Every finding on record at Park Terrace Care Center

Based on observation, record review, and interviews, during the Recertification and Abbreviated Survey (Intake #797338), the facility failed to provide a clean, comfortable and homelike environment for the residents. Specifically, housekeeping and maintenance services were not maintained in Unit 4. The findings include: The facility's General Maintenance Policy with a revised date of 10/2024 stated the purpose of the policy is to ensure that the facility's premises, equipment, and systems are maintained in a clean, safe, and functional condition, promoting a safe environment for residents, staff, and visitors. 1.During environmental rounds with the Housekeeping Director on 09/05/2025 and multiple observations in Unit 4 on 09/08/2025, the following were observed: room [ROOM NUMBER] - The wall baseboard had peeling paint. room [ROOM NUMBER]- The top of the air conditioning unit was very dirty, with peeling black and white paint. The baseboard had peeling paint. And the bathroom floor had dirt in between the tiles. room [ROOM NUMBER]- The window was dirty, and the baseboard had brown stain. The air conditioning unit had a lot of dirt. room [ROOM NUMBER]- The air conditioning unit had a gray duct tape on top. room [ROOM NUMBER]- The air conditioning unit had a brown tape on top. room [ROOM NUMBER]- There were peeling paint on the wall and dirty baseboard by the window. room [ROOM NUMBER] – The window baseboard had a lot of dirty brown spots. room [ROOM NUMBER]- The bathroom entrance had lots of dirty black stains and there was black dirt on the bathroom door. room [ROOM NUMBER]- There was a black dirt on the air conditioning unit and in the corner near the bathroom. room [ROOM NUMBER]- There were black stains at the bathroom entrance and black peeling paint at the window baseboard and the air conditioning unit. room [ROOM NUMBER]- There was a peeling paint by the air conditioning unit and wall baseboard. room [ROOM NUMBER]- There was a dirty white peeling paint on top of the air conditioning unit and window baseboard. room [ROOM NUMBER]- There were lots of dirt by the window baseboard and the air conditioning unit. room [ROOM NUMBER]- The bathroom entrance and under the sink had lots of dirt and rusty black color with a sticky floor. room [ROOM NUMBER] – The bathroom heater had rusty brown color. The resident's training bathroom and shower room had lots of dirt in between the floor tiles. During an interview on 09/09/2025 at 10:51 AM, the Housekeeping Director stated that they will give an in-service education to all the housekeeping staff about room cleaning. They stated that all baseboards need to be cleaned and that the water for mopping the floor must be changed more often. The Director stated that the findings were well noted and that next year, the unit will be spotless. 2. During multiple observations from 09/02/2025 through 09/05/2025, the following were observed in room [ROOM NUMBER]: There was a brownish grime on the floor towards front of wardrobe closet D. There was dirt on the floor in between wardrobe closets B & C, where the baseboards and floor meet. There was also a large brown, round stain observed on the ceiling near the windows. On 09/05/2025 at 10:15 AM, Housekeeper #3 was interviewed and stated they will ask the [NAME] to move the wardrobe closets in order to clean the brown grime on the floor. They were unable to explain why the buildup of grime was not cleaned prior. On 09/09/2025 at 10:03 AM, the Housekeeping Director was interviewed and stated closets are bolted to the wall and maintenance can unbolt for the housekeeper to clean the grime from the floor. The housekeepers are instructed to pay attention to the edges and corners on the floors as they mop. They stated they have a foam spray that is designated for cleaning baseboards. The Housekeeping Director also stated there is no excuse why the floors near the wardrobe closets and baseboard areas were not cleaned properly. On 09/09/2025 at 10:45 AM, the Director of Maintenance was interviewed and stated there was a leak on the floor above from the last winter. The leak was fixed but they still have to prime and paint the stained area. The Director of Maintenance also stated they were unaware of the ceiling stain. On 09/09/2025 at 1:23 PM, the Administrator was interviewed and stated there are daily environmental rounds where the Housekeeping and Maintenance Directors check areas for cleanliness and any repairs needed. The Administrator stated other staff should report areas that need attention as well. 10 NYCRR 415.5(h)(2)

Based on observation, record review, and interviews, the facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complications of enteral feeding. This was evident for three (3) (Residents #137, #41, and #52) out of 25 residents reviewed for medication administration task. Specifically, licensed nurses did not appropriately verify placement of gastrostomy tube prior to administering medications and enteral feeding. The findings include: The facility policy titled Medication Administration with a last revised date of 05/2025 documented when administering medications via enteral route, placement must be checked by introducing air and listen to gurgling sound using a stethoscope. The facility policy titled Gastrostomy Tube Feeding with a last revised date of 01/2025 documented placement of tube must be checked prior to administration of tube feeding. 1. Resident # 137 had diagnoses of Gastrostomy status, Dysphagia, and Malnutrition. The Significant Change in Status Minimum Data Set assessment dated [DATE] documented that Resident # 137 had a feeding tube. A physician's order dated 08/19/2025 documented a tube feeding administration order of Glucerna 1.5 to be administered at a rate of 60 milliliters per hour for 24 hours. The start time was at 4:00 PM. The formula amount per feeding is 1000 milliliters. During medication administration observation conducted on 09/05/2025 at 3:50 PM, Licensed Practical Nurse #5 was observed checking the gastrostomy tube placement by injecting about 50 cc of air into the resident's feeding tube and then auscultating for sounds. Licensed Practical Nurse #5 stated a gurgling sound was heard. On 09/05/2025 at 4:06 PM, the Inservice Coordinator was interviewed and stated they do not know that the appropriate means to check placement of the gastric tube is by aspirating gastric content. They stated they have been injecting air into the stomach and listening for gurgling sound. 2. Resident #41 had diagnoses of Gastrostomy status, Dysphagia, and Parkinsonism. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #41 had a feeding tube. A physician's order dated 08/12/2025 documented a tube feeding administration order of Jevity 1.5 to be administered at a rate of 75 milliliters per hour for 24 hours. The start time is at 4:00 PM. The formula amount per feeding is 1000 milliliters. During a medication administration observation conducted on 09/04/2025 at 1:14 PM, Registered Nurse #1 administered medications to Resident #41 via gastrostomy tube. Registered Nurse #1 checked the placement of gastrostomy tube by introducing air and auscultating with a stethoscope. On 09/04/2025 at 2:39 PM, Registered Nurse #1 was interviewed and stated they were instructed to introduce air and listen to gurgling sound using a stethoscope to ensure placement in the stomach. Registered Nurse #1 also stated they were not instructed to verify tube placement buy checking for gastric residual volume. 3. Resident #52 was admitted to the facility with diagnoses that included Diffuse Traumatic Brain Injury with loss of consciousness of unspecified duration sequela, Gastrostomy status and Unspecified protein-calorie malnutrition. The admission Minimum Data Set assessment dated [DATE] documented that Resident #52 had severely impaired cognition, had no swallowing disorder and received 51 percent or more of feedings and 501 milliliters or more of fluids through a percutaneous endoscopic gastrostomy tube. The physician's orders for Resident #52 included Jevity 1.5, 1000 milliliters to be administered at a rate of 65 milliliters per hour with a start time of 4:00 PM. On 09/04/2025 at 4:01 PM, Licensed Practical Nurse #2 administered Resident #52's enteral feeding. The Licensed Practical Nurse verified the gastrostomy tube placement by introducing air to the resident's stomach and assessed the abdomen with a stethoscope; the Licensed Practical Nurse stated they heard a gurgling sound. During an interview on 09/04/2025 at 4:20 PM, Licensed Practical Nurse #2 stated that feeding tube placement must be checked by gastric residuals, however, they stated that the resident had not been fed since this morning so there was no need to check for residuals. On 09/09/2025 at 12:45 PM, the Director of Nursing was interviewed and stated nurses are instructed to check the placement of the gastrostomy tube by auscultating and listening for gurgling sound. They stated they changed the policy last week and started doing competencies and in-services on checking residuals by aspirating gastric contents. The Director of Nursing further stated checking for placement is not documented in the physician orders as it is considered a standard of care. 10 NYCRR 415.12(g)(2)

Based on observation, record review, and interviews, the facility failed to ensure physicians reviewed the residents' total program of care. This was evident for two (2) (Residents #107 and #184) of three (3) residents reviewed out of 40 total sampled residents. Specifically, the physician's progress notes did not accurately reflect the residents' total care plan and current condition. The findings include:The facility's undated policy regarding Documentation stated that the facility staff were to document appropriately assessments, orders, goals and interventions for each resident. 1. Resident #107 had diagnoses that included Hemiplegia, Traumatic Brain Injury, and Anxiety Disorder. The physician's progress notes dated 09/03/2025 at 10:42 PM documented that Resident #107 had increased weakness, balance, and coordination deficits due to recent prolonged hospitalization. The progress notes documented that Physical and Occupational Therapy were ordered to improve the resident's mobility and self-care abilities; and the therapy goal was ultimately aimed in returning the patient to their optimal level of function and enhance independence. A review of Resident #107's medical record revealed that their last admission to the facility was on 02/18/2025.The Quarterly Minimum Data Set (a resident assessment tool) dated 08/21/2025 documented Resident #107 had moderately impaired cognition, and required partial assistance with personal and oral hygiene, toileting, and transfer. Section O of the assessment had no documentation that Resident #107 was receiving Physical and Occupational therapy. A review of Resident #107's physician orders dated 08/19/2025 did not include Physical and Occupational therapy. The Physical Therapy notes dated 05/07/2025 documented that Resident #107 was discharged from skilled therapy. The resident was reassessed on 08/22/2025, the physical therapy notes documented that Resident #107's functional / ambulatory status remained unchanged from last physical therapy screen.The Occupational Therapy notes dated 05/06/2025 documented that Resident #107 has been discharged from skilled therapy services secondary to achieving the highest maximum potential and had reached their prior level of function. The resident was reassessed on 08/07/2025, no occupational therapy intervention was indicated. 2. Resident # 184 had diagnoses that included Cerebrovascular Accident, Hemiplegia, and Traumatic Brain Injury.The physician's progress notes dated 09/02/2025 at 10:28 PM documented that Resident #184 had increased weakness, balance, and coordination deficits due to recent prolonged hospitalization. The progress notes documented that Physical and Occupational Therapy were ordered to improve the resident's mobility and self-care abilities; and the therapy goal was ultimately aimed in returning the patient to their optimal level of function and enhance independence. A review of Resident #184's medical record revealed that their last admission to the facility was on 06/28/2021.The Quarterly Minimum Data Set 3.0 dated 07/02/2025 documented Resident # 184 independent consistent cognition, and required supervision assistance with personal and oral hygiene, toileting, and transfer. Section O of the assessment had no documentation that Resident #184 was receiving Physical and Occupational therapy.A review of Resident #184's physician orders dated 08/26/2025 did not include Physical and Occupational therapy. The Physical Therapy notes dated 12/13/2024 documented that Resident #184 had achieved their maximum overall potential and was discharged from skilled therapy. The resident was reassessed on 06/30/2025, the physical therapy notes documented that Resident #184's functional / ambulatory status remained unchanged from last physical therapy screen.The Occupational Therapy notes dated 06/24/2025 documented that Resident #184 had no significant changes in bilateral upper extremities range of motion, therefore no occupational therapy intervention was indicated. On 09/05/2025 at 10:42 AM, an interview was conducted with Medical Doctor #1 who stated that the physical and occupational therapy documentation in Residents #107 and #184's medical progress notes was an error and will be corrected. On 09/05/2025 at 11:48 AM, Registered Nurse #6, who was the Rehabilitation Nurse, was interviewed stated that Residents #107 and #184 are not on skilled Physical nor Occupational therapy program. On 09/09/2025 at 1:05 PM, the Director of Rehabilitative Therapy was interviewed stated that Residents #107 and #184 were assessed by the Physical and Occupational Therapists. Skilled Physical nor Occupational therapy programs were not recommended. On 09/09/2025 at 2:48 PM, the Medical Director was interviewed and stated they will speak with the medical providers in the facility to ensure accurate documentation at all times. 10 NYCRR 415.15(b)(2)(iii)

