Every finding on record at Plattsburgh Rehabilitation and Nursing Center

Based on interviews and record review during a recertification survey, the facility did not ensure a Registered Nurse was scheduled for at least 8 consecutive hours a day, 7 days a week. Specifically, there was no registered nurse working for 8 consecutive hours on 6/06/2024, 6/23/2024, 7/14/2024, and 9/28/2024. This is evidenced by: Record review of the written working schedules for 6/06/2024, 6/23/2024, 7/14/2024, and 9/28/2024 revealed no registered nurse was scheduled to be in the building that day. The census was 80 at the time of the survey. Record review revealed the facility submitted a letter to the Department on 10/02/2024 with a request to waive this Federal regulatory requirement. The letter read in part: - 'Request for waiver from 8-hour Registered Nurse requirement under 42 Code of Federal Regulations Section 483.35(b). I am writing to formally request a waiver from the 8-hour Registered Nuse requirement, as stipulated under 42 Code of Federal Regulations Section 483.35(b). There is an Registered Nurse on the night shift, however, it does not constitute 8 hours concurrently as the schedule is 10 PM to 6 AM, which splits the hours. Despite our extensive efforts to recruit qualitied nursing personnel, we have been unable to secure the necessary staff to meet [the requirement]. Our recruitment initiatives have included sign on bonuses, as the need arises opportunities with flexibility, outreach to nursing schools, collaboration with nursing agencies.' - 'We have a registered nurse and a practitioner available to respond to phone calls from the facility during periods when the registered nurse is not in the building. This arrangement guarantees that any urgent medical needs can be promptly addressed.' During an interview on 10/23/2024 at 1:35 PM, Director of Nursing #1 stated when they are on call, they live ten minutes away and would physically come into the building to deal with issues such as falls and resident change in condition. During an interview on 10/24/2024 at 11:32 AM, Administrator #1 stated the facility had 'aggressively' advertised for registered nurses, including online postings, physical job fairs, and roadside advertising. They stated there was an on-call schedule for currently employed registered nurses including the Director of Nursing, the Assistant Director of Nursing, and unit managers for registered nurse coverage, but there were several days that the facility was unable to meet the regulation. They stated the building was always covered with an offsite, on call registered nurse that could come in for emergencies but not for a whole shift. At the time of the interview, surveyor requested facility documentation that would support the waiver request. 10 New York Codes, Rules, and Regulations 415.13 42 Code of Federal Regulations Section 483.35(b)

Based on observation and interview during the recertification survey, the facility did not store, prepare, distribute, or serve food in accordance with professional standards for food service safety. Specifically, equipment in the main kitchen and 1 of 2 unit kitchenettes were not clean, equipment was not in good repair, and a test kit for checking the concentration of chemical sanitizing solution was not provided. This is evidenced by: All observations were conducted on 10/20/2024 between 12:11 PM and 1:10 PM. The following equipment was soiled with food particles or a dusty oily buildup: Microwave oven. Can opener and holder. Utensil drawers. Shelving. Fire extinguishers. Floor behind the floor fan in dishwashing machine room. B-wing nourishment station refrigerator door gasket. The thermometer for the sanitizing rinse on the automatic dishwashing machine was not functioning. The label of the chemical concentrate used to manually sanitize food equipment stated that the efficacy range of the sanitizer was to be between 200 parts per million and 400 parts per million; the facility could not provide a test kit with a graduation above 400 parts per million to show a solution that was too concentrated. During an interview on 10/21/2024 at 12:09 PM, Food Service Director #1 stated that they would contact the maintenance department to repair the dishwashing machine thermometer, contact the vendor for the correct test papers, and clean the areas found. 10 New York Codes, Rules, and Regulations 415.14(h) Chapter 1 State Sanitary Code Subpart 14-1

Based on record review and interview during a recertification and abbreviated survey (Case # NY00316460), the facility did not ensure each resident was free from misappropriation of resident property and exploitation for 1 (Resident #78) of 3 residents reviewed. Specifically, former Activities Director # 1 used Resident #78 ' s checkbook to write checks that were deposited into their personal account and a partner ' s account amounting to over $11,000. This is evidenced by: Resident #78 was admitted with the diagnoses of end stage renal disease, non-traumatic intracranial hemorrhage, and dementia. The Minimum Data Set (an assessment tool) dated 2/22/2023, documented the resident could be understood, usually understand others, and had moderate cognitive impairment. The facility's Abuse Prevention and Investigation Policy effective 8/2020 documented the facility was committed to providing residents an environment that was free from verbal, mental, and physical abuse, mistreatment, neglect, misappropriation of resident property, and Exploitation through the following Seven Components of a Systematic Approach to Abuse Prohibition. Misappropriation of property was defined in the policy as: The use of deliberate means to exploit, misplace, or the wrongful use of a resident ' s belongings or money-whether permanently or temporarily, without the resident ' s consent. The undated facility document titled Job Description, Activity/Recreation Director, documented one of the essential job functions was to assist residents in handling personal funds. The