2018 documented the amount of fluid the resident consumed only 6 times. The rest of the documentation was blank. -1/5/2018 from 6:00 AM - 2:00 PM the resident consumed 360 ml of fluids -1/5/2018 from 10:00 AM - 2:00 PM consumed 500 ml of fluids -1/6/2018 from 6:00 AM - 2:00 PM consumed 120 ml of fluids -1/6/2018 from 10:00 AM - 2:00 PM consumed 240 ml of fluids -1/9/2018 from 6:00 AM - 2:00 PM consumed 360 ml of fluids -1/9/2018 from 10:00 AM - 2:00 PM consumed 240 ml of fluids A Clinical Monitoring Intake/Output Summary report documented the resident's daily fluid consumption (including fluids provided with medications): -1/2/2018 total fluid intake was 0 -1/3/2018 600 ml - 1/4/2018 460 ml -1/5/2018 1100 ml -1/6/2018 600 ml -1/7/2018 540 ml -1/8/2018 390 ml -1/9/2018 1080 ml -1/10/2018 360 ml -1/11/2018 480 ml -1/12/2018 240 ml -1/13/2018 120 ml -1/14/2018 360 ml -1/15/2018 300 ml -1/16/2018 720 ml -1/17/2018 720 ml -1/18/2018 320 ml A nursing progress note dated 1/11/2018 documented due to nutritional and hydration issues the NP had ordered labs for 1/12/2018. A physician order [REDACTED]. There was no documented evidence the labs ordered on [DATE] were completed. A NP progress note dated 1/16/2018 documented the resident was evaluated for her history of failure to thrive. The resident had an order for [REDACTED]. A laboratory report dated 1/17/2018 documented the resident's BMP showed sodium was 155 (normal range 136-145), potassium 5.4 (3.6-5.2), chloride 115 (100-108), Urea Nitrogen (BUN) 83 (7-24) results verified by repeat testing, creatinine 2.57 (0.60-1.0). The CBC showed the resident hematocrit (HCT) was 30.7 (normal range 36.0-47.0) and hemoglobin was 9.8 (12.0-16.0). A nursing progress note dated 1/17/2018 documented clysis (hydration therapy) was started. A NP progress note dated 1/18/2018 documented the resident was being seen for laboratory studies that showed marked [MEDICAL CONDITION]. She was very fatigued and clysis for hydration was started the previous day with no improvement. The resident was sent to the emergency room for dehydration and possible bowel obstruction. During an interview with CNA #17 on 1/24/2018 at 0812 AM she stated most day shift they would work with only 3 CNAs for 35- 40 residents and typically only 1-2 CNAs for the evening shift. She stated showers, toileting, bowels and eating were documented by the CNAs and that was not able to get done because there were not enough CNAs During an interview with CNA #7 on 1/29/2018 at 11:45 AM she stated intakes were supposed to be documented for every meal and whenever any fluid was given. She was unable to get her documentation done as they often worked with 2-3 CNAs and it was more important to try to get the residents up and out of bed. During an interview with the registered dietitian (RD) on 2/6/2018 at 9:35 AM she stated the resident was high risk for weight loss and dehydration as she had a history of [REDACTED]. There was little documentation on her consumption and fluid intake so she asked the NP for labs to determine her hydration status. The NP ordered them and initially they were not done and when she ordered them a second time the labs showed the resident was dehydrated and clysis was started. She stated she was unable to complete thorough nutrition and hydration assessments on residents as weights were not obtained as ordered and CNAs were not able to document. She had reported her concerns to administration on multiple occasions. During an interview with the NP on 2/7/2018 at 1:30 PM she stated the resident's fluid consumption was not being documented and there was a decline in the resident's condition since her admission so she ordered laboratory studies on 1/11/2018 and they were not completed. She reordered them on 1/17/2018 and they indicated she was dehydrated and had [MEDICAL CONDITION]. Cylsis hydration was started by the physician on 1/17/2018 and when she evaluated her on 1/18/2018 the residents conditioned had worsened and she was lethargic so she sent the resident to hospital to treat her dehydration and rule out a bowel obstruction. 10NYCRR415.12(i)(1)(j)

Based on observations, interviews and record review conducted during the standard survey, it was determined for 2 of 3 residents (Residents #4 and 10), reviewed for pressure ulcers, the facility did not ensure necessary treatment and services were provided to promote healing. Specifically, Resident #10's pressure ulcers were not reassessed by a qualified person (registered nurse, physician) after the initial assessment, and pressure relieving interventions were not implemented as planned, and the pressure ulcer progressed larger in size and developed slough (soft, moist, dead tissue) which was actual harm and Resident #4's heels were not provided with pressure relief as planned which was no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1) Resident #10 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 10/25/2013, documented the resident's cognitive status was severely impaired. The resident required extensive assistance for all activities of daily living (ADLs) and did not ambulate. The MDS documented the resident had no skin