Based on observation, record review, and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This was evident during the Kitchen task and during meal pass observation. Specifically, 1.) Expired food items were observed in the kitchen. 2.) Kitchen staff were observed without beard restraint while preparing food in the kitchen. 3.) Food was not in acceptable temperature range. 4.) Egg salad, ham, and tuna sandwiches were stored at room temperature in Unit 4 and Unit 6. 5.) Certified Nursing Assistant #3 failed to perform hand hygiene while assisting residents. The findings include:1. The following were observed during the kitchen observation:An open box of chicken pot pie with a best by date of 01/29/2025 was observed in the refrigerator. Fourteen (14) cartons of Jevity 1.2 with best by date of 08/01/2025, 23 cartons of Osmolite 1.2 with use by date of 09/01/2025, and 9 cartons of Glucerna with best by date of 07/01/2025 were found in the emergency food storage. During an interview on 09/02/2025 at 10:30 AM, the Food Service Director stated the vendor came last Friday to take the expired food items but did not take the closed cases of liquid supplement. 2. During an observation on 09/02/2025 at 11:09AM -11:16AM, [NAME] #1 was observed with a hair net on but their mustache and beard were visible and not restrained while handling tuna sandwiches. During the interview, [NAME] #1 stated that beard nets were not available.Dietary Aide #4 was observed in the kitchen preparing supplements for the residents without a beard cover. Dietary Aide #4 stated during the interview that they never used beard restraints while in the kitchen. During observation on 09/04/2025 at 12:03 PM, Dietary Aide #5 was observed in the kitchen without a hair net. During the interview, Dietary Aide #5 stated that they must wear a hair net, so hair don't fall in residents' food. 3. During tray line observation on 09/05/2025 between 11:32 AM to 11:47 AM, the following food were not in acceptable temperature range: Gyro veggies 41.5 degrees Fahrenheit, egg salad sandwich at 42.1 degrees Fahrenheit, and turkey sandwich at 41.7 degrees Fahrenheit.During an interview on 09/05/2025 at 11:47 AM, the Food Service Director stated the temperature danger zone is between 41-140 degree Fahrenheit where bacteria can grow. They stated that the sandwiches were made yesterday and were in the refrigerator all night. During an interview on 09/09/2025 at 10:29 AM, the [NAME] # 2 stated that the cold sandwiches should be at 35 degrees Fahrenheit. 4. During observation in Unit 4 and Unit 6 on 09/08/2025 at 4:48 PM - 5:09 PM, tuna, egg salad, and ham sandwiches were stored in a metal cart at room temperature in the pantry. During an interview on 09/08/2025 at 4:53 PM, Registered Nurse # 5 stated that the sandwiches were delivered at 8:00 AM for residents' snacks at 8:00 PM. They stated they do not store the sandwiches in the refrigerator because it will get hard.During an interview on 09/8/2025 at 5:15PM, Licensed Practical Nurse #4 stated that sandwiches were delivered at 4:30 PM and will be served at 7:00 PM. They stated that sandwiches were not stored in the fridge because the bread gets hard. On 09/09/2025 at 10:53AM, the Food Service Director stated that sandwiches must be kept in the refrigerator to prevent bacterial from growing rapidly and prevent food borne illness. 5. The facility policy titled Hand Hygiene Protocol effective 11/2017 documented the facility will follow a hand hygiene protocol in preventing the spread of potential pathogens on the hands. During dining pass observation in Unit 3 on 09/03/2025 at 12:47 PM, Certified Nursing Assistant #3 was observed assisting residents with hand hygiene prior to meals in the dining room. Certified Nursing Assistant #3 cleaned Resident #304, #57, and #98 with bare hands and handed wipes to the residents also with bare hands. The nursing assistant failed to perform hand hygiene in between residents. When the nursing assistant was done with wiping residents' hands, they placed a lunch tray in front of Resident #16 and then sanitized their hands after. During an interview on 09/04/2025 at 2:49 PM, Certified Nursing Assistant #3 stated they could not recall if they cleaned their hands in between residents. During an interview on 09/09/2025 at 1:23PM, Registered Nurse #3 stated staff should clean their hands before dining and between assisting residents to prevent the spread of germs and for infection control. On 09/09/2025 at 1:05 PM, the Infection Preventionist stated staff are supposed to do hand hygiene before giving out resident trays. They stated hand hygiene is important since residents may ingest microorganisms they are not supposed to. 10 NYCRR 415.14 (h)

Based on observations, record review, and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This was evident during kitchen observation and in five (5) (Units 2, 3, 4, 5 and 6) of five (5) units observed. Specifically, ripped chairs were observed in the dining rooms in all units, dust accumulations were observed in the kitchen, and dirty floors and walls were observed in Unit 4, along with corroded metal cabinet. The findings include: The facility's General Maintenance Policy with a revised date of 10/2024 stated the purpose of the policy is to ensure that the facility's premises, equipment, and systems are maintained in a clean, safe, and functional condition, promoting a safe environment for residents, staff, and visitors. 1. During environmental rounds on the 4th floor from 09/05/2025 at 3:26 PM, and 09/08/2025 at 11:22 AM, the following were observed: 1. The floor in the unit dining room were embedded with black colored substance, dirt, and debris. 2. The medication room had brown stains on the floor and was very sticky. 3. The metal filing cabinet in the medication room had rusty brown color. 4. The wall baseboard in the nurses' station had accumulation of black stain. 5. The floor along the edges in the hallway by the elevator had a lot of black colored substance, dirt and debris. 6. The paint in the nurses' station were peeling. 7. The unit day room had lots of black dirt on the wall base. 8. The hallway by the elevator also had dirty wall base. On 09/09/2025 at 1:23 PM, the Administrator was interviewed and stated there are daily environmental rounds where the Housekeeping and Maintenance Directors check areas for cleanliness and any repairs needed. The Administrator stated other staff should report areas that need attention as well. 2. During kitchen observation on 09/02/2025 from 9:50 AM to 10:09 AM, the refrigerator coil was noted with accumulated dusts, also on the food shelves and the large fan. 3. During observation from 09/02/2025 – 09/08/2025, the chairs in the dining rooms in Unit 2, 3, 5, and 6 were noted with ripped vinyl and cushion. During an interview on 09/02/2025 at 11:00 AM, the Food Service Director stated dusting was done in the kitchen 4 to 5 months ago. At that time, the shelves were also cleaned, and any maintenance concerns were referred. They stated the fan brings the air from outside that makes the storage room dusty. During an interview on 09/09/2025 at 1:23PM, Registered Nurse #3 stated they conduct daily rounds and had not observed any issues with the furniture. 10 NYCRR 415.29

Based on observation, record review, and interviews, during the Recertification and Abbreviated Survey (Intake #797338), the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents. This was evident for one (1) (Unit 4) of 5 floors and the kitchen. Specifically, multiple reports of roach and rodent sightings were made by staff and residents. Additionally, a roach was observed crawling on top of the dish machine during kitchen observation. The findings include: The facility's policy and procedure titled Pest Control with a last revised date of 12/2023 stated it is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. 1. On 09/09/2025 at 10:04 AM, during kitchen observation, a roach was observed crawling on top of the dish machine. During an interview on 09/09/2025 at 10:10 AM, Dietary Aide #2 stated they see flies all the time in the kitchen, but this was the first time they saw a live roach in the kitchen. 2. On 09/02/2025 at 2:18 PM, a representative stated they often visit Resident #199 and observed roaches in the resident's room. A review of the Pest Elimination Division Service Request Log indicated that the following pest sightings were reported on Unit 4; roaches on 01/14/2025, 02/04/2025, 02/11/2025, 03/09/2025, 06/04/2025, 06/10/2025, 06/11/2025, 06/18/2025, 07/02/2025, 07/29/2025, 08/02/2025, 08/12/2025, 08/20/2025, and 08/29/2025; a mouse on 06/11/2025, and mice on 01/14/2025, 06/03/2025, 06/18/2025, 08/02/2025, and 08/20/2025. The pest-control service reports from 02/04/2025 to 08/29/2025 were reviewed and revealed that the facility was treated for roaches and mice. On 09/09/25 at 10:03 AM, the Housekeeping Director was interviewed and stated that the exterminator comes every Wednesday and if there is an urgent issue, they come in the same day or the next morning. The Housekeeping Director also stated during the summer, there were roaches and mouse sightings. They stated that over the past few weeks the exterminator helped to decrease the roaches and there haven't been any sightings of a mouse in a while. On 09/09/2025 10:52 AM, Resident #68 who resided in room [ROOM NUMBER]A, stated they see roaches in their room every morning, and they have reported this to the staff. Resident #68 also stated the exterminator came the other day and comes to their room once in a blue moon, but the situation is not any better. On 09/09/2025 at 10:57 AM, Resident #150 who resided in room [ROOM NUMBER]A, stated they see roach in their room every day for the last 3 days. They stated the exterminator was in their room yesterday. On 09/09/2025 at 11:00 AM, Certified Nursing Assistant #2 was interviewed and stated they work on every floor have seen roaches all around the facility. They stated they reported the sightings to the nursing staff. On 09/09/2025 at 11:07 AM, Registered Nurse #1 was interviewed and stated they sometimes see roaches in Unit 4 staff bathroom and reported this to Maintenance Department. On 09/09/2025 at 12:30 PM, the Director of Nursing was interviewed and stated the exterminator visits the facility once a week and any pest sightings are addressed right away. On 09/09/2025 at 1:23 PM, the Administrator was interviewed and stated they have the same exterminator for years and never had pest control issues. The Administrator stated they do not have an answer as to the recent roach sights but will be switching pest control companies. 10 NYCRR: 415.29(j)(5)

Based on record review and interviews during the Recertification and Abbreviated Survey (Intake #797338), the facility failed to ensure Resident #199's representative was informed about a bed bug infestation in the resident's room. This was evident for one (1) (Resident #199) of one (1) resident reviewed for Notification of Change out of 40 total sampled residents. The findings include:The facility policy titled Notification of Changes with a revised date of 05/2025 documented the intent of the policy was to provide appropriate and timely information about changes relevant to a resident's condition or changes in room to the parties who will make decisions about care, treatment, and preferences to address the changes.Resident #199 had diagnoses of Vascular Dementia, Type 2 Diabetes Mellitus, and Malignant Neoplasm of Colon.The Annual Minimum Data Set assessment dated [DATE] documented that Resident #199 had modified independence with their cognitive skills for daily decision making and a short/long-term memory problem.The Pest Elimination Division Service Requesting Log dated 06/10/2024 documented Resident #199's room had bed bugs.The Pest Control Service Report dated 06/10/2025 documented Resident #199's room was treated with Bedlam and Transport Mikron Pesticides for presence of bed bugs.There was no documented evidence that Resident #199's representative was notified.09/02/2025 at 2:18 PM, Resident #199's representative was interviewed and stated they were not notified of bed bugs in the resident's room. On 09/09/2025 at 12:05 PM, Registered Nurse #2 was interviewed and stated they were unaware Resident #199 had a past infestation of bed bugs in their room. Registered Nurse #2 stated when a resident has a bed bug infestation in their room, the Social Worker is responsible for notifying the family.On 09/09/2025 at 12:30 PM, the Director of Nursing was interviewed and stated the resident's family should be informed by their Social Worker when there is a bed bug infestation in the resident's room. The family is also encouraged to let the facility send out the resident's laundry so it can be washed in high temperatures in order to kill the bed bugs.On 09/09/2025 at 1:04 PM, the Director of Social Work was interviewed and stated either nursing or Social Service department notifies the family if bed bugs are present in a resident's room. They stated that at the time Resident #199 had bed bug infestation in their room, the social services department was short of a staff member, and they were covering 4 floors. However, the Director of Social Work stated this communication would not necessarily be documented in the progress notes. 10 NYCRR 415.3(d)(2)(ii)(c)