facility's investigative report dated 5/12/2023 documented the Administrator #1 was notified by Plattsburgh Police Department that the facility Activities Director #1 had been cashing personal checks from Resident #78 and depositing them into their account and an account of their partner. The transactions dated back to 2020, with the most recent being February 2023. The amount taken totaled over $11,000. On 5/15/2023 Activities Director #1 was arrested and charged with grand larceny and check fraud and their employment was terminated. The police Incident Report dated 5/15/2023 documented that a request for a welfare check was received from the North [NAME] Credit Union on 5/02/2023 due to suspicious activity and depletion of Resident #78 ' s bank account. A Police Case Supplemental Narrative Report dated 5/16/2023 documented that Activities Director #1 was interviewed at the Police Department on 5/15/2023. They admitted to filling out, signing checks, and keeping some of the money. Activities Director #1 was arrested on charges of forgery and grand larceny. During an interview on 10/24/2024 at 11:15 AM, Administrator #1 stated there had been no incidents of financial exploitation since this case. All residents that had a personal checkbook or credit card were encouraged to keep it in their locked drawer, which is offered to all residents on admission. Administrator #1 further stated that such items could be kept in the Administrator ' s office for safekeeping. When a resident requests for staff to make a withdrawal or purchase, it is done by Administrator #1 with a witness. The facility had no indication of any issues with the accused staff until they were notified by the Police Department, at which time Activity Director #1 was immediately suspended and then terminated. Administrator #1 further stated they were not informed of the final disposition of the legal matter; however, the resident was reimbursed for the money taken. Past Non-compliance -F602 Based on the following corrective action taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement at the time of this survey: - Facility staff cooperated with the local Police Department to facilitate their investigation and arrest of the perpetrator. - The alleged perpetrator was not permitted entrance to the facility to protect the residents from further misappropriation. - The incident was reported appropriately to the State Survey Agency. - A thorough investigation was completed, and it was determined there were no other victims of misappropriation. - The facility policy titled, Personal Funds-Resident, was updated to include securing personal checkbooks, bank cards, and cash in a locked drawer or in the Administrators office. - Education was provided on 5/26/2024 to all facility staff on abuse, abuse reporting, misappropriation of property, exploitation, and updated facility policy and procedures on resident funds At the time of survey, there were no additional incidents of misappropriated personal property identified. 10 New York Codes, Rules, and Regulations: 415.4(b)

Based on record review and interviews during a recertification and abbreviated survey (Case #NY00347220), the facility did not ensure each resident had an environment that was as free of accident hazards as was possible to prevent accidents for 1 (Resident #20) of 4 residents reviewed for accident hazards. Specifically, when Resident #20 was holding a lit sparkler, the tip fell on their thigh and resulted in a burn. This is evidenced by: Resident #20 was admitted to the facility with diagnoses of dementia, edema, and asthma. The Minimum Data Set (an assessment tool) dated 09/25/2024 documented they could be understood, usually understand others, and was cognitively intact. The Policy and Procedure titled, Accident/Incident- Investigation and Reporting, dated 12/2023 documented guidelines for the completion, investigation, care plan intervention, and timely regulatory reporting of all accidents and incidents with appropriate follow up and monitoring post-incident occurrences. A Progress Note dated 07/04/2024 documented Resident #20 attended an outside festivity for the holiday and received a burn from the sparkler they were holding. Review of the facility incident report dated 07/04/2024, documented Resident #20 was participating in a July 4th holiday activity outside and was holding a sparkler. It documents Activity Director #1 standing right next to the resident. As soon as the sparkler tip fell on to Resident #20 ' s lap, Activity Director #1 contacted the nurse, who then assessed and treated Resident #20. The nurse notified the family, provider, and Director of Nursing #1. Resident #20 was noted to be psychosocially okay following the incident. During an interview on 10/22/2024 at 09:50 AM, Activity Director #1 stated that they offered each resident that could hold a sparkler to hold one and stood by each resident as they handed them a lit sparkler to hold and watch. They further stated that since children were holding sparklers, they thought it okay for residents to, as well. When Activity Director #1 was with Resident #20, the ashes fell on the resident ' s polyester pajama pants and burned a hole in them. This startled both Activity Director #1 and Resident #20, and Activity Director #1 retrieved the nurse. On the scene, the nurse assessed Resident #20 and removed pants, applied cold compress, applied bacitracin, and covered with a non-stick gauze pad During an interview on 10/22/2024 at 10:04 AM, Director of Nursing #1 stated the incident timeline was as Activity Director #1 stated, Resident #20 was outside during a facility activity when asked if they wanted to hold a sparkler and while holding it the tip fell off into their lap. Director of Nursing #1 stated that Resident #20 received. Director of Nursing #1 went through the treatment and healing of the area, reddened and then open on Resident #20 ' s right thigh. Director of Nursing #1 stated they would no longer provide sparklers to residents for them to hold in their hands, as it was a hazard and ' best to avoid. ' At the time of survey, there were no additional incidents of accidents due to sparklers identified. 10 New York Codes, Rules, and Regulations: 415.12(h)(2)