impairment, was at risk for pressure ulcer development, and received skin treatments including a pressure reducing device for the chair. The comprehensive care plan (CCP), dated 11/7/2013, documented the resident was at risk for impaired skin integrity related to immobility, bowel and bladder incontinence, diabetes, and [MEDICAL CONDITION] medication usage. The goal was for her skin integrity to remain intact. Interventions included: assessing the resident's skin every shift during ADL care; avoiding pressure over bony prominence's; and using a pressure reducing mattress in the bed and a pressure reducing cushion in the chair. The current, undated, resident care card (care instructions), documented the resident required extensive assistance for all ADLs and had a foam cushion for pressure relief. The registered nurse (RN) supervisor's note, dated 11/28/2013 at 9:55 PM, documented the resident had a new open area, on the coccyx, measuring 1 centimeter (cm) x 1 cm. The note recorded the physician was notified. The physician's orders [REDACTED]. The RN supervisor progress note, dated 12/06/2013 at 4:12 AM, documented the resident had a new open area on the left buttock measuring 0.5 cm x 0.7 cm x 0.1 cm. The note recorded the physician was notified and ordered Sensicare (a protective ointment) to be applied every shift. The physician's visit, dated 12/9/2013, documented the resident had weight loss, diabetes, dementia and no pressure ulcers, or open wounds. The nursing progress note, dated 12/16/2013 at 8:06 PM, documented the resident had a quarter sized open area on the coccyx. The note recorded "Sensicare seems to be making it worse." The physician was notified, the Sensicare was discontinued, and the resident was to be seen on "skin rounds in AM." The physician's orders [REDACTED]. The treatment administration record (TAR), dated 12/2013, documented Duoderm thin was applied to the open area on the resident's coccyx on 12/1, 12/3, 12/7, 12/10, 12/13, 12/16. The TAR documented the resident's Sensicare to the left buttock was discontinued on 12/16/2013. There was no documented evidence, in the resident's medical record, of an assessment by a qualified person of the open areas on the resident's left buttock and coccyx since 12/6/2013. The treatment administration record (TAR), dated 12/2013, documented Duoderm thin was applied to the open area on the resident's coccyx on 12/19, 12/22, and 12/25/2013. There was no documented evidence on the TAR the Duoderm was changed on 12/28/2013 as ordered. The physician's orders [REDACTED]. The resident's Weekly Skin Check Flow Sheet dated 1/1/2014 did not document a skin check. The physician's visit, dated 1/3/2014, documented the resident was seen for a UTI and had no rashes, [MEDICAL CONDITION], or ulcers. The physician's visit, dated 1/7/2014, documented the resident was seen for a UTI and diarrhea, and had no rashes, [MEDICAL CONDITION], or ulcers. The resident's Weekly Skin Check Flow Sheet dated 1/8/2014 documented the resident's skin was intact. The physician's visit, dated 1/10/2014, documented the resident was seen for a UTI, lower gastro-intestinal bleeding, and diabetes. The note documented the resident's skin had no rashes, [MEDICAL CONDITION], or pressure ulcers. The resident's treatment administration record (TAR), dated 1/2014, documented Duoderm thin was applied to the open area on the resident's coccyx on 1/1, 1/4, 1/7, 1/10, and 1/13/2014. There was no documented evidence the resident's pressure ulcers were reassessed or the treatment was evaluated, by a qualified person, for effectiveness from 12/16/2013 until 1/14/2014. On 01/14/2014 from 10:18 AM to 11:35 AM, the resident was observed sitting in a wheelchair in front of the TV at the end of the hall, there was no cushion in the wheelchair. On 1/15/2014 at 8:25 AM, the resident was observed in the dining room sitting, without a cushion, in the wheelchair. During an interview with the registered nurse (RN) Manager, on 1/15/2014 at 9:40 AM, she stated the resident did not have a pressure ulcer. During an interview with the certified nurse aide (CNA), on 01/15/2014 at 11:30 AM, she looked at the resident's care card and stated the resident was planned to have a cushion in her chair and did not have one. She said she was unable to find a cushion in the resident's room. The CNA stated the resident had a pressure ulcer on her bottom. During a pressure ulcer treatment observation on 1/15/2014 at 11:35 AM, the licensed practical nurse (LPN) removed a soiled Duoderm thin from the resident's coccyx, cleansed the open area and applied a new Duoderm thin. The coccyx pressure ulcer edges were white and moist, the wound bed was pink with a dark area, on the right side, along the edge. There was an unopened red/pink area on the resident's left buttock, and the licensed practical nurse stated to the surveyor that it was an old area. On 1/15/2014 at 12 PM, the physical therapist (PT) was observed providing the resident with an air cushion for her wheelchair. During an interview with the PT, on 1/15/2014 at 12 PM, she stated the resident was care planned for a foam cushion which she changed to an air cushion due to the