Based on record reviews and interviews during the Recertification survey conducted from 08/24/2023 to 08/31/2023, the facility did not ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This was evident for Resident #144 reviewed out of a sample of 37 residents. Specifically, after admission to the facility, the resident developed a new left buttock pressure ulcer, which worsened and became infected requiring the resident to be admitted to the hospital. There was no evidence the wound was evaluated between identification as an excoriation on 03/06/23 and becoming an unstageable ulcer on 3/21/2023. The actual ulcer care plan had no goals or interventions, and a physician's order for an immediate surgical consult was not followed until 6 days later. Subsequently, Resident #144 was hospitalized from 04/10/2023 to 04/27/2023, and they were diagnosed with infected pressure ulcers and received intravenous antibiotic therapy. This resulted in actual harm that is not Immediate Jeopardy to Resident #144. The findings are: The facility policy titled Wound Management, Pressure Injury Care and Prevention effective January 12, 2017, last revised May 2023 documented when a resident is identified as at risk for pressure ulcers, the Interdisciplinary Team will initiate a care plan that recognizes the resident's needs and goals and addresses the same with individualized interventions that are consistent with recognized standards of practice. Resident #144 was admitted with diagnoses that included Cerebrovascular Accident (Stroke), Hemiplegia (paralysis on one side of the body), and Respiratory Failure. The Admission Minimum Data Set 3.0 (MDS) assessment dated [DATE], documented that on admission Resident #144 had no discernible consciousness, was totally dependent on staff to perform Activities of Daily Living (ADL), was at risk for developing pressure ulcers, and had one unstageable pressure ulcer. The Nursing-Decubitus Report dated 01/10/2023 documented that the resident had an unstageable pressure ulcer on the sacrum. On 08/29/2023 at 12:30 PM, an interview was conducted with the Resident Representative (RR) of Resident #144 who stated in April 2023, a new pressure ulcer was discovered, and Resident #144 was transferred to the hospital. The RR also stated that the hospital determined the wound was infected. The Physician's Order dated 03/06/23 documented orders for silver sulfadiazine 1% topical cream, (an antibiotic treatment) to be applied a left buttock excoriation (scratches, abrasions to top layer of skin) every shift after cleansing with soap and water and pat dry. The excoriation should be covered with a dry protective dressing (DPD). The Nursing Progress Note dated 03/06/2023, written by Staff #11, documented that Resident # 144 was noted to have excoriation (scratches, abrasions to top layer of skin) to the left buttock. The RNS (Registered Nurse Supervisor) was made aware, and a physician's order was placed to clean the left buttock with soap and water, pat dry, and apply silver sulfadiazine (an antibiotic treatment ointment) every shift. The Rehabilitation Nurses Note dated 03/07/2023 documented they were called to see Resident #144 because of the excoriation to the left lower buttock. The resident was at risk for skin breakdown due to immobility (wheelchair bound and unable to turn self) and incontinence. The rehabilitation nurse recommended an air mattress for the bed, a pressure-relieving cushion placed in the wheelchair (w/c) and turning every 2 hours while in bed The Resident Nursing Instructions documented that Resident #145 should be turned and positioned every two hours. The Resident Certified Nurse Aide (CNA) Documentation History Detail report documented turning and positioning was completed each shift. The record reflected a signature once per shift by the assigned Certified Nursing Assistant. The facility did not record the turning and positioning every 2 hours. The Nursing-Decubitus Report-Skin Exam dated 03/14/2023 documented Resident #144 had a healing sacral ulcer. The note did contain any documentation about Resident #144's left buttock. The Physician's Order dated 03/20/2023 documented that the left lower buttock excoriation was to be cleansed and pat dried. The treatment was changed to an ointment to be applied daily and as needed that contained enzymes used to aid in the healing of skin wounds. The Wound Management Note dated 03/21/2023 documented the pressure ulcer to the sacrum was healed. The note also documented for the first time that there was a new unstageable pressure ulcer on the left buttock which measured 4 cm (centimeters) long by (x) 4 cm wide with 80% slough (yellow tissue which prevents the wound from healing) and 20% pink, healing tissue covering the wound. The Care Plan Activity Report (CPAR) titled Actual Decubitus Ulcer to lower buttock, dated 03/21/2023 documented Resident #144 had wounds to the left (L) lower buttock, sacrum, and Bilateral (B) heels. There were no goals or interventions documented on the care plan. There was no documented evidence the left buttock wound was monitored or evaluated by the wound team or attending physician from 03/06/2023 to 03/21/2023. During that time, the wound progressed from an excoriation to an unstageable pressure ulcer. The Wound Management Note dated 03/28/2023 documented that the unstageable pressure ulcer on the left buttock had increased in size and now measured 5 cm x 6 cm. The wound also had 80% slough (yellow tissue which prevents the wound from healing) and 20% pink, healing tissue covering the wound. The Wound Management Note dated 04/04/2023 documented that the left buttock pressure ulcer had increased in size to 10 cm x 10 cm and was covered with 90% dead tissue and 10% slough tissue. The wound was to be cleansed with Sodium Hypochlorite 0.125% solution (an inorganic compound used to clean wounds), an ointment containing enzymes to help healthy tissue to grow was to be applied, and the wound was to be covered with a dressing twice daily and as needed. The Nursing Progress Note dated 04/04/2023 at 9:25AM documented Resident #144 was seen and examined by the Wound MD (Medical Doctor). A Surgical consult for debridement STAT (immediately) along with an Infectious Disease (ID) consult was ordered. The Nursing Progress Note dated 04/10/2023 documented Resident #144 left the facility at 11:30 AM to go to the STAT surgical consult appointment ordered on 4/4/2023. There was no documented evidence the facility attempted to complete the STAT surgical consult immediately. The consult was not done until 6 days after it was ordered. The Nursing Progress Note dated 04/10/2023 at 10:35 PM documented that Resident #144 was transferred to the ER (emergency room ) from the surgical consult appointment and admitted to the hospital. The hospital history and physical note dated 04/11/2023 at 10:04 AM documented Resident #144 was seen in the emergency department on 04/10/2023 at 6:30 PM for an infected pressure ulcer. Resident #144 was noted to have an elevated temperature of 101.6 and was given intravenous fluids and antibiotics. On 04/11/2023 at 7:22 PM the hospital Infectious Disease Physician documented Resident #144 had a deep pressure ulcer on their left buttock that was foul smelling with green tissue present. The plan was to treat Resident #144 with three antibiotics. On 08/31/2023 at 11:54 AM, an interview was conducted with the Wound Care Nurse (WCN) RN #2 who stated that Resident #144 was admitted with one sacral wound. The left buttock wound was an excoriation when it was identified. After 2 weeks, the area was noted with discoloration. The WCN stated the Wound MD was asked to evaluate the wound on 03/21/2023, and the Wound MD advised them to continue with the prescribed ointment to remove dead tissue. The WCN further stated that their role is to make rounds with the wound doctor and check if there are any changes. The unit nurses were responsible for doing the daily wound treatments at that time. The unit nurses were supposed to notify the WCN if the wound was worsening and required a possible treatment change. The WCN stated they started doing all treatments at the beginning of August 2023. The WCN indicated they had no formal training in wound care, but they attended seminars and in-services prior to the COVID-19 pandemic. On 08/31/2023 at 01:11 PM, Registered Nurse (RN) #3 was interviewed and stated that the CNAs document once every shift in the Electronic Medical Record (EMR) to confirm that turning and positioning occurred during the shift. RN #3 also stated that the Nursing Supervisors perform wound care on the weekends. RN #3 further stated that when the residents are out of bed, they make sure they are returned to bed by 2 PM so they are not out of the bed for prolonged periods. RN #3 stated that they use a pressure relieving cushion when residents are out of bed, and they remind the CNA's when turning and positioning needs to be done. On 08/31/2023 at 03:45 PM, the Medical Director (MD) who was also the attending Physician was interviewed and stated that they did not know why the resident developed a second ulcer. The Wound Care doctor takes care of the ulcers, and they did not know what could have contributed to the ulcer becoming infected. The MD also stated that they could not recall if they had ever examined the resident or observed the wound. The MD further stated that they refer all concerns to the Wound Care doctor and could not recall if they had reviewed the resident's records upon their return from the hospital. When the resident returned from the hospital, they were referred to Wound Care doctor once again. 10 NYCRR 415.12(c)(1)

Based on record review and interviews conducted during the Recertification survey from 8/24/23 through 8/31/23, the facility did not ensure an Infection Preventionist (IP) with specialized training was designated to be responsible for the facility's Infection Prevention and Control Program (IPCP). This was evident during the review of the Infection Control Task. Specifically, the facility's designated IP did not have documented evidence of completing specialized infection prevention and control training. The findings are. The Centers for Medicare and Medicaid Services (CMS) memo titled Center for Clinical Standards and Quality/Quality, Safety & Oversight Group. Ref: QSO-19-10-NH dated 3/11/19 documented Specialized Infection Prevention and Control Training for Nursing Home Staff in the Long-Term Care Setting. Effective 11/28/19, the final requirement includes specialized infection prevention and control training for the individual(s) responsible for the facility's IPCP. The course is approximately 19 hours long and comprises 23 modules and submodules. The facility's policy and procedure, titled, Infection Preventionist (IP) with a revised date of 4/10/23, documented that the IP is responsible for coordinating the implementation and updating of established infection and control policies and practices. The facility will designate one or more individuals as the IP who are responsible for the facility's IPCP. The IP will have professional training in nursing, medical technology, microbiology, epidemiology, or other fields. The IP must be qualified by education, training, experience, or certification. The facility's IP's certificate of training dated 6/14/23 documented that the IP has successfully completed Module 1 of the Infection Control Prevention & Control Program from the Nursing Home Infection Preventionist Training Course. During an interview on 8/28/23 at 3:47 PM, the Infection Preventionist (IP) stated they became the facility's IP on 12/2019. The IP started the ICP training in 2019 but did only 1 Module. They did not complete the training in 2019 and had to do it again. They started the training again in June 2023, took module 1, and finished it on 6/14/23. They only took 1 module and completed the rest on 8/27/23. During an interview on 8/31/23 at 12:02 PM, the Director of Nursing (DNS) stated that they were unaware that the IP must have specialized training and certification before they can be the facility's IP. The IP has been working as an IP for five years since 2019. The IP completed 15 modules of the training over the weekend. 415.19

Based on observations, record review and interview conducted during the recertification survey from 8/24/23 to 8/31/23, the facility did not ensure that the results of the most recent survey report and plan of correction of the facility was posted in a place readily accessible to residents, and family members and legal representatives of residents. Specifically, the survey report was posted at an elevated level, in a locked glass case on the wall opposite the main lobby elevators. This was evident for 12 of 12 attendees of the Resident Council meeting. The findings are: The facility policy titled Accessibility of Survey Results revised April 2022 documented that a copy of the most recent standard survey, including any subsequent extended surveys, follow-up revisit reports, etc. along with state approved plans of correction of noted deficiencies, is maintained in an area frequented and accessible to residents, such as in the main lobby. On 08/25/23 at 10:38 AM, during the Resident Council meeting, residents stated that they did not know where the results of the state inspection were located. During multiple observations conducted at various times from 8/24/23 to 8/31/23, the survey report was observed placed in a plastic sleeve, positioned above shoulder height in a locked glass case on the wall opposite the main lobby elevators. On 08/31/23 at 01:26 PM, an interview was conducted with the Facility Administrator (FA) who stated that the survey results are located on the bulletin board across from the elevator. The FA stated that the facility had a number of residents who had a behavior of ripping the survey results off the wall, so the decision was made to place the results in a locked glass cabinet to prevent them being destroyed. The FA further stated they had not considered relocating the results but would place the results outside of the cabinet. On 8/31/23 at 3:00 PM, the survey results were observed placed in a plastic folder, and secured with clear plastic tape to the front glass of the bulletin making the results still inaccessible to residents. 415.3(d)(1)(v)

Based on observations and interviews conducted during a Recertification survey conducted from 08/24/23 to 8/31/2023, the facility did not ensure that proper sanitation and food handling practices were conducted to prevent potential foodborne illnesses. Specifically, 1) portions of the meat slicer were washed and sanitized but replaced on the machine with ungloved hands and 2) unlabeled, undated food and staff food was observed stored in a pantry refrigerator on a resident unit (Unit 4). The findings are: 1. The facility's slicer Cleaning and Sanitizing Directions state, Remove both the knife cover, cover knob, slice deflector by unscrewing the stainless-steel knob. Wash, rinse and sanitize the knife cover knob, knife deflector and both sides of the knife. On 08/30/2023 at 11:08 AM, the slicer was observed during cleaning. The Acting Director Food and Nutrition Services (ADFN) washed their hands, donned gloves and removed the knife cover, cover knob, slice deflector and blade. They placed them in the soapy water in the sink, then cleaned the rest of the slicer. Once the rest of the slicer was cleaned and sanitized, they removed the parts, rinsed and sanitized them and left them to air dry. They then removed their gloves. When the parts were dry, they replaced them on the machine without donning new gloves. The ADFN was interviewed immediately and stated that there is no written protocol for cleaning the slicer. However, the dietary worker assigned to the task is usually instructed to double glove to replace the removeable parts because replacing the blade is hazardous and can cause injury. The ADFN also stated I removed my gloves too soon, it was a slip-up. 48931 2. The facility policy and procedure titled Pantry/Food Storage with last effective date 4/2023 noted the following information: Food will be stored in a manner that maintains the integrity of the food and the safety of the resident. A sign posted on the refrigerator door indicated food in the fridge must be dated and can be kept for only one day On 08/24/23 at 10:02 AM, the refrigerator in the Resident Pantry was observed to contain 3 Bologna Sandwiches which, were not labeled or dated, two packages that were labeled for residents but were not dated, and one package of food that was labeled for a staff and was not dated. On 08/24/23 12:48 PM an interview was conducted with Certified Nursing Assistant (CNA) #2 who stated resident drinks, and items from the kitchen are stored in the refrigerator. CNA #2 stated their child had brought food for them today and they placed it in the pantry refrigerator because they did not want it to go bad. CNA #2 also stated that they did not know where staff food should be sure and was not sure whether there was somewhere in the basement where it could be stored. On 08/31/23 at 10:52 AM, an interview was conducted with Licensed Practical Nurse (LPN) #2 who stated that food should be labeled with residents name and should be discarded after two days. LPN #2 also stated that the refrigerator should only contain food for staff and staff food should not be stored there. LPN #2 further stated that things were chaotic that morning and they did not know why there were extra sandwiches in the refrigerator that did not have dates. 415.14 (h)

Based on observations and interviews during the recertification survey from 8/24/23 through 8/31/23, the facility did not ensure that garbage was disposed of properly. Specifically, the trash bin was not covered when being transported from the kitchen and the trash was placed in an uncovered and unlocked dumpster. The findings are: The facility's policy and procedure titled, Trash Disposal, last reviewed 04/2023, documents that that all trash is bagged and placed in the trash compactor located in the back parking lot and all cardboard boxes are placed in the cardboard container. On 08/30/2023 at 1:07 PM, trash removal was observed. Dietary Aide #2 washed hands, donned gloves and bagged all the kitchen scraps. However, the Dietary Aide placed the cardboard in the trash bin on top of the sealed trash bags, so that the bin was overfull and could not be covered. The Dietary Aide transported the open bin to the back parking lot, where both trash and cardboard were deposited in an uncovered, unlocked dumpster. On 08/31/2023 at 10:09 AM, the Acting Director Food and Nutrition Services (ADFN) was interviewed and stated that they were aware that food waste and cardboard should not be mixed in the bin and are usually transported separately. They were not aware that the bin needed to be transported covered and said they would educate Dietary Worker #2. The ADFN further stated that Administration was responsible for the trash removal contract and the trash receptacles. On 08/31/2023 at 11:10 AM, the Administrator was interviewed and stated they were aware of the regulations regarding trash containment; the facility usually uses a trash compactor but it is currently being repaired. It broke on 08/23/2023 and was removed for repair by the contracted company, which will return it when it is repaired. The company provided the dumpster in the interim. The Administrator stated that the trash removal company does not have any covered containers and said, We know it's not what the guidelines say but what can we do? 415.14(h)