Based on observation, record review, and interviews during the recertification survey, the facility did not ensure foods brought to residents by family and other visitors was in accordance with adopted regulations. Specifically, expired food brought to residents was not discarded. This is evidenced by: During observations on [DATE] at 1:05 PM, entrees (rice and rice with tofu) labeled as belonging to Resident #13 were dated [DATE]. The document posted on the nourishment kitchen refrigerators titled, Resident Food Only, and dated [DATE] stated that food greater than 3-days old was to be discarded. During an interview on [DATE] at 1:06 PM, Licensed Practical Nurse #1 stated that dietary staff was responsible for discarding food brought in for residents that were more than 3-days old. During an interview on [DATE] at 4:40 PM, Family Member #1 stated that they labeled and dated the food brought to their relative (their personal preference), that the food dated [DATE] was correct, and that they relied on the facility to discard old food. During an interview on [DATE] at 11:49 AM, Administrator #1 stated that either dietary aides or nursing staff were to ensure resident food that was more than 3-days old were to be discarded, and the policy on food brought to residents would be updated to include which staff are responsible for discarding old food. 10 New York Codes, Rules, and Regulations 415.14(h)

Based on record review and interviews during an abbreviated survey (Case #NY00332449), the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse, to the Administrator of the facility and to the State Survey Agency for 1 (Resident #1) of 3 residents reviewed. Specifically, the facility did not ensure that an allegation of physical abuse observed by staff on 1/26/2024 at 9:15 PM was reported to the New York State Department of Health within 2 hours after the allegation was made. The allegation was reported to the New York State Department of Health on 1/29/2024 at 10:36 AM. This is evidenced by: The facility Policy and Procedure titled Abuse Identification, effective 8/2020, documented all staff members were responsible for reporting indicators of abuse to the supervisor immediately. All alleged violations of abuse would be reported immediately, but no later than 2 hours if the alleged violation involved abuse. All reports of abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source will be thoroughly investigated and promptly reported to local, state, and federal agencies. Resident #1: Resident #1 was admitted to the facility with diagnoses of dementia with behaviors, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and anxiety. The Minimum Data Set (an assessment tool) dated 12/01/2023 documented the resident could rarely or never be understood, or understand others, and had severe cognitive impairment. A handwritten statement signed by Certified Nurse Aide #3, dated 1/27/2024, documented they told the shift supervisor when they saw the resident being dragged down the hall by Certified Nurse Aides #1 and 2 on 1/26/2024. A handwritten statement signed by Certified Nurse Aide #4, dated 1/27/2024, documented that they saw Certified Nursing Aides #1 and 2 dragging a resident by their arms on 1/26/2024. A typed statement by Registered Nurse Supervisor #1 documented they remember hearing the resident crying in the hallway which was not unusual, and did not recall any other information pertaining to the event or any reports or allegations made. An Incident Report completed on 1/29/2024 documented the evidence was substantiated by video surveillance and witness statements. On 1/26/2024 at 9:15 PM, Certified Nurse Aides #1 and 2 were observed on either side of Resident #1 holding the resident's arms and dragging the resident approximately 10 feet down the hall. The New York State Department of Health Incident Report Submission for Case #NY00332449 documented the facility submitted an incident report for this event on 1/29/2024 at 10:36 AM. During an interview on 2/01/2024 at 10:30 AM, Director of Nursing #1 stated the incident occurred on 1/26/2024 at around 9:15 PM. They stated they were not aware until they came in Monday morning, 1/29/2024 to find written statements from staff under their office door. They further stated they immediately notified the Administrator, an investigation was started, and the Department of Health was notified as well as local Law Enforcement. During an interview on 2/02/2024 at 12:50 PM, Administrator #1 stated they were aware of the 2-hour reporting time. They stated that they still could not determine who [which staff] did not do what they should have done. Administrator #1 further stated that Certified Nurse Aide #3 stated they told Registered Nurse Supervisor #1, and the Registered Nurse Supervisor denied being told; either way it was not reported as it should have been. 10 New York Codes, Rules and Regulations 415.4(b)(2)