coccyx pressure ulcer. She stated this was the first time she was informed the resident had a pressure ulcer, and did not have a cushion for her chair. The licensed practical nurse (LPN) note, dated 1/15/2014 at 2:47 PM, documented the dressing on the resident's buttocks was changed, and a new Duoderm thin was applied. The note recorded the pressure ulcer had a light red wound bed, with white skin around it, and a darker colored area above it. The physician's visit, dated 1/15/2014, documented the resident had a pressure ulcer on her mid coccyx/sacral area, measuring 2.5 cm x 0.9 cm, consisting of 90% granulation tissue and 10% yellow slough (soft, moist, dead tissue). The Dermal Tracker Sheet dated 1/15/2014 documented the resident had a Stage II pressure ulcer, measuring 2.5 cm x 0.9 cm, was 90% granulation and 10% slough. The dermal tracker dated 1/15/2014 recorded the pressure ulcer was first found on 11/28/2013 and the physician was notified on 11/28/2013. During an interview with the RN Manager, on 1/16/2014 at 10:55 AM, she stated she did not know when the resident's pressure ulcer developed. The resident's pressure ulcer was not documented on 24 hour report. She said she did not know the resident had a pressure ulcer until yesterday, and she did not know her nurses had been administering treatments. She stated the resident's pressure ulcers should have been recorded on a pressure ulcer tracking sheet, and documented on the 24 hour report. The RN said the resident did not have a cushion for her chair. During an interview with the physician, on 1/16/2014 at 11:45 AM, she stated she expected to be notified within the day of any resident with skin breakdown. She said herself or the nurse practitioner (NP) assessed pressure ulcers, documented a plan, and followed up weekly. She stated she was informed of the resident's pressure ulcer yesterday and she examined the resident. She stated she examined the resident last week for a UTI, hemorrhoids, and a lower gastro-intestinal bleed but there was stool covering the pressure ulcer area and she did not see it. She stated she did not remember ordering Duoderm thin and one of the NPs might have been on call. She stated she electronically signed a lot of orders at once after a weekend, and overlooked the resident's order for Duoderm thin. During an interview with the DON, on 1/16/2014 at 12:10 PM, she stated she was conducting an investigation. During an interview on 1/16/2014 at 2:15 PM, the physician stated she checked with her answering service and a NP, formerly employed by her, received the call and ordered the treatment. The physician said the NP should have documented and tracked the resident's pressure ulcer. She stated she looked at the resident's pressure ulcer for the first time yesterday, it measured 2.5 cm x 0.9 cm, and was not new. 2) Resident #4 had [DIAGNOSES REDACTED]. The nurse practitioner (NP) acute visit progress note dated 10/10/2013 documented the resident was quite kyphotic (curvature of the spine) with wasting away of the lower extremities. The facility skin assessment protocol (Braden Scale) dated 10/16/2013 documented the resident required extensive assistance with bed mobility, had a decreased sensory perception and was at moderate risk for developing pressure ulcers,with a compromised nutritional status. The Minimal Data Set (MDS) assessment dated [DATE] documented the resident was severely impaired, required extensive assistance for bed mobility, transferred with impairment of the lower extremities. The resident was at risk for developing pressure ulcers and currently had a Stage II pressure ulcer. The comprehensive care plan (CCP) dated 1/7/2014 documented the resident had an overall decline, and alteration in skin integrity. The goal was for the resident to remain free from additional pressure ulcers. Interventions included elevating/floating the resident's heels when in bed, and avoiding pressure over bony prominence's. The certified nurse aide (CNA) care card (care instructions) dated 1/15/2014 did not document to float the resident's heels when in bed. The resident was observed, on 1/14/2014 at 12:10 PM, lying in bed, positioned on her left side, with her heels resting directly on the mattress. The resident's was observed, on 1/15/2014 at 11 AM, lying in bed, with her heels resting directly on the mattress. The resident's was observed, on 1/15/2014 at 12:25 PM, lying in bed with her heels resting directly on the mattress. During the interview with the registered nurse (RN) Manager on 1/16/2014 at 9 AM, she stated the resident had preventative measures in place to prevent further breakdown including repositioning, spot Duoderm, Roho cushion (pressure relieving cushion for chair) and to float heels off the bed. The resident's was observed, on 1/16/2014 at 9:35 AM, lying in bed with her heels resting directly on the mattress. During the interview with the CNA on 1/16/2014 at 9:35 AM she stated she knew from the care card when a resident needed to have their heels floated off the bed. The CNA reviewed the care card, and stated it did not document the resident's heels were to be floated off the bed. 10NYCRR 415.12 (c)(1)(2)