Based on observation, record review, and interviews conducted during the recertification survey from 8/24/2023 to 8/31/2023, the facility did not ensure the resident's right to a dignified existence. This was evident for 3 (Resident #28, #45, and #135) out of 54 total sampled residents. Specifically, 1) Residents #28 and #135 were fed by staff standing over them, and 2) staff placed clothing protectors on Resident #45 without asking permission. The findings are: The facility policy titled Resident's Rights and Dignity, with the last effective date of April 2023, documented that the facility's goal is to deliver quality healthcare services to promote resident's comfort and well-being. All residents should be treated with consideration, courtesy, respect, and sensitivity to their background, culture, religion, and heritage. 1. Resident #28 was admitted with diagnoses that include Traumatic Brain Injury and Dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #28 cognition as severely impaired and never/rarely made decisions. The resident is dependent and requires one-person physical assistance in eating. On 8/24/23 at 1:00 PM, during dining observation, Registered Nurse #3 (RN #3) stood over Resident #28 while feeding the resident. 2. Resident #135 was admitted with diagnoses that include Dementia and Multiple Sclerosis. The quarterly MDS assessment dated [DATE] documented Resident #135's cognition as severely impaired and never/rarely made decisions. The resident is dependent and requires one-person physical assistance in eating. On 8/24/23 at 12:50 PM, RN #3 stood over Resident #28 during dining observation while feeding the resident. During an interview on 8/24/23 at 2:27 PM, RN #3 stated that they usually stand when feeding residents. RN #3 prefers to stand because it is comfortable, making RN #3 move fast. RN #3 is aware that they are required to sit and feed residents. During an interview on 8/31/23 at 8:39 AM, the Staff Educator stated that the staff is supposed to sit when feeding the residents to have eye level with them. During an interview on 8/31/23 at 11:36 AM, the Director of Nursing (DON) stated that the residents are to be fed at eye level. The staff are supposed to sit when they are feeding the residents. 48931 3. The Quarterly Minimum Data Set (MDS) dated [DATE] documented Resident #45 with severely impaired cognition. On 08/24/23 at 11:44 AM, Licensed Practical Nurse (LPN) #2 was observed placing a clothing protector on Resident #45. Resident #45 asked LPN #2 what the item was, LPN #2 stated that it was to keep clothing clean when eating. Resident #45 proceeded to pull the clothing protector off. LPN #2 replaced the clothing protector which Resident #45 again pulled off. LPN #2 placed another clothing protector on Resident #45 and asked them to keep that one on. Resident #45 was later observed moving the clothing protector to the side of their body. LPN #2 did not request Resident #45's permission before placing a clothing protector on 3 occasions. On 08/29/23 at 11:50 AM, Certified Nursing Assistant (CNA) #2 was observed placing clothing protector on Resident #45 without asking permission prior to doing so. On 08/31/23 at 01:38 PM, an interview was conducted with CNA #2, who stated that they will wash the residents' hands or use wipes and put residents at their assigned tables. They will tell the residents that the clothing protector is being applied and why. CNA #2 also stated that on 8/29/23 they were getting the residents ready for lunch, and it slipped their mind to ask before placing the clothing protector. CNA #2 further stated that they had recently been provided in-service on resident's rights and dignity. On 08/31/23 at 10:52 AM, an interview was conducted with LPN #2 who stated that clothing protectors are placed on residents, and the residents are asked before this is done. LPN #2 also stated that on 8/24/23, Resident #45 removed the clothing protector, balled it up, and threw it across the room repeatedly. LPN #2 further stated that they could not recall when the last in-service was done. On 08/31/23 at 12:42 PM, an interview was conducted with the Registered Nurse Supervisor (RNS) #1 who stated that wipes and clothing protectors are provided by the CNAs, and the nurse will give the trays to the residents. Before the meal a clothing protector will be provided, and the CNA must ask before applying. RNS #1 also stated that if a resident refuses the clothing protector the CNAs will not provide them. RNS #1 further stated that the LPNs are responsible for supervising this task. On 08/31/23 at 03:51 PM, an interview was conducted with the Director of Nursing (DON) who stated that CNAs must identify themselves and talk through all procedures with residents. The DON also stated that with all care consent must be given, and if a resident cannot verbalize, the CNAs must still ask. 415.5(a)

Based on record review and staff interview conducted during the Recertification survey from 8/24/2023 to 8/31/2023 the facility did not ensure that a resident Comprehensive Care Plan was reviewed and revised as needed with interventions to reflect the resident's changing needs. This was evident for 1 (Resident #162) of 4 residents reviewed for Accidents out of a sample of 54 residents. Specifically, Resident #162's Fall CCP was not revised with new interventions after a fall while Resident #162 was trying to use the bathroom. The findings are: The facility's policy and procedure titled Comprehensive Care Plan, last revised on 7/2023, documented that it is the responsibility of each discipline to monitor effectiveness of the stated interventions and to revise the Plan of Care as necessary. Resident #162's diagnoses include: End stage renal disease (ESRD), Dependence on renal dialysis, and Type 2 diabetes mellitus. The Quarterly Minimum Date Set 3.0 (MDS) dated [DATE] documented Resident #162 had intact cognition and required supervision and setup for bed mobility and transfers and extensive assistance of one-person for toilet use. A CCP titled Falls effective on 12/12/22 and included a goal that the resident will be free from injury X 3 months with an intervention to instruct resident to call for assistance as needed. Care Plan Activity Report dated 3/02/23 documented that the resident had a fall on 2/28/23. There was no documented evidence that the CCP was reviewed and revised with new interventions after a fall on 2/28/23. On 8/30/23 at 3:30 PM, the Assistant Director of Nursing (ADNS) was interviewed and stated the intervention for Resident 162's fall on 2/28/23 was an x-ray of the foot and ankle. The ADNS further stated this intervention was documented on 3/2/23 under the notes section of the Falls Care Plan. On 8/31/23 at 11:04 AM, the Director of Nursing (DON) was interviewed and stated that the intervention on Resident #162's Fall CCP is a specific intervention for that fall which is documented in the CCP note. Also, the intervention to call for assistance was reinforced with the Resident. The DON further stated if a resident has a fall the supervisor on duty documents an intervention right away in the Fall CCP and then the ADNS reviews the interventions. 415.11(C)(2)(i-iii)

Based on record review, observation and interview conducted during the Recertification survey from 8/24/23 to 8/31/23, the facility did not ensure that services provided met professional standards of quality care. Specifically, blood pressure was not taken before a resident was administered blood pressure medication to ensure it was within the parameters to safely administer medication as ordered by the physician. This was observed during the Medication Administration Task. (Resident #145) The findings are: The facility Policy and Procedures titled Medication Administration last revised 8/28/2023 documented that it is the policy of the facility that all medications are administered by licensed nursing personnel as ordered by the physician. On 08/28/23 at 08:58 AM, during Medication Administration observation, Licensed Practical Nurse (LPN) #3 was observed administering medication which included medication for Hypertension (high blood pressure) to Resident #145. The Quarterly Minimum Data Set (MDS) dated [DATE] indicated that the resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 15. The Physician Order for Resident #145 with a start date of 4/23/23 documented Metoprolol Succinate ER (Extended Release) 25 mg, once daily. Monitor BP and Pulse. Hold for BP less than 100. Hold for Pulse less than 60. On 08/28/23 at 08:58 AM, during Medication Administration observation it was observed that Licensed Practical Nurse (LPN) #3 did not assess Resident #145's blood pressure prior to administering Metoprolol Succinate ER (a medication to regulate blood pressure). Review of the vital signs monitoring section in the Electronic Medical Record (EMR) revealed that on 08/28/23 at 09:11 AM, LPN #3 documented a blood pressure reading of 128/70 mmHg for Resident #145. On 08/28/23 at 02:18 PM, an interview was conducted with LPN #3 who stated that the blood pressure (BP) was assessed prior to medication being given to all residents. LPN #3 also stated that they assessed and memorized Resident #145's BP prior to giving medication and then entered the BP readings after administering the medication. LPN #3 further stated that they could not recall what the BP reading was for this resident and this was the only resident for whom BP readings were entered after medication was given. On 08/28/23 at 02:27 PM, an interview was conducted with Resident #145 who stated that BP was not assessed today as is usually done, and the LPN probably forgot. On 08/28/23 at 02:43 PM, a follow-up interview was conducted with LPN #3 who stated that Resident #145's blood pressure had not been assessed today prior to medication being given, and the BP reading entered was documented without first assessing the resident's BP. On 08/31/23 at 12:34 PM, an interview was conducted with the Registered Nurse Supervisor (RNS) #1 who stated that prior to administering BP medications, the nurse should check the orders, and ensure the resident's vital signs are within the parameters and then document the vital signs. RNS #1 also stated that documentation should be accurate and be placed in Sigma when the BP is assessed before the medication is administered. RNS #1 further stated that rounds are done in the morning by the Unit Coordinator to ensure compliance. On 08/31/23 at 03:55 PM, an interview was conducted with the Director of Nursing (DON) who stated that if BP medications require a parameter, the BP must be assessed prior to administration. If medication is to be held, the MD must be informed. The DON also stated that the assessment of the BP should be documented in sync with the administration, and the system will prompt staff to enter the information. 415.11(c)(3)(i)

Based on observation, record review, and interviews conducted during the Recertification survey conducted from 8/24/23 through 8/31/23, the facility did not ensure residents who could not carry out Activities of Daily Living (ADL) received the necessary services to maintain good nutrition. This was evident for 1 of 4 residents (Resident #153) out of a sample of 54 residents reviewed. Specifically, Resident #153, who requires assistance with meals, was not assisted with their meals. The findings include: The facility policy and procedure titled A.D.L.'s, with the last revised date of July 5. 2022 documented that the resident will receive A.D.L. care daily to ensure that the needs are met and that residents may function at their optimal level. A.D.L. care provides stimulation interaction and supports the resident's quality of life. The facility policy and procedure titled Mealtime, with the last revised date of April 2023, documented that Mealtime is an important event providing basic nutrition, relaxation, and an enjoyable social experience. All available nursing personnel will assist residents at Mealtime to ensure safety, comfort, enjoyment, individuality, independence, and adequacy of nutrition. Resident #153 was admitted with diagnoses that include Dementia and Depression The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident # 153 cognition as severely Impaired, never/rarely made decisions, and requires limited assistance from one person in eating. On 8/28/23 at 9:17 AM, Resident # 153 was observed out of the bed in a wheelchair in their room. The resident's breakfast tray was on the table, untouched. During an interview on 8/28/23 at 9:20 AM, Registered Nurse #3 (RN #3), also the unit clinical coordinator, stated that Resident #153's family member was coming in to feed the resident. Breakfast was delivered to the floor at 8:00 AM. The resident family member requested they leave the tray until they came to provide it to the resident. On 8/28/23 at 9:45 AM, Resident #153's family member visited the resident. During an interview on 8/28/23 at 9:50 AM, Resident #153 family member stated that they did not ask them to leave the tray until they came to feed the resident. They are supposed to assist the resident with their meal, but they do not. Yesterday afternoon, their sibling came to visit during lunch. They asked the resident if they had eaten, and the resident said they had not eaten. They asked to see the tray and they brought it to the resident's room untouched. The sibling assisted the resident with the lunch when they returned the tray, and Resident #153 ate. The Resident Nursing Instruction dated 2/2/23 documented that Resident #153 requires limited assistance of one person in eating. On 8/28/23 at 12:45 PM, Resident #153 was out of bed in their wheelchair in their room. The resident lunch tray was on the bedside table. Resident # 153 lunch tray remained on the bedside table untouched at 12:57 PM, 2:22 PM, and 3:15 PM. A review of the progress notes dated 8/1/23 to 8/29/23 has no documented evidence that Resident #153 refused meals from the staff. During an interview on 8/29/23 at 2:33 PM, Certified Nursing Assistant #5 (CNA #5) stated that Resident #153 needs assistance with their meals. They gave the resident their breakfast tray yesterday, 8/28/23, and fed the resident. Resident #153 ate the banana and said they no longer wanted to eat. The tray was left at the bedside because the family would say that they did not feed the resident. If she removes the tray, the son will say they did not feed the resident. The lunch tray was left at the bedside because the family was coming to assist the residents with their meals. During an interview on 8/29/23 at 2:54 PM, Registered Nurse #3 (RN #3), the unit clinical coordinator, stated they left the tray at the bedside. Resident #153's family gets upset when they found out the resident had not been fed, and the tray was not at the bedside. Resident #153's family member is the one who usually assists the resident with their meals. It is not documented that the resident family assisted the resident with their meals. RN #3 is unsure who fed resident #153 lunch yesterday (8/28/23). It is not documented that the resident refuses meals from the staff. During an interview on 8/31/23 at 11:36 AM, the Director of Nursing (DNS) stated that Resident # 153 is more of a behavior. The resident family requested a modified visiting time from 9:00 AM to assist with feeding the resident. The staff are not required to leave the tray at the bedside. The resident likes familiar faces and eats when there is a regular staff. The charge nurse and the clinical coordinator ensure that the resident gets their meals and are fed. 415.12(a)(3)