Based on record review and interviews during an abbreviated survey (Case #NY00332449), the facility did not ensure that in response to allegations of abuse, immediate and effective measures were put in place to ensure that further potential abuse while an investigation was in progress for 1 (Resident #1) of 3 residents reviewed. Specifically, the administrative staff were not informed and involved as necessary and did not remove the alleged perpetrators from resident care when allegations of abuse were reported by staff on 1/26/2024 at 9:15 PM. This was evidenced by: The facility Policy and Procedure titled Abuse Identification, effective 8/2020, documented all staff members were responsible for reporting indicators of abuse to the supervisor immediately. Employees accused of participating in the alleged abuse would be immediately reassigned to duties that do not involve resident contact or would be suspended until the findings of the investigation have been reviewed by the Administrator. Resident #1: Resident #1 was admitted to the facility with diagnoses of dementia with behaviors, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and anxiety. The Minimum Data Set (an assessment tool) dated 12/01/2023 documented the resident could rarely or never be understood, or understand others, and had severe cognitive impairment. A handwritten statement signed by Certified Nurse Aide #3, dated 1/27/2024, documented they told the shift supervisor when they saw the resident being dragged down the hall by Certified Nurse Aides #1 and 2 on 1/26/2024. A handwritten statement signed by Certified Nurse Aide #4, dated 1/27/2024, documented that they saw Certified Nursing Aides #1 and 2 dragging a resident by their arms on 1/26/2024. A typed statement by Registered Nurse Supervisor #1 documented they remember hearing the resident crying in the hallway, which was not unusual, and did not recall any other information pertaining to the event or any reports or allegations made. An Incident Report completed on 1/29/2024 documented the evidence was substantiated by video surveillance and witness statements. On 1/26/2024 at 9:15 PM, Certified Nurse Aides #1 and 2 were observed on either side of Resident #1 holding the resident's arms and dragging the resident approximately 10 feet down the hall. During an interview on 2/01/2024 at 10:30 AM, Director of Nursing #1 stated the incident occurred on 1/26/2024 at around 9:15 PM. They stated they were not aware until they came in Monday morning, 1/29/2024 to find written statements from staff under their office door. The two staff accused completed their 2:00 PM to 10:00 PM shifts on 1/26/2024 and were not on the schedule to work the weekend. On 1/29/2024, they were both suspended pending the investigation. During an interview on 2/02/2024 at 11:55 PM, Certified Nurse Aide #3 stated they observed two Certified Nurse Aides, one on each arm, sliding the resident down the hall, one foot on the floor, the other foot up in the air. They stated they stopped them and told the Registered Nurse Supervisor #1. During an interview on 2/02/2024 at 12:50 PM, Administrator #1 stated the accused staff should have been removed from the building as soon as the accusations were made by the other staff. Administrator #1 also stated Registered Nurse Supervisor #1 was involved in a recent incident where staff were accused of abuse and Registered Nurse Supervisor #1 knew what to do, however in this incident they deny being told about the incident and that was why nothing was done. 10 New York Codes, Rules and Regulations 415.4(b)(3)

Based on record review and interviews during an abbreviated survey (Case #NY00332449), the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, Resident #1's care plan was not followed resulting in an abuse allegation. Resident #1 was not assessed by a Registered Nurse, the resident's family and physician were notified following the allegation. This was evidenced by: Resident #1: Resident #1 was admitted to the facility with diagnoses of dementia with behaviors, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and anxiety. The Minimum Data Set (an assessment tool) dated 12/1/2023 documented the resident could rarely or never be understood, or understand others, and had severe cognitive impairment. The Comprehensive Care Plan titled Potential to be abused, initiated 10/11/2019, documented the following interventions: respect personal space if re-direction attempts are unsuccessful walk away and allow resident time to calm down and re-approach at a later time. An Incident Report completed on 1/29/2024 documented witnesses reported on 1/26/2024 at 21:15 two Aides were observed holding either side of resident's hand/arm dragging them down hall approximately 10 feet before being stopped. Assessment found a 5 centimeter purple bruise under the left axilla. Medical Doctor Notified 1/29/2024 at 11:00 AM and Resident's family notified 1/29/2024 at 11:00 AM. The medical record did not contain documentation of Physician or family notification from the time of the incident on 1/26/2024 until 1/29/2024. The medical record did not contain documentation of an assessment of the resident was completed from the time of the incident on 1/26/2024 until 1/29/2024. A handwritten statement signed by Certified Nurse Aide #1 on 1/30/2024 documented the resident had been yelling and hitting staff trying to meet the resident's needs. This had been going on for over an hour. Resident was assisted carried to hallway. An undated handwritten statement signed by Certified Nurse Aide #2 documented, they picked the resident up out of the chair and helped the resident to walk. During an interview on 2/02/2024 at 11:20 AM, Certified Nurse Aide #1 stated the resident needed incontinence care and was refusing to get up to go to their room for care. The resident was yelling and distraught. They stated they asked Certified Nursing Aide #2 to help them get the resident up. They further stated they believed the resident was having leg pain and that by helping the resident to stand and supporting some of their weight to walk would help. During an interview on 2/02/2024 at 12:15 PM, Director of Nursing #1 stated the Nurse Manager found a bruise on the resident and reported it to them - Director of Nursing #1 - on Monday morning, 1/29/2024. They stated they - Director of Nursing #1 - notified the doctor and there were no new orders. There was no assessment done prior to that and the Physician was not notified of the incident until after the bruise was found. During an interview on 2/2/2024 at 12:30 PM, Physician #1 stated they were not notified of the incident until Monday morning, 1/29/2024. They were told there was a bruise that was not indicative of being caused by the incident. Physician #1 further stated that they did not examine the resident as they were told there were no other injuries and did not feel the bruise warranted any treatment. 10 New York Codes, Rules and Regulations 415.12