Based on observation, record review, and interviews conducted during the Recertification survey from 8/24/23 to 8/31/23, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This was evident for 2 of 5 residents reviewed for Limited Range of Motion out of 37 sampled residents (Resident #77). Specifically, 1) Resident #77 had bilateral upper extremity contractures and was observed without resting hand splints or elbow splints when out of bed and without hand rolls and soft elbow splints when in bed as per Medical Doctor Order (MDO), and 2) Resident #12 with a right-hand contracture was not provided with a splint device as per Medical Doctor Orders. The findings are: The facility policy and procedure titled Assistive/Adaptive, and Positioning Devices dated 4/2020, last reviewed 4/2023 documented that it is the policy of this facility to ensure that assistive/adaptive and positioning devices are provided as indicated in the plan of care, and monitored for proper fit and use as well as care and follow-up completed according to the resident's plan of care as determined by the interdisciplinary Care Plan Team. The assigned CNA will be responsible for the application of devices according to the Plan of Care and signs the CNA Accountability record every shift daily. 1. Resident #77 was admitted to the facility with diagnoses of Stroke, Brain Dysfunction, and Spinal Cord Injury. The Annual Minimum Data Set 3.0 (MDS) dated [DATE] documented that Resident #77 was severely cognitively impaired, was totally dependent on staff for Activities of Daily Living (ADLS), and had impaired mobility on both sides of their upper and lower extremities. The Physician's Order initiated 2/28/23 and renewed 8/10/23 documented hand rolls when in bed except hygiene, resting hand splints when OOB (out of bed) except hygiene and Range of Motion (ROM). Soft elbow splints when in bed except hygiene and ROM. The Care Plan Activity Report titled ADL Functional/Rehabilitation Potential effective 7/26/2020 documented that the Resident has contractures on both elbows, wrists, and finger joints. Severely impaired mobility and total dependence with all ADLS. Occupational Therapy OT screen/evaluation on 5/26/23 and 8/30/23 prescribe interventions and goals as follows: continue bilateral (B) hand splints, bilateral (B) elbow splints when out of bed (OOB). Bilateral (B) hand rolls & soft elbow splints when in bed. Resident will be free from development of further contractures. On 08/24/23 at 10:27 AM, 08/28/23 at 09:11 AM, and 08/31/23 at 10:07 AM, Resident #77 was observed lying in bed with bilateral elbow, wrist and hand contractures without a splint device or hand roll. On 08/25/23 at 12:50 PM, 8/28/23 at 10:23 AM, 8/29/23 at 12:30 PM, and 8/30/23 at 12:30 PM, Resident #77 was observed out of bed with bilateral elbow, wrist and hand contractures without a splint device or guard in place. On 8/31/23 at 10:32 AM, an interview was conducted with Certified Nursing Assistant (CNA) #4 who stated that they perform care for the resident in the morning and then take Resident #77 out of bed. CNA #4 also stated that splint devices are applied on resident's extremities while the resident is in bed which includes elbow and hand splints placed on both arms while in and out of bed. CNA #4 further stated that when the resident shows on their face that they do not want the splints on, they would leave them off and tell the nurse. CNA #4 stated that there was nowhere to document that devices were removed, and they could only document that they put splints on once every shift. CNA #4 also stated that they remove for 15 minutes every two hours, but there was nowhere in the record where they could document that this had been done. On 08/31/23 at 10:42 AM an interview was conducted with Licensed Practical Nurse (LPN) #2 who stated that CNAs are reminded during morning meeting and the Rehabilitation Nurse checks once a shift to ensure that this is being done. LPN #2 also stated that the devices had not been applied for the last two days as the resident started crying as soon as they saw that the CNA was getting ready to place the devices. The CNA was instructed not to apply the device. Rehab was informed and will be evaluating the resident. LPN #2 stated that they were not aware of any reason why the devices had not been in place during observations conducted prior to 08/29/23. LPN #2 also stated that they do review in the electronic medical record to confirm that devices are being applied every shift. 48931 2. Resident #12 was admitted with diagnoses that included Stroke, Non-Alzheimer's Dementia and weakness on one side of the body. The Minimum Data Set (MDS) dated [DATE] documented that Resident #12 was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 9 and was dependent on staff for assistance with Activities of Daily Living. The Physician's Orders dated 4/15/23 noted Right (R) Elbow splint when out of bed and hygiene, and Right Hand roll splint when OOB except hygiene/ROM (Range of Motion). Care plan with an effective date of 6/17/2020, noted as follows: Right hand roll splint at all times, remove during hygiene, Right elbow splint out of bed, Splints per Physical Therapy (PT) Plan of Care (POC). Last review completed on 7/11/23 On 08/24/23 at 11:00 AM, Resident #12 was observed in the hallway being transported in a wheelchair to the activity room. Resident #12 was observed with a contracture of the upper right extremities. No splint device or hand roll was observed in place on Resident #12's right hand. On 08/24/23 at 12:37 PM, Resident # 12 was observed sitting in the hallway at the nurse station, no splint device or hand roll were in place on the resident's right arm. On 08/25/23 at 12:43 PM, 08/29/23 at 11:39 AM and at 2:25 PM, Resident #12 was observed in the activity room, sitting in their wheelchair with a splint device in place but no hand roll was being worn. ON 08/31/23 at 09:59 AM, an interview was conducted with Certified Nursing Assistant (CNA) #3 who stated that Range of Motion (ROM) exercises, 3 sets lasting between 8-10 minutes, flexing both upper and lower extremities are done with Resident #12. CNA #3 also stated that the Resident #12 gets two devices, one for the elbow and one for the hand. Physical Therapy (PT) comes to get them on sometimes, they apply a heating pad because the elbow brace is too tight, and there is difficulty putting it on almost every other day. CNA #3 further stated that when they cannot get the device on, they let the nurse and therapist know, but they had not seen the Physical Therapist recently to let them know they were having difficulty getting the devices on. CNA #3 stated that is the responsibility of the night shift to apply the devices after breakfast. On 08/31/23 at 12:39 PM, an interview was conducted with Registered Nurse Supervisor (RNS) #1 who stated that the Certified Nursing Assistant (CNA)s and Rehabilitation CNAs are responsible for doing the Range of Motion (ROM) exercises for the residents. RNS #1 also stated that the Rehabilitation CNAs and the regular CNAs are aware that this information can be found in the medical doctor orders. RNS #1 also stated that compliance with devices is monitored by Unit Managers, and if a device is missing it should be reported to the Rehabilitation CNAs. On 08/31/23 at 03:54 PM, an interview was conducted with the Director of Nursing who stated that all splint device concerns must be documented in the Certified Nursing Assistant (CNA) Accountability Notes and communicated to the Licensed Practical Nurse (LPN), who will then refer the information to the Rehabilitation Nurse and Occupational Therapist. 415.12 (e)(2)

Based on a record review and interviews conducted during a recertification and complaint (NY00312405) survey from 8/24/23 to 8/31/23, the facility did not ensure a resident received adequate supervision and assistance to prevent accidents. This was evident for 1 (Resident #90) of 4 residents reviewed for accidents out of 54 sampled residents. Specifically, Resident #90 fell out of bed after the resident was transferred to bed with a Hoyer lift and sustained a laceration on the right facial cheek. The findings are: The facility policy and procedure titled Accidents-Residents, Visitors, Volunteers, last reviewed August 2023, documented that Accidents refer to any unexpected or unintentional occurrence or chain of events which may or may not result in injury or illness to a resident. The policy also documents that fall refers to unintentionally falling to rest on the ground, floor, or other lower level. Resident #90 was admitted to the facility with diagnoses that include Dementia, Traumatic Brain Injury (TBI), and Tracheostomy Status. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented that Resident # 90 is dependent and requires two-person assistance for bed mobility, transfer, and toilet use and one person for personal hygiene. The Comprehensive Care Plan (CCP) related to the fall initiated on 12/24/19 documented Resident #90 has the potential for injury as evidenced by diagnoses of vascular dementia and traumatic brain injury. The interventions include total dependence and two-person physical assistance. A care plan note dated 2/27/23 documented that around 2:30 PM, Resident #90 had a jerking movement post-bed transfer and slid on the left side of the bed in a right-lying position. A Patient Accident/Incident Report dated 2/27/23 documented that Resident #90 was found lying on the left side of the floor in a right-side lying position post-CNA care. The resident had a jerky movement post-transfer. A Nurse's Progress Note dated 2/27/23 at 3:09 PM documented that around 2:30 PM, Resident #90 had a jerking movement post-bed transfer and slid on the left side of the bed in a right lying position. CNA #6 was at the bedside but unable to break the fall. The resident sustained approximately a 2-centimeter laceration on the right facial cheek. The primary physician was informed with orders to transfer the resident to the emergency room (ER). A Nurse's Progress Note dated 2/28/23 at 1:10 AM documented that Resident # 90 returned at 12:30 AM. Brain impression showed no intracranial hemorrhage and no acute facial fracture. During an interview on 8/29/23 at 11:44 AM, Certified Nursing Assistant #6 (CNA #6) stated that Resident # 90 is a two-person assistant for everything apart from mouth care. The resident was transferred to bed from a chair with a Hoyer lift after 2:00 PM, and the fall occurred. CNA #7 assisted with the transfer. The resident was placed in the middle of the bed. CNA #7 moved the Hoyer lift out of the room while CNA #6 turned their back to move the table and the supplies closer to the bed. Resident # 90 had one big cough. CNA #6 turned around, and the resident was on the floor. CNA #6 could not prevent the fall and screamed; CNA #7 returned and informed the nurse. During an interview on 8/29/23 at 11:56 AM, CNA #7 stated that they helped CNA #6 to put Resident # 90 back to bed. CNA #7 was pushing the lifter out and heard CNA #6 screaming. CNA #7 returned to the room, saw the resident on the floor, and went and called the nurse. Resident # 90 was placed in the middle of the bed. The fall happened within seconds. CNA #6 was standing on the left side of the bed facing the resident when CNA #7 was leaving the room. During an interview on 8/29/23 at 12:31 PM, Registered Nurse #3 (RN #3) stated that the CNAs were in the room, they shouted, and RN #3 went to the room. Resident # 90 was on the left side of the bed with blood on their face. The resident sustained a laceration on the right cheek. The doctor saw the resident and ordered to transfer the resident to the hospital. RN #3 initiated the Accident /Incident Report. The CNAs were in-serviced on safe transfer and instructed to ensure everything was at the bedside before transferring a resident back to bed. During an interview on 8/31/23 at 10:57 AM, the Assistant Director of Nursing (ADNS) stated that RN #3 initiated the investigation. They interviewed CNA #6 and found out that the resident had a jerky movement after the transfer and fell . The resident tends to have a strong cough and involuntary jerky movement. Resident # 90 was sent to the hospital for evaluation. The investigation concluded that there was no evidence of abuse, neglect, or mistreatment. It was not a care plan violation. They provided counseling CNA #6 to ensure that everything was safe at the bedside to ensure safety. The accident occurred after CNA #6 turned their back towards Resident #90. During an interview on 8/31/23 at 11:57 AM, the Director of Nursing (DNS) stated that it was an isolated incident and was Resident #90's first fall. The resident has been in the facility for almost five years. The resident was sent to the ER, and the staff was in service that they had to ensure they had all supplies before and during care. They should not turn their back to ensure that the resident is safe. The resident coughed, had a jerky movement, and fell out of bed. 415.12(h)(1)

Based on observation, record review, and interviews conducted during the recertification survey from 8/24/23 through 8/31/23, the facility did not ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice. This was evident for 1 out of 2 residents reviewed for respiratory care out of 54 sampled residents (Resident #173). Specifically, Resident #173 was observed using oxygen via trach collar with no label on the tube. The findings are. The facility's policy and procedure, titled Oxygen Tubing Change, with the last revised date of 4/2023, documented that the oxygen tubing is changed by 11-7 Nurse or Respiratory Therapist every Sunday and as needed. Resident #173 was admitted with diagnoses that include Cerebral infarction, Persistent vegetative state, and Pneumonia. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #173 is in a persistent vegetative state and received oxygen therapy. On 8/28/23 at 3:29 PM and 8/29/23 at 12:51 PM, Resident #173 was observed in bed with oxygen via trach collar in use. No label was noted on the tube. The Medical Doctor's Orders dated 8/15/23 documented Oxygen at 28% via tracheal collar continuously. A review of the Respiratory Therapy and Treatment Administration Records dated 8/15/23-8/30/23 had no documented evidence of when the oxygen tubing was changed. On 08/30/23 at 3:34 PM, the Respiratory Therapist (RT) was interviewed and stated that Resident #173's oxygen tubing is usually changed every Sunday and as needed, and the Respiratory Therapist is responsible to change the oxygen tubing. The RT further stated we do not date the tubing when it has been changed and there is no where to document that it was changed on the Respiratory Therapy Record either. On 8/30/23 at 3:56 PM, the Director of Respiratory Therapy (DRT) was interviewed and stated that the RT is responsible for changing the oxygen tubing on a regular basis, and they do not date tubing or document in the EMR that the tubing was changed. On 8/31/23 at 11:09 AM the Director of Nursing (DON) was interviewed and stated the Respiratory Therapists are responsible for changing the oxygen tubing and they will review their oxygen policy regarding how to communicate when oxygen tubing is changed. 415.12(k)(6)

Based on observation, record review, and interviews conducted during the Recertification survey from 8/24/23 to 8/31/23, the facility did not ensure that the resident records were accurately documented in accordance with professional standards of practice. This was evident for 2 residents (Resident #153 and # 145) Specifically, 1) the Resident CNA Documentation History Detail dated 8/28/23 documented that Resident #153 ate 100% and drank 100% liquids for breakfast and lunch while the tray was observed at the bedside untouched, and 2) the Licensed Practical Nurse (LPN) documented a blood pressure reading for Resident #145 without assessing the resident's blood pressure. The findings are: The facility's policy title, CNA Accountability Documentation, with the last revised date of April 2023, documented that CNA will sign the Accountability record after each ADL function. The charge nurse will review the accountability record to ensure the completion of CNA documentation. The CNA will report any changes in the resident's condition and ADL function to the charge nurse. 1. Resident #153 was admitted with diagnoses that include Dementia and Depression The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #153 cognition as severely impaired, never/rarely made decisions, and required limited assistance from one person for eating. On 8/28/23 at 9:17 AM, Resident #153 was observed out of the bed in a wheelchair in their room. The resident's breakfast tray was on the bedside table, untouched. On 8/28/23 at 12:45 PM, Resident #153 was out of bed in their wheelchair in their room. The resident lunch tray was on the bedside table untouched. Resident #153 lunch tray remained on the bedside table untouched at 12:57 PM, 2:22 PM, and 3:15 PM. The Resident CNA Documentation History Detail dated 8/28/23 at 7:00 AM-10:00 AM and 11::00 AM -2:00 PM documented that Resident #153 ate 100% and drank 100% liquids. During an interview on 8/29/23 at 2:33 PM, Certified Nursing Assistant #5 (CNA #5) stated that Resident #153 ate a banana and refused to eat. CNA #5 said they did not feed Resident #153 or see the resident eating. Resident #153 had only the banana and did not drink liquid. CNA #5 stated they did not know why they documented that Resident #153 ate and drank 100% liquids. CNA #5 said that they did not feed the resident during lunch. They wrote that Resident #153 ate and drank 100% liquids during lunch. CNA #5 did not see how much the resident ate and does not know why they documented 100%. During an interview on 8/29/23 at 2:54 PM, Registered Nurse #3 (RN #3) stated that they asked the CNAs how much the resident consumed. The CNA #5 was required to document in the accountability the amount that the resident consumed. They depend on the CNAs to do accurate documentation. RN #3 is unaware that CNA #5 documented 100% for Resident #153. During an interview on 8/31/23 at 8:46 AM, the Staff Educator stated that CNAs are educated during orientation on how to do documentation. The CNAs must document how much the residents eat and drink after meals. The CNAs must be with the resident to see how much they eat and then document. The charge nurse and the unit coordinator ensure that the CNAs do accurate documentation. During an interview on 8/31/23 at 11:36 AM, the Director of Nursing (DON) stated that the CNAs must document the amount of what the resident eats and drinks. They are trained to do accurate documentation. The unit clinical coordinator is responsible for ensuring that Resident #153 gets their meals and is fed, and the intake is documented accurately. 48931 2. Resident #145 was admitted with diagnoses that included Hypertension and Seizure Disorder. The Quarterly Minimum Data Set (MDS) dated [DATE] indicated that the resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 15. The Physician Order for Resident #145 with a start date of 4/23/23 documented Metoprolol Succinate ER (Extended Release) 25 mg, once daily. Monitor BP and Pulse. Hold for BP less than 100. Hold for Pulse less than 60. On 08/28/23 at 08:58 AM, during the Medication Administration Task it was observed that Licensed Practical Nurse (LPN) #3 did not assess Resident #145's blood pressure prior to administering Metoprolol Succinate ER (a medication to regulate blood pressure). Review of the vital signs monitoring section in the Electronic Medical Record (EMR) revealed that on 08/28/23 at 09:11 AM, LPN #3 documented a blood pressure reading of 128/70 mmHg for Resident #145. On 08/28/23 at 02:18 PM, an interview was conducted with LPN #3 who stated that the blood pressure (BP) was assessed prior to medication being given to all residents. LPN #3 also stated that they assessed and memorized Resident #145's BP prior to giving medication and then entered the BP readings after administering the medication. LPN #3 further stated that they could not recall what the BP reading was for this resident, and this was the only resident for whom BP readings were entered after medication was given. On 08/28/23 at 02:27 PM, an interview was conducted with Resident #145 who stated that BP was not assessed today as is usually done, and the LPN probably forgot. On 08/28/23 at 02:43 PM, a follow-up interview was conducted with LPN #3 who stated that Resident #145's blood pressure had not been assessed today prior to medication being given, and the BP reading entered was documented without first assessing the resident's BP. On 08/31/23 at 12:34 PM, an interview was conducted with the Registered Nurse Supervisor (RNS) #1 who stated that prior to administering BP medications, the nurse should check the orders, and ensure the resident's vital signs are within the parameters and then document the vital signs. RNS #1 also stated that documentation should be accurate and be placed in Sigma when the BP is assessed before the medication is administered. RNS #1 further stated that rounds are done in the morning by the Unit Coordinator to ensure compliance. RNS #1 stated that documentation should be done at the time the medication is given and should accurately reflect the readings that were obtained. On 08/31/23 at 03:55 PM, an interview was conducted with the Director of Nursing (DON) who stated that if BP medications require a parameter, the BP must be assessed prior to administration. If medication is to be held, the MD must be informed. The DON also stated that the assessment of the BP should be documented in sync with the administration, and the system will prompt staff to enter the information at the time the medication is being administered. 415.22(a)(1-4)

Based on record review and interviews conducted during an abbreviated survey (NY 809), the facility failed to ensure that the resident environment remains as free from accident hazards as is possible, and each resident receives adequate supervision and assistance devices to prevent accidents. This was evident in 1 out of 3 residents sampled (Resident #1). Specifically, on 05/05/2021 at 6:10 AM, Certified Nursing Assistant (CNA) #1 initially reported that Resident #1 hit their head on the side rail during care. Resident #1 sustained laceration to the outer corner of left eye, was transferred to the hospital, and received three sutures to the left orbital (bony cavity that contains the eyeball). Additionally, on 05/06/2021, Resident #1 was observed with swelling and pain to the right hip and knee. CNA #1 reported on 05/06/2021 that Resident #1 had fallen out of bed during care on 05/05/2021 at 6:10 AM. The x-ray results of 05/06/2021, revealed that Resident #1 sustained an acute impaction fracture (broken ends of the bone are jammed together by the force of the injury) at the distal femur. On 05/07/2021, Resident #1 received an Open Reduction and Internal Fixation (ORIF, a surgery to repair the fractured bones). This resulted in actual harm to Resident #1 that is not Immediate Jeopardy. The findings include: Review of the facility's policy and procedure entitled Accidents- Residents, Visitors, Volunteers dated December 2006 and last revised in May 2021 documented that an accident is any unexpected or unintentional occurrence or chain of events which may or may not result in injury or illness to a resident. It does not include adverse outcomes associated as a direct consequence of treatment or care. Under procedures, documented that when an accident occurs the Nurse in charge of the unit/designee AND Nursing Supervisor MUST be informed. Review of the facility's policy entitled Mechanical Lifter Transfer Techniques, issued date 04/2022 documented that it is the policy of the facility to ensure safety of the residents during transfer using the Mechanical Lifter. To ensure safe transfer of residents using facility procedure. Procedure includes all CNAs to check Accountability Record for type of Mechanical Lit and type of Sling to be used on the resident. Resident #1 was admitted to the facility with diagnoses including [CONDITION(S)] Disease (a group of conditions, diseases, and disorders that affect the blood vessels and blood supply to the brain), Dementia, and Hypertension. The Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #1 had a Brief Interview of Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and score 03 indicating severely impaired cognition. Resident #1 required total assistance with two people for bed mobility, transfer, turning and positioning. A review of a Care Plan (CP) entitled Falls dated 06/08/2020, documented interventions that Resident #1 should be lifted mechanically with two people and transferred with two plus persons' physical assist. A review of a CP entitled ADL Function/Rehabilitation Potential dated 06/08/2020, documented under Etiology: Mobility, severely impaired with no ability to make decisions. There was no intervention documented in the comprehensive care plan for two person's physical assist with bed mobility. A review of the Resident CNA Documentation History Detail (CNA accountability) record dated 05/02/2021, documented instructions for support provided: two or more person (staff support required) physical assist for transfer. Turn & Position dated 05/02/2021, documented instructions for two or more-person physical assist and dressing, one-person physical assist. A review of the facility's Patient Accident/Accident Report, initiated by Registered Nurse (RN) #1, dated 05/05/2021, documented that RN #1 was called by CNA #1 to Resident #1's room. Resident #1 was observed with laceration to the outer corner of the left eye. Moderate bleeding observed and pressure applied, and bleeding stopped. Resident #1 denied pain. The facility's summary investigation, completed by Director of Nurse (DNS) dated 05/07/2021 documented that on 05/05/2021 at 6:10 AM, CNA #1, who worked on the 11-7 shift, reported that during morning care, while CNA #1 was dressing Resident #1, the resident's head hit the siderail. Resident #1 sustained a 1 cm superficial laceration on the lateral corner of the left eye. Resident #1 was transferred to the hospital for evaluation and treatment. Resident #1 received 3 sutures to the laceration. A CT (Computed Tomography) Scan of the resident's head was done with negative result. Resident #1 returned to the facility at 9:52 PM with discharge instructions for vital signs and neurological checks every 2-hours for 24-hours. Results were normal and the resident had no changes in mental status. Resident had no complaints of pain. On 05/06/2021 during morning care, Resident #1 was observed with swelling, redness and discoloration to the right knee and a bump on the right upper thigh. STAT (immediately, without delay) x-rays were done and revealed right acute distal femoral impaction fracture with joint effusion. Resident #1 was transferred to the hospital for evaluation. An immediate investigation was completed to determine the events leading up to the fracture and discrepancy in CNA #1's statement. CNA #1 provided a second statement noting that he/she was performing Activity of Daily Living (ADL) care and when he/she turned Resident #1, the resident fell out of the bed. CNA #1 stated that he/she called CNA #2 for help, and they lifted Resident #1 off the floor and put the resident back in bed. The CNAs did not utilize the lifter and did not call the nurse until after the resident was in bed. The facility concluded that abuse, neglect, and mistreatment cannot be ruled out. A review of a Nursing Progress Note, by Registered Nurse Supervisor (RNS) #1, dated 05/05/2021 at 7:00 AM documented that CNA #1 informed RNS #1 that Resident #1 hit the outer corner of his/her eye on the siderail while CNA #1 was turning and pulling up the resident's pants. Resident #1 sustained a 2 cm laceration to the area. The area was cleansed with Normal Saline and a sterile dressing was applied. Resident #1 was alert with no sign or symptoms of pain. The Medical Doctor (MD) #1 ordered Resident #1 to be transferred to the hospital for possible suturing of laceration. A review of a Nursing Progress Note, by the RN #2, dated 05/05/2021 at 9:52 PM documented that Resident #1 returned from the hospital at 8:30 PM. The resident had 3 stiches to the left orbital area. Recommendation include cleaning the wound with soap and water and monitor for signs of infection. Resident #1 was placed on neurological checks every 2-hours for 24 hours. A review of MD #1's Progress Note dated 05/06/2021 documented that Resident #1 had a fall on 05/05/2021 during the early morning. The Resident sustained a laceration on the left orbital area. Resident #1 was sent to the hospital where the laceration was sutured. A review of the hospital Emergency Department (ED) Provider Notes dated 05/05/2021 under History of Present Illness documented that Resident #1 sustained a fall earlier this morning. Resident sustained a small superficial 1 cm laceration to the left orbital region. No bleeding and dressing applied. The ED Procedure Note dated 05/05/2021 documented that Resident #1 received three sutures. Post-procedure included antibiotic ointment and sterile dressing. A review of a Nursing Progress Note, by RNS #2, dated 05/06/2021 at 11:21 AM documented that Resident #1 was found with swelling, redness, discoloration, and a small, opened area around the right knee and right hip. The MD ordered a STAT x-ray to bilateral hip and pelvis. An x-ray was also ordered of the right femur and right knee. Acetaminophen for pain. A review of a Diagnostic Result dated 05/06/2021 at 4:05 PM, revealed that an x-ray was completed of Resident #1's Femur. An acute fracture noted distal femur with impaction and large effusion present with deformity. [CONDITION(S)] seen throughout. Impression: Acute distal femoral impaction fracture identified with joint effusion. A Physician's Order dated 05/06/2021, documented to transfer Resident #1 to the hospital with diagnosis: Status Post (s/p) fall and abnormal x-ray report: Acute impaction fracture to distal femur with joint effusion. A review of a Medical Doctor's Progress Note, by MD #1, dated 05/07/2021 documented that Resident #1 had a fall. X-ray of the pelvis showed [CONDITION(S)]- chronic [CONDITION(S)], Acute impacted fracture of right femur with joint effusion. Resident #1 was transferred to the hospital for treatment. A review of the hospital Discharge Summary dated 05/20/2021, documented that Resident #1 was found to have closed fracture of the right distal femur s/p ORIF on 05/07/2021. Resident underwent ORIF of the right femur fracture on 05/08/2021. During a telephone interview on 05/17/2022 at 10:37 AM, CNA #1 stated that he/she did not recall the incident and that he/she gave a statement to the facility. Review of CNA #1's initial statement, dated 04/05/2021, to the facility revealed that while CNA #1 was dressing Resident #1, the CNA turned Resident #1 on the left side and the resident hit their head on the bed rail. On 04/06/2021, CNA #1 provided the facility with a second statement documenting that on 04/05/2021 at 6:10AM, he/she turned Resident #1, and the resident fell to the floor. A co-worker, CNA #2, assisted CNA #1 to put the resident back in bed. During a telephone, interview on 06/22/2022 at 2:50 PM, The DON stated that CNA #1 used an international date format. The DON stated that the dates on CNA #1's statements were inaccurately documented. The DON stated that the initial statement was written on 05/05/2021 and the second statement was written on 05/07/2021. During an interview on 05/13/2022 at 2:00 PM, CNA #2 stated on 05/05/2021, CNA #1 called him/her to assist with picking up Resident #1 off the floor. CNA #2 stated that he/she entered the resident's room and observed the resident on the floor. CNA #2 stated that he/she assisted CNA #1 and they picked up the resident from the floor and transferred the resident in bed. CNA #2 stated that they did not use a mechanical lift to transfer Resident #1 back to bed. CNA #2 stated that he/she did not report the incident to the nurse in charge. During a telephone interview on 05/16/2022 at 12:06 PM, RNS #1 stated that it was almost the end of the 11-7 AM shift when he/she was called by the Registered Nurse (RN) #1 on 05/05/2021. RNS #1 stated that Resident #1 had a laceration on the left eyebrow. RNS #1 stated that they interviewed CNA #1 and CNA #1 stated that Resident #1 hit their head on the side rail while CNA #1 was changing and turning the resident on the left side. RNS #1 stated that a full body check was completed with RN #1. RNS #1 stated that they checked the resident knees and hip with no injuries identified. RNS #1 stated, Resident #1 had moderate amount of bleeding to the injured area. RNS #1 stated that they applied a pressure dressing on the site to stop the bleeding. RNS #1 stated that CNA #1 did not tell him/her that Resident #1 fell off the bed. RNS #1 stated that Resident #1 was aphasic (loss of ability to understand or express speech, caused by brain damage) and had no reaction of pain. RNS #1 stated that MD #1 was called, and Resident #1 was transferred to the hospital for stiches. Two unsuccessful attempts were made to contact Registered Nurse (RN) #1. During a telephone interview on 05/16/2022 at 2:20 PM, CNA #3 stated that on 05/06/2021 he/she was assigned to Resident #1 on the 7-3 shift. CNA #3 stated that he/she went to Resident #1's room and observed discoloration and swelling to the resident's right knee. CNA #3 stated that he/she immediately reported it to the Licensed Practical Nurse (LPN) #1 on the floor. During a follow up telephone interview on 06/13/2022 at 2:20 PM, CNA #3 stated that he/she does not remember the time, but he/she went to Resident #1's room to leave supplies on 05/06/2021. CNA #3 stated that he/she took the sheet off Resident #1 and observed swelling and discoloration to Resident #1's right hip. CNA #1 stated that Resident #1 was not moaning or groaning in pain. During a telephone interview on 05/16/2022 at 1:40 PM, RNS #2 stated that on 05/06/2021, he/she was called on the 7-3 shift (does not remember the time), to evaluate Resident #1 who was observed with swelling and discoloration to the surrounding area of the right knee and right hip. RNS #2 stated that he/she called MD #1 and x-rays of the pelvis, right knee, and right femur were ordered. RNS #2 stated that the x-ray result showed that Resident #1 had a fracture to the right femur. RNS #2 stated that Resident #1 was transferred to the hospital as per MD's order. Two unsuccessful attempts were made to contact LPN #1. During a telephone interview on 05/16/2022 at 2:30 PM, the DON stated that Resident #1 was assessed and was at risk for falls. The DON stated that once a resident is at risk for fall, the interdisciplinary team completes an assessment of appropriate interventions and strategies to prevent occurrences. The DON stated that a plan of care with individualized interventions was developed for the resident. The DON stated that Resident #1's plan of care was documented for the use of a mechanical lift for transfers. The DON also stated that when a resident is observed on the floor, staff must call the nurse to assess if it is safe to move the resident. The DON stated that CNA #1 provided an inaccurate report of the incident causing for a delay in treatment. The DON stated that both CNAs were suspended, and CNA #1 subsequently terminated. CNA #2 was in-serviced upon return to the facility. During a telephone interview on 06/13/2022 at 1:41 PM, MD #1 stated that on 05/05/2021 he/she received a call from the RNS #1 informing that Resident #1 had an accident and sustained a laceration to the left orbital area of the eye. MD #1 stated that he/she ordered Resident #1 to be transferred the hospital for sutures. MD #1 stated that he/she saw Resident #1 the next day on 05/06/2021 in the facility and observed Resident #1 with swollen right hip and right knee. MD #1 stated that Resident #1 was sent back to the hospital for fracture repair. MD #1 stated that while Resident #1 was in the hospital, the resident had X-ray done that also showed advanced [CONDITION(S)] and fracture of the right femur. MD #1 stated that both advanced [CONDITION(S)] and the fall contributed to the fracture. 10NYCRR 415.12(h)(2)