Based on record review and staff interviews during an abbreviated survey (Case #s NY00291781, NY00292325, and #NY00300243), the facility did not ensure in response to allegations of abuse and neglect the facility must have evidence that all alleged violations are thoroughly investigated for 4 (Resident #'s 2, 3, 4, and #5) of 5 residents reviewed for abuse and neglect. Specifically, the facility did not ensure alleged incidents of abuse and neglect that occurred on 3/7/2022, 8/7/2022, 9/12/2022, and 12/30/2022 were thoroughly investigated. This was evidenced by: The Policy and Procedure titled, Completing an Accident/Incident Investigation Guidelines dated 8/21/2020, documented it was the facility's responsibility to immediately initiate and conduct a thorough investigation that included a written conclusion. The summary must include the synopsis, the factual details, conclusion that includes if the DOH reportable element has been met or not for reporting to DOH, if sufficient credible evidence exists to suspect abuse, neglect, or mistreat is present, and the facility corrective action as deemed necessary. Resident #2 Resident #2 was admitted to the facility with diagnoses of dementia, diabetes, and peripheral vascular disease. The Minimum Data Set (MDS- an assessment tool) dated 3/18/2022 documented the resident was cognitively intact, could usually be understood, and could understand others. Resident #4 Resident #4 was admitted to the facility with diagnoses of intermittent explosive disorder, anxiety disorder, and chronic obstructive pulmonary disease. The MDS dated [DATE], documented the resident had severe cognitive impairment, could be understood, and could understand others. The MDS dated [DATE], documented the resident had severe cognitive impairment was usually understood, and could usually understand others. Resident #5 Resident #5 was admitted to the facility with diagnoses of dementia with behavioral disturbance, post-traumatic stress disorder, and Alzheimer's disease. The MDS dated [DATE], documented the resident had severe cognitive impairment, could be understood, and could understand others. Incident dated 3/7/2022 (Resident #2) The Resident Accident/Incident (A/I) Report dated 3/7/2022, documented that at 8:30 PM, Resident #2 was found to have a skin tear on the bottom of their left foot. It documented staff failed to follow the care plan. Staff did a stand/pivot transfer (they stood the resident up and turned them around to sit on the shower chair). The resident's care plan documented they were supposed to be transferred using a full mechanical lift. There was no Abuse Investigation Summary for the 3/7/2022 incident that documented findings, resident specific interventions initiated, or a conclusion. The summary did not include a formal statement from Nurse Aide Trainee #1 or Certified Nursing Assistant #2, both of whom were involved in the incident. Incident dated 9/12/2022 (Resident #s 4 and 5) The Resident A/I Report dated 9/12/2022 documented at 7:15 AM, Resident #4 struck Resident #5 on the right temple area of their head when Resident #5 did not stop waving a sock in their face when asked. There was no Abuse Investigation Summary that documented findings, resident specific interventions initiated, or a conclusion. There was one eyewitness statement for Resident #5. There were no other staff interviewed for Resident #s 4 or 5. Incident dated 12/30/2022 (Resident #s 4 and 5) The Resident A/I Report dated 12/30/2022 documented at 3:20 PM, Resident #5 wandered into Resident #4's room. Resident #4 began to yell, stood up from their wheelchair, and stuck Resident #5 several times in their back telling them to get out. There was no Abuse Investigation Summary that documented findings, resident specific interventions initiated, or a conclusion. RN #2 completed a statement form for Resident #s 4 and 5. There were no other statements obtained. During an interview on 1/27/2023 at 2:04 PM, Registered Nurse Manager (RNM) #1 stated during an investigation they immediately responded to an incident if they were in the building. They separated the abuser from the victim, assisted with assessments, notified the Director of Nursing (DON), medical provider, gathered staff statements, filled out an incident report, and updated the resident's care plans. Incidents were reviewed by the Interdisciplinary Team. During an interview on 1/27/2023 at 2:20 PM, the Director of Nursing (DON) stated they felt they likely needed some training in doing an investigation. The DON stated they thought they only needed to do an investigation summary if DOH requested one. During an interview on 1/27/2023 at 2:42 PM, the Administrator (ADM) stated a thorough investigation consisted of obtaining statements, record review, witness statements, resident statements, video review if needed, and an investigative summary. An investigation needed to be completed within 5 days. The ADM stated it was confusing whether or not an investigation needed to be done if DOH did not request one, but they should be doing an investigation anyway. The ADM stated thorough investigations were not completed for the incidents that occurred on 3/7/2022, 8/7/2022, 9/12/2022, and 12/30/2022. 10 NYCRR 415.4(b)(3)