Based on observations, records review and staff interviews, the facility did not ensure that care and services to prevent the development of avoidable pressure ulcers and/or to promote the healing of pressure ulcers were provided. Specifically, (1) A resident admitted with intact skin and a discoloration on the Left lateral foot plantar was not properly assessed and evaluated. The resident developed an unstageable pressure ulcer. In addition, the resident's plan of care to wear a left air boot at all times after the pressure ulcer was identified, was not followed. (Resident #223). (2) A resident at risk for pressure ulcers, and receiving continuous oxygen via nasal cannula developed a Stage 2 pressure ulcer on the right ear that was not identified by the staff (Resident #30). This was evident for 2 of 3 residents reviewed for Pressure Ulcers (Resident #223 and #30). The findings are: 1) Resident #223 is a resident admitted [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident is in a persistent vegetative state. The MDS further documented the resident required total assist of two persons with bed mobility, transfer, and toilet use. The resident required total assist of one person with locomotion, dressing, personal hygiene, and eating. The MDS documented that the resident had no pressure ulcers, but was at risk of developing pressure ulcers. The MDS documented the resident received pressure reducing devices for bed and chair, turning/repositioning program, and application of nonsurgical dressings. The Nursing Admission assessment dated [DATE] documented the resident's Left (L) lateral foot had a bluish blackish discoloration on the Skin integrity diagram. The Braden Pressure Ulcer Risk assessment dated [DATE] indicated the resident was at High Risk for pressure ulcers. The Physician's (MD) History and Physical Exam dated 10/2/16 documented the resident's skin was intact. The nutrition progress note dated 10/4/16 documented the resident had an [MEDICATION NAME] of 4.1 suggestive of adequate protein stores. The Comprehensive Care Plan dated 10/7/16 identified the resident as at risk for developing pressure ulcers. It documented the following interventions: Turn and position every two hours while in bed; range of motion exercises as ordered. passive range of motion to both upper extremities twice a day. Keep clean and dry. Apply lotion to buttock area after incontinence and as needed. Monitor to ensure adequate nutritional intake via Peg tube; Use gel cushion with Dycem (assistive device used in performing ADL (Activities of Daily Living)care); Use pull sheet to help move resident in bed; Avoid elevating head of bed more than 30 degrees except with meals; Out of bed to tilt in space wheel chair every day. Monitor skin integrity every day; Monitor lab values per MD order. The Nursing Note dated 10/7/16 noted the discoloration on left lateral foot was increasing in size. The nursing note indicated that the physician was aware and ordered the application of protective dressing once daily, and as needed. A physician's orders [REDACTED]. The resident was not referred to the Wound Care Nurse for the worsening discoloration. The Nursing Note dated 10/17/16 documented that the resident had an active treatment for [REDACTED]. The area was noted open with minimal non-foul smelling drainage. Treatment with [MEDICATION NAME] Ointment initiated. Will continue to monitor. The MD Order dated 10/17/16 instructed to cleanse [MEDICAL CONDITION] on left lateral sole of left foot with normal saline, apply [MEDICATION NAME], cover with dry dressing twice a day and as needed. The CCP for At Risk for Pressure Ulcer was updated 10/17/16 with a discontinuation of the dry protective dressing to L lateral foot. There was no documented evidence in the medical record that the Physician or Wound Care Nurse assessed the resident's skin opening. The MD Order dated 10/18/16 instructed to discontinue the use of left soft pro AFO (Ankle Foot Orthosis) boots. The order further instructed to apply left pressure relief boot when out of bed and transfers except hygiene, and use an abductor pillow when out of bed except when performing hygiene. The Rehab Nurses Notes dated 10/19/16 documented that on 10/18/16 the physical therapy department provided the resident with a pressure relief boot for the left foot to be used when out of bed & transfers except when performing hygiene. It was noted that the left soft pro AFO boot was discontinued. The physician's orders [REDACTED]. Then instructed to discontinue treatment of [REDACTED]. There was no documented evidence in the medical record that the opening was assessed to see what type of [MEDICAL CONDITION] the resident had. There was also no documented evidence of the reason why the treatment was changed from [MEDICATION NAME] to A&D ointment. The physician's orders [REDACTED]. The MD Monthly Orders dated 10/31/16 documented orders for A&D ointment to left lateral foot lesion twice a day. The Treatment Administration Record (TAR), written by the RN Unit Coord #1, dated November 2016 was updated 11/16/16 with the following: lateral foot continue to monitor still with bluish blacking discoloration. Treatment continue as ordered. Bilateral bootie. Will continue to monitor. The nutrition Progress Note dated 11/21/16 documented a GT ([DEVICE]) Note. The note documented the resident's skin was intact and recommended to continue the current GT feeding. There was no documented evidence in the medical record that the MD or Wound Care Nurse assessed and monitored the resident's L foot despite the nurses identifying problems with the foot. The problems documented in the record were not consistent. There was bluish black discoloration, a skin opening, blackish discoloration, and then redness. The Rehab Nurse Note (documented by the Wound Nurse) dated 12/2/16 documented: Called to see resident and noted with open area on left lateral foot with 80% yellow/black tissue & 20% pink tissue, with redness around about 1.5 x 1.5 x .4 centimeters (cm). Resident prone to skin breakdown (secondary to) immobility, incontinence, wheel chair bound, inability to turn self, low Hgb (Hemoglobin), HCT (Hematocrit), Dx of TBI, [MEDICAL CONDITION] c (with) Depression & anxiety. MD made aware change tx to Santyl oint OD (Once Daily), Vit (Vitamin) C, MVI, & Tylenol as ordered, wound consult. & change bootie as per physical therapy. Continue with Comfortex mattress. Turn every 2 hours while in bed. Gentle handling, assess skin every shift. Keep clean and dry at all times. The Decubitus Report (documented by the Wound Nurse) documented the resident was first observed with a L lateral foot Stage IV pressure ulcer on 12/2/16 measuring 1.5 x 1.5x .4 cm. Area with some yellow to black tissue 80% & 20% pink tissue. The MD order dated 12/2/16 documented Change Tx to L lateral Foot ulcer clean with normal saline, then apply Santyl ointment, and cover with bordered gauze once a day at 10:00 AM, Vit C 500 mg (milligrams) via GT OD, MVI 5 cc via GT OD, Tylenol 640 mg via GT 1 hr (hour) prior to dressing change, wound consult, Change bootie to full foam Boots at all times and refer to PT for boots. The order for full foam boots was discontinued on 12/2/16. The MD Order dated 12/2/16 instructed to apply left pressure relief air boot at all times except hygiene and ROM, right spenco boot when in bed except hygiene, right soft pro AFO boot when OOB (out of bed) except hygiene. The Comprehensive Care plan was updated on 12/2/16 to reflect an actual stage four decubitus ulcer on left lateral foot. The interventions were: monitor skin integrity every shift, treatment as ordered by MD, turn and position every 2 hours; avoid pressure to bony prominences, Comfortex mattress to bed, gel set seat cushion to chair when out of bed and right spenco boot when in bed initiated 12/2/16. Discontinued interventions on the care plan included: left soft Pro AFO boot when OOB (d/c 12/2/16), left pressure relief boot when OOB (d/c 10/27/16), Discontinue both spenco boots when in bed 12/2/16. Nutritional interventions included: Prostat 30 ml (milliliters) via GT twice daily. The use of full foam boots at all times was discontinued. Skin to be kept clean and dry, monitor lab values, vitamin therapy and supplements as ordered by MD, and monitor weight. The CCP listed the dosage of vitamins, and supplements: Vit C 500 mg via GT OD, MVI 5 cc via GT daily, Tylenol 640 mg via GT 1 hour prior to dressing change. A wound consult was planned. The Comprehensive Care Plan for ADLs was updated 12/2/16 with the intervention L pressure relief air boot at all times. The CNA Monthly Accountability Record dated December 2016 documented resident was on a turning and positioning program. Signed every shift to indicate it is done. Devices were updated on 12/2/16 with: left pressure relief air boot at all times except for hygiene. Right spenco boot when in bed except hygiene. The Wound Care Assessment (completed by the Wound Doctor) dated 12/6/16 documented the following: Pressure Injury . Unstageable . L foot distal, Lateral, Plantar, (over fifth metatarsal head) . Length: 1.3 Width: 1.0 Depth: 0.0 . Yellow slough: 100% .Moist with light drainage .Exudate: Serous .Recommended Primary Dressing: Collegenase . QD (every day) .Offload wound. Advise pain evaluation and pre-medication prn with dressing changes .Summary: This appears to be a medical device associated PI (Pressure Injury) (MDAPI), likely from splinting at one point .Status: Stable. The Wound Care Assessment (completed by the Wound Doctor) dated 12/13/16 documented the resident's Left foot Distal, Lateral, Plantar wound measured 1.3 x .8 x .3 cm. The assessment further documented that surgical wound debridement was done at bedside, and necrotic tissue was removed from the wound. The Wound Care Assessment (completed by the Wound Doctor) dated 12/20/16 documented the Left Foot Distal, Lateral, Plantar Unstageable pressure ulcer was improving and measured .8 x .5 x .2 cm with Pink 100% granulation tissue. The recommended treatment was Hydrogel BID (twice per day) after cleansing with normal saline. The assessment also recommended the peri-wound (the area surrounding the pressure ulcer) be treated with skin prep QD and PRN (as needed). The MD order dated 12/20/16 changed the treatment for [REDACTED]. On 12/21/16 the physician ordered the treatment to be increased to twice daily. The CCP was updated on 12/21/16 with an intervention to clean wound and apply Hydrogel dressing and bordered gauze twice a day. On 12/21/16 at 2:52 PM, the RN Wound Nurse was interviewed and stated she began following the resident on 12/2/16. She stated that when she first saw the resident's wound it was Stage 4 with necrotic tissue. She added that the wound doctor assessed it as unstageable. She stated that the before 12/2/16 she had not seen the resident. The RN stated that she does not see all residents upon admission and she does not review all the skin assessments. She stated residents are referred to her by the floor nurses for any skin breakdown or questionable skin conditions. She stated that once a resident is referred to her, she follows the resident and attends weekly wound rounds with the doctor and rehab CNA. On 12/21/16 at 2:58 PM, RN Unit Coord #2 was interviewed. She stated that any bony prominence area noticed with discolorations, redness, or open wounds should be referred to the wound nurse. She stated the resident did have a condition that should have been referred to the wound nurse. She stated the unit nurses are responsible for making sure residents are seen and followed by the wound nurse. She further stated the resident's skin opened and the treatment was upgraded, but she did not know why the resident was not referred to the wound nurse. She stated the wound nurse usually follows up on all admissions by checking the initial assessments to make sure things are being checked. On 12/21/16 at 4:20 PM, RN Unit Coord #1 was interviewed. She stated that every week the medication nurse that does the treatment (an RN or LPN) is supposed to document a note regarding the resident's skin condition or wound progress. She stated the nurse should write whether it is healed or describe the area, and they have to update the Unit Coordinator on the resident's skin every week. She stated if the wound is closed, monitoring continues. She stated, If there are any changes in the color or size, we tell the wound nurse. If there is an opening, we tell the wound nurse. There was no opening until we called her. On 12/21/16 at 4:34 PM, the Resident was observed in a tilt wheelchair (w/c) with an air boot on the left foot and an AFO on the right foot. CNA #2 then took resident into the room to provide care and put her into the bed. At 5:33 PM the Resident was observed in bed. The Resident was wearing spenco boots on both feet. Her left foot pressure relieving air boot was observed in the w/c. The RN showed the surveyor the resident's feet because the resident's feet were not visible. The RN did not notice that the resident was wearing the wrong boot on the left foot. CNA #2, the resident's evening shift aide, was interviewed on 12/21/16 at 4:40 PM and 12/22/16 at 4:00 PM. She stated she has been the resident's regular evening shift aide for a couple of months. The resident requires turning and positioning in bed every 2 hours, and she conducts skin checks and looks for scratches or changes. She stated the resident's foot was always covered with a dressing so she was not able to see it during her skin checks. The CNA further stated she has to change the resident's boots when putting her into bed. She stated the resident wears an AFO boot on the right foot and an inflated air boot on the Left foot while out of bed, but she puts spenco boots on both feet when the resident is put into bed. She further stated that when the aides arrive, they get the report so that they know what is going on with the resident. She said that she does not review the CNA Accountability instructions every day. She was not aware that the resident was supposed to wear the inflatable boot at all times. She was told that resident should wear the spenco boots in bed. She stated, If I do not see the devices in the room, I check the book to see if it has been discontinued, but if it is in the room I continue to use it. The regular nurse always lets me know the changes that the resident has when I get to work. They let you know what has happened with the resident when I was out. We should check the CNA Accountability every other day or once in a week or something like that. On 12/22/2016 9:52: AM, the SA observed Wound Care conducted by the RN. The resident was wearing a pressure relieving air boot on the left foot. The RN washed her hands and donned gloves before removing the dirty dressing. The old dressing was sticking to the inside of the boot when it was removed. The left foot lateral plantar was observed with an open circular wound with a pink wound bed. A sterile drape placed beneath the foot. The RN washed hands and donned gloves, cleaned scissors with alcohol prep wipes, washed hands and donned new gloves cleansed wound and applied hydrogel and clean dressing. She removed her gloves, washed hands, and labeled the gauze. There was no wrap placed around the foot and border gauze to keep the dressing in place. When the CNA went to put the resident's foot in the air boot, the dressing moved and started coming off. The RN attempted to tape it, then sanitized her hands and donned gloves to fix the dressing but could not because it completely fell off into the boot. The RN apologized to the resident and had to redo the dressing. The border gauze did not appear to adhere to the skin well and moved a little when the boot placed on the resident's foot after the dressing was done for the second time. The wound dressing that was on the foot prior to the dressing change was coming off the foot and was stuck inside the resident's air boot. This means the dressing was not properly secured. The RN had to complete the dressing twice because of the same issue. The Hydrogel treatment is an impregnated gauze. If the dressing is not properly secured, it would not stay in contact with the wound. On 12/22/16 at 10:39AM, RN #1, who was assigned to administer the resident's treatments since 12/4, was interviewed. The RN stated that sometimes the border gauze may have trouble sticking to the foot if it has lotion on it, but it could be wrapped with tape to secure it. The RN stated that she completed the initial nursing admission assessment on 9/30. She stated the discoloration on the resident's left lateral foot was bluish blackish, and the tissue in the discolored area was softer than the surrounding area. She stated that the discoloration was in the same location where the wound developed. The RN stated that the unit coordinator is responsible for checking the resident's skin upon admission and making a referral to the Wound Nurse if needed. She also stated that she took the telephone order for the dressing to be changed from [MEDICATION NAME] to A&D ointment on 10/19/16, but she could not remember the reason for the change. The RN stated that dressings are recommended by the wound nurse and she calls the physician to make the order. She stated that she does not always document the reason for new orders in the nursing notes, but it should be on the 24 hour report. On 2/22/16 at 11:47AM, the RN Supervisor (RNS) who covers the 3-11 shift and wrote the nursing note on 10/17/16 was interviewed. The RNS stated the resident's foot was being monitored daily for discoloration, and on 10/17/16, the skin was starting to peel off and there was serous drainage. She stated that she did not consider it a pressure ulcer at the time, and she considered it a superficial injury from the initial lesion the resident had. The RNS stated it started as a dark spot on the foot, but when it opened it was very superficial and closed after 2 days. The opening was put on the 24 hour report and the morning shift informed the wound care nurse. She stated that that the treatment was changed back to A&D ointment because it closed, and the evening nurse told her about it and showed her the area. She stated the area was a blackish discoloration at that time. The RNS further stated that all residents are seen by the Wound nurse automatically upon admission, and the resident's discoloration was referred to the wound nurse. On 12/22/16 at 2:30 PM, RN #2 (3-11 nurse who documented nursing note dated 11/24) was interviewed. She is a regular nurse on the 3-11 shift and was assigned to the resident from mid-October to November. The RN stated she applied the daily dressings to the resident's left foot, and she recalled the wound being treated with A&D ointment on her shift. She stated the skin was intact with slight redness and a little black, and it was not boggy. She stated the resident always wore spenco boots in bed to protect the skin, and the resident wore soft boots during the day to wear to therapy. The RN further stated that a weekly wound check note with the current status of the wound should be documented on the Treatment Administration Record (TAR). The note is documented by the day shift for twice per day dressings. She also stated that if a wound heals, it is documented on the TAR and the treatment is discontinued. She stated that any changes such as skin openings, soft or boggy areas, discolorations, redness, skin tears, and excoriation should be reported to the supervisor. On 12/22/2016 at 2:50PM, RN #3 (3-11 shift) was interviewed and stated at first the resident had a discoloration that was treated with A&D ointment and a protective dressing. She further stated that she noticed a peeling of the skin and reported it to the Supervisor, and [MEDICATION NAME] was ordered. The RN stated that after 2 days, she noticed A&D was ordered, and the area was dry with no discoloration that she could remember. She stated she was reassigned to the resident about 2 weeks ago, and the resident wears special blue booties in bed and gets turning and repositioning by the CNA. On 12/22/16 at 4:12 PM, the RN In-Service Coordinator for the past 2 years was interviewed. She stated the CNA is supposed to review the CNA Accountability at the beginning of their shift, and they are instructed to do that in the mandatory In-Services. She gives training on pressure ulcer prevention. She further stated the nurses do not receive in-services on pressure ulcer staging, but they do get training on identification of skin impairments in a general sense because we have a wound nurse who follows up. Any skin impairments- excoriation, discoloration, openings, etc should be reported to the charge nurse, unit coordinator. The unit coordinator should report any skin problems to the wound nurse. She stated any skin opening on a bony prominence is reported to the wound nurse. Whether or not a discoloration is referred to the wound nurse is a judgment call. She stated I cannot say whether it should be reported. Discolorations could be from different sources. On 12/22/16 at 4:54 PM, the attending Physician (MD) was interviewed and stated that she remembered being called by staff a few times about this resident, and she was surprised she did not have any notes in the chart regarding the resident's foot. It is possible she though podiatry was covering it. She further stated she evaluated the resident's foot twice during the month of December, but she could not remember if she saw it before that time. The MD stated that at one point there was an opening that was treated with [MEDICATION NAME], and the resident was referred to the Wound Care nurse. She stated that she identified the pressure ulcer in late November, to her knowledge. She stated that she recommended the protective dressings, devices to off-load pressure, and A&D ointment until the wound nurse could evaluate the wound. The MD stated she remembered being very active about it, and she told the unit coordinator to refer the resident to the wound nurse. She stated when the wound was treated with [MEDICATION NAME], it appeared to be an excoriation. The [MEDICATION NAME] was given to prevent infection. The MD apologized and stated she could not remember everything because she did not have the chart. On 12/22/16 at 6:03 PM, the DON (Director of Nursing) was interviewed and stated, The fact that the CNA did not apply the correct bootie is disturbing to me. I would expect the nurses to get the wound nurse involved on any skin issue on a bony prominence right away. I expect that they would monitor the area closely and do the weekly documentation regarding how the area is progressing. That should have been done. I am not sure if the outcome would have been different had we done a better job of that. On 12/23/16 at 11:12: AM, the resident's regular CNA for the past 2 months was interviewed. She stated that she does skin checks during care and informs the nurse of any redness, discoloration, or openings. The resident has two hands splints and an elbow cushion, and she wears a special softer boot on the Left foot and a regular boot on R foot. The CNA #1 stated the resident's L foot has had a dressing on it for months, which is done by the nurse. 2) Resident #30 is a [AGE] year old, readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) 3.0 dated 11/23/16 documented: severely impaired cognitive skills for decision making, total assistance of two person physical assistance for all activities of daily living. Always incontinent of bowel and bladder, oxygen therapy, at risk for pressure ulcer development and one or more stage 1 or greater pressure ulcer. The MDS further documented the presence of one unhealed stage 3 and one stage 4 pressure ulcer. The most severe tissue type was Eschar- black, brown, tan tissue that adheres firmly to the wound bed. Skin and ulcer treatments included: turning and repositioning program, pressure ulcer care and application of non-surgical dressings (with or without topical medications) other than to the feet. The Comprehensive Care Plan (CCP) dated 4/9/16 documented: At risk for pressure ulcer related to decreased mobility and the resident's inability to reposition self at regular intervals. Interventions included turn and position every 2 hours, observe, record and report signs of ischemia and monitor skin integrity every day. The CCP for Actual Decubitus Ulcer on the left ear dated 11/15/16 documented the intervention to pad the nasal cannula near the ear. On 12/22/16 at 10:25 AM, the resident was observed in bed with oxygen via nasal cannula in place. A wound care observation of the resident's stage 4 left ear and stage 4 sacral/coccyx pressure ulcers was conducted. During the observation a partial thickness open area to the resident's right ear with shallow depth and pink wound bed was also observed. The oxygen tubing was observed with a thin piece of border gauze wrapped around it with a thin piece of gauze holding the tubing in place. There was no documented evidence in the medical record that the staff were monitoring the resident's right ear. There is no documented evidence that skin checks were conducted. There was no documented evidence in the medical record that the Licensed or Registered Nurses identified, assessed, monitored or obtained treatment for [REDACTED]. The Licensed Practical Nurse (LPN #1) who provided the wound care was interviewed on 12/22/16 at 10:46 AM. The LPN stated that she was unaware that the resident had a pressure ulcer to the right ear prior to the observation. The LPN further stated that the residents skin is checked every shift by the nurses and nursing assistants in addition to assessment from the wound care team every Tuesday. An interview was immediately conducted with Registered Nurse (RN #4) who stated that she was not aware of any skin opening to the resident's right ear. The RN further stated that she will call the wound care nurse to evaluate the right ear. The CCP dated 12/22/16 for Actual decubitus ulcer on right ear- Stage 2-secondary to receiving oxygen (nasal cannula) continuously, inability to turn self. Interventions included monitoring skin integrity every shift, pad the nasal cannula near the ear, and to apply [MEDICATION NAME] ointment after normal saline solution cleanse and covering with dressing STAT (Now). On 12/22/16 at approximately 10:45 AM an interview was conducted with the Certified Nursing Assistant (CNA #3) who stated that she provides total care for the resident. The CNA further stated that she is responsible for reporting any skin changes or openings that she observes and added that she was not aware of an opening to the resident's right ear. An interview was conducted on 12/22/16 at approximately 3:10 PM with CNA #4 who stated that she cared for the resident on 12/21/16 and did not see an opening to the right ear. She further stated that she is responsible for daily skin checks and reporting any findings to the nurse. 415.12(c)(1)