Based on record review and staff interview during an abbreviated survey (Case #s NY00291781, NY00292325, and #NY00300243) the facility did not ensure in response to allegations of abuse, that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse for 2 (Resident #'s 4, and 5) of 5 residents reviewed for abuse. Specifically, for Resident #'s 4 and 5, the facility did not ensure the resident-to-resident physical altercations that occurred on, 9/12/2022 and 12/30/2022 were reported within 2 hours.This was evidenced by: The Abuse Prevention Manual dated 8/2020, documented an alleged violation of abuse will be reported immediately, but not later than 2 hours. Resident #4 Resident #4 was admitted to the facility with diagnoses of intermittent explosive disorder, anxiety disorder, and chronic obstructive pulmonary disease. The Minimum Data Set (MDS-an assessment tool) dated 9/2/2022, documented the resident had severe cognitive impairment, could be understood, and could understand others. The MDS dated [DATE], documented the resident had severe cognitive impairment was usually understood, and could usually understand others. Resident #5 Resident #5 was admitted to the facility with diagnoses of dementia with behavioral disturbance, post-traumatic stress disorder, and Alzheimer's disease. The MDS dated [DATE], documented the resident had severe cognitive impairment, could be understood, and could understand others. Incident dated 9/12/2022 The Resident Accident/Incident (A/I) Report dated 9/12/2022 at 7:15 AM, documented Resident #5 stated they were hit in the right temple area of their face by Resident #4. The Resident A/I Report dated 9/12/2022 at 7:15 AM, documented Resident #4 stated Resident #5 was waving their sock in front of their face and hit them in the face with it. Resident #4 stated they slapped Resident #5 in their face. The New York State Department of Health Nursing Home Incident Form documented the incident on 9/12/2022 occurred at 7:30 AM and documented the facility reported the incident on 9/12/2022 at 3:48 PM. Incident dated 12/30/2022 The Resident A/I form dated 12/30/2022 at 3:20 PM, documented Resident #5 walked into Resident #4's room. Resident #4 began to yell, got out of their wheelchair, and struck Resident #5 several times on the back, yelling at them to get out. An email from DOH dated 1/1/2023 at 11:16 AM, documented the facility reported the incident on 1/1/2023 at 11:09 AM. During an interview on 1/27/2023 at 2:20 PM, the Director of Nursing stated abuse was to be reported within 2 hours and they believed in some cases within 24 hours if the facility had intervened in the incident. During an interview on 1/27/2023, the Administrator stated abuse must be reported as soon as possible or within 2 hours. 10 NYCRR 415.4(6)

Based on observation, record review and interviews during an abbreviated survey (Case #NY 935), the facility did not ensure each resident was free from abuse for 1 (Resident #2) of 3 residents reviewed. Specifically, the facility did not ensure Resident #2, who had severe cognitive impairment, was free from physical abuse when they were physically restrained against their will and dragged to their room by Licensed Practical Nurse (LPN) #1. This is evidenced by: The Policy and Procedure for titled Abuse Prevention Manual dated ,d+[DATE], documented and defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, with resulting physical harm and mental anguish. Physical abuse included corporal punishment in which physical means are utilized to assert control over a resident. Resident #2 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Comprehensive Care Plan (CCP) dated [DATE] and last revised on [DATE], documented the resident had impaired cognitive function and impaired thought processes related to dementia. The interventions on the CCP documented that staff use consistent, simple direct sentences. Provide the resident with necessary cues- stop and return if agitated. The CCP dated [DATE] documented the resident had a behavior problem related to depression, dementia, and anxiety and could become agitated with redirection at times. The CCP documented interventions for staff to approach and speak in a calm manner, divert attention, and to move the resident to an alternate location. Review of a Nursing Note dated [DATE] at 3:39 PM, documented the resident's family member was notified of a bruise on the resident's right forearm and was a reportable incident. The physician (MD) was aware. The Health Electronic Response Data System (HERDS-form used to report to the DOH) dated [DATE] at 3:37 PM, documented a staff person reported an interaction that occurred with Licensed Practical Nurse (LPN) #1 and Resident #2 and prompted the Administration's review of the facility's surveillance video. The facility Investigation (The Professional Discipline Complaint Form) dated [DATE], documented LPN #1 was attempting to redirect a resident with advanced dementia. The resident became resistant to the LPNs attempt to redirect and began striking LPN #1 becoming notably agitated. LPN #1 proceeded to cross both the resident's arms across their chest. Video surveillance revealed the resident's feet were planted in attempts to stop the movement forward. RN assessment completed on the resident with a dime-sized bruise noted to the right forearm. A New York State (NYS) Department of Health (DOH) Report was filed. It was the policy of the facility to report allegations of abuse and mistreatment. A written statement dated [DATE] from the Administrator (ADM) documented they reviewed footage from the video surveillance camera placed on the B-Wing unit facing the middle of the old B hallway and showed LPN #1 had their arms around Resident #2 from the backside around her chest restraining Resident #2's arms. Resident #2's feet were dragged on the floor as they were not moving with the LPN while being taken to their room. The footage from the second video camera was at the angle facing the B wing nurses station and the beginning showed LPN #1 trying to redirect the resident by having their arm around the resident but the resident resisted and tried to walk away. LPN #1 took the resident's other arm and hugged the resident and restrained them from behind. LPN #1 proceeded to force the resident down the hall to their room. During an interview on [DATE] at 1:45 PM, the Director of Nursing (DON) stated the incident was reported by a staff member who stated they witnessed LPN #1 do something and was not sure what they saw. The DON stated that prompted a review of the surveillance video, which had since expired. The DON stated the incident showed abuse and mistreatment by LPN #1. During an interview on [DATE] at 3:00 PM, the ADM stated video footage was reviewed regarding a reported incident involving LPN #1 and Resident #2. The ADM stated that the surveillance video showed abuse from LPN #1 and the abuse was reported to the DOH. 10 NYCRR 415.4(b)(1)(i)

Based on record review and interviews during an abbreviated survey (Case #NY 115) the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (Resident #1) of 3 residents reviewed for abuse and neglect. Specifically, the facility did not report an allegation of sexual abuse reported to the Director of Nursing on Sunday, 1/23/2022 at 9:15 PM, within 2 hours after the allegation was made. This is evidenced by: The facility policy and procedure (P&P) titled Abuse-Investigation, Protect and Reporting dated 9/2017 and last revised on 8/2020 documented hat the facility will notify the Department of Health (DOH) when the reasonable cause threshold had been established; meaning that there is sufficient evidence for a prudent person to believe that abuse, had occurred. The facility must immediately (within 24 hours), access the Health Commerce System to submit an electronic form to the DOH. The Center for Medicare/Medicaid Services (CMS) had defined immediately as as soon as possible, but not to exceed 24 hours after the discovery of the incident. Resident #1 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 10/15/2021 documented the resident had mildly impaired cognition, could make themselves understood and could understand others. The Facility Investigation dated 1/26/2022, and finalized on 1/25/2022, signed by the Director of Nursing (DON) and the Administrator (ADM), documented that an allegation of sexual abuse was unfounded and not reported to DOH as the elements were not met as determined within the 2 hours of the alleged event and preliminary internal investigation. During an interview on 1/26/2022 at 1:41 PM, the Social Worker (SW) stated that on Monday, 1/24/2022 at morning report the allegation of sexual abuse made by Resident #1 on 1/23/2022 was discussed and the Interdisciplinary Team determined the allegation was unsubstantiated. During an interview on 1/26/2022 at 12:39 PM, the resident's family member that reported the resident's allegation stated the resident called them on Saturday, 1/22/2022 and told them that during care that evening on 1/22/2021 two Certified Nursing Assistants (CNAs) who looked like boys put their fingers in Resident #1's vagina. The family member stated that it bothered them all night and that on the next day, Sunday 1/23/2022, they called the facility to report the resident's allegation of sexual abuse. During an interview on 1/26/2022 at 2:59 PM, the Director of Nursing (DON) stated that on 1/23/2022 at 9:15 PM, the DON was made aware of Resident #1's allegation of sexual abuse. The DON stated that they have 24 hours to report the allegation, but the investigation was unfounded and did not meet the elements for reporting to the police or the Department of Health (DOH). During an interview on 1/27/2022 at 2:53 PM, the Administrator stated an allegation of sexual abuse was reported to them on Sunday, 1/23/2022, between 9-10 PM. It was not reported to the DOH because the investigation was unfounded and there was no need to report. 10 NYCRR 415.4(b)(2)

Based on interviews and record review during a Recertification survey, the facility did not develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 8 (Resident #'s 12, 16, 32, 70, 74, 272, 322, and 323) of 13 residents reviewed for baseline care plans. Specifically, for Resident #'s 16, 32, 74, and #272, the facility did not ensure a baseline care plan was developed or completed within 48 hours of the resident's admission and for Resident #'s 12, 70, 322 and #323, the facility did not ensure written summaries of the baseline care plans were provided to the resident and/or the resident's representative. This is evidenced by: The facility Policy and Procedure titled Base Line Care Plan Policy dated 10/2017, documented that a baseline care plan must be developed and implemented for each resident/resident representative according to regulatory grouping §483.21 as an update to the most recent CMS Manual and Procedure titled Base Line Care Plan Policy dated 10/2017. It documented that the purpose was to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan. The Procedure documented that Within 48 hours of a resident's admission, the facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Resident #272: Resident #272 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS- an assessment tool) was not due to be completed as the resident was admitted to the facility within the last 14 days. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . The baseline care plan did not include the minimum healthcare information necessary to properly care for a resident including, all Physician orders, Dietary orders, Therapy services, Social services, and PASARR recommendation, if applicable. During an interview on 9/23/2021 at 9:29 AM, Registered Nurse (RN) #2 stated each discipline had a section of the baseline care plan that was supposed to completed within 48 hours of a resident's admission. RN #2 stated the baseline care plan for Resident #272 was initiated but had not been completed. There were sections of the baseline care plan that were incomplete. RN #2 stated after the baseline care plan was completed, it was supposed to be printed out and reviewed with the resident if the resident was able and/or the resident representative. Resident #12: Resident #12 was admitted with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE], documented the resident was without cognitive impairment, was understood and could understand. During a review of the resident's medical record, the 48-hour baseline care plan dated 6/14/21, did not include a documented signature or date the baseline care plan was reviewed, and a copy given to the resident or resident representative. Resident #322: Resident #322 was admitted with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- an assessment tool) dated 9/1/2021 documented the resident was without cognitive impairment, was understood and could understand others. Review of the resident's medical record, the 48-hour baseline care plan dated 8/27/2021, did not include a documented signature or date the baseline care plan was reviewed, and a copy given to the resident or resident representative. During an interview on 9/22/2021 at 9:51 AM, Registered Nurse Unit Manager (RNUM) #3 stated completed the Baseline Care plans for Resident #'s 12, 70, 322 and #323 were done but a printed copy was not presented to the resident and or the resident's representative but should have been reviewed and signed. During an interview on 9/23/2021 at 11:35 AM, the Director of Nursing (DON) stated the Registered Nurse Manager (RNM) was expected to complete the baseline care plan within forty-eight hours of the resident's admission to the facility. The RNM was expected to provide a written copy of the baseline care plan to the resident and or their representative. 10NYCRR415.11

Based on record review and interview conducted during the Recertification survey and an abbreviated survey (Case #NY 384), the facility did not ensure the development and implementation of comprehensive person-centered care plans, that included measurable objectives and timeframe's to meet the resident's medical, nursing, and mental and psychosocial needs, for 7 (Residents #'s 12, 31, 57, 70, 73 322, and #323) of 22 residents reviewed for comprehensive care plans (CCP). Specifically, for Resident #12, the facility did not ensure a resident specific CCP for behavior/emotion was developed; for Resident #31, did not ensure a CCP was developed to address the resident's respiratory care related to the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #57, did not ensure a CCP for impaired skin integrity was developed for the resident's persistent back rash; for Resident #70, did not ensure the CCP for pain management contained resident specific non-pharmacological interventions; for Resident #73, did not ensure that a CCP was developed to address discharge planning; for Resident #322, did not ensure the CCP for ADL's included resident specific information for personal hygiene; and for Resident #323, the facility did not ensure the CCP developed for the resident's fungal infection included resident specific interventions. This is evidenced by: A facility policy titled Comprehensive Care Planning dated 10/2013 documented, it is the facilities policy that an individualized or person-centered Comprehensive Care Plan must be initiated by a Registered Nurse (RN) upon admission for all residents. Resident goals for admission and desired outcomes, preference and potential for future discharge, and discharge plans should be included as part of the Comprehensive Care Plan. Resident #12: Resident #12 was admitted to the facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool)) dated 6/16/2021, documented the resident was without cognitive impairment, was understood and could understand. The MDS documented the resident received antipsychotic and antidepressant medications. The Comprehensive Care Plan (CCP) for depression and [CONDITION(S)] documented interventions to consult psychiatry as indicated and monitor, document and report signs and symptoms of depression as needed. The CCP did not include resident specific interventions to manage Resident #12's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During observations on 9/20/2021 at 9:07 AM, 9/20/201 11:35 AM, 9/21/2021 at 9:58 AM, 9/22/2021 at 8:33 AM, 9/23/2021 at 10:34 AM the resident was observed lying in bed facing the wall with their eyes closed. During an interview on 9/21/21 at 8:58 AM, Resident #12 stated they had a decrease in appetite and declined breakfast secondary to a decreased in appetite. The resident reported they had a doctor appointment today and did not know what the outcome of the appointment would be. The resident was lying in bed with a flat affect facing the wall during the interview and declined further discussion with the surveyor. During an interview on 9/21/2021 at 11:35 AM, Registered Nurse Unit Manager (RNUM) #3 stated Resident #12 had increased anxiety related to an upcoming outpatient appointment that day. During an interview on 9/22/2021 at 11:30 AM, Certified Nurse Assistant (CNA) #5 stated Resident #12 slept a lot and didn't come out of their room. The CNA stated they were unsure what to do when the resident was anxious or depressed. During an interview on 9/23/2021 at 10:34 AM, RNUM #3 stated Resident #12 had anxiety and depression and often isolated themselves. RNUM #3 stated it was their responsibility to develop and update the CCP and they did not know the CCP should contain resident specific information. During an interview on 9/23/2021 at 11:35 AM, the Director of Nursing stated the CCP should contain resident specific intervention to manage the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated it was the Unit Managers responsibility to ensure the CCP contained resident specific interventions. Resident #31: Resident #31 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 7/23/2021, documented the resident had moderately impaired cognition, could understand others and could make self understood. The Comprehensive Care Plan (CCP) did not include a care plan to address the resident's respiratory care related to the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/23/2021 at 9:15 AM, the Registered Nurse (RN) #2 stated Resident #31 should have had a respiratory care plan in place. The RN stated the RN was responsible for care planning. The RN stated when the RN developed care plans for a resident the RN reviewed the resident's diagnoses, past medical history, and physician orders. The RN stated the resident should have had a care plan for respiratory care based on the resident's diagnoses, medical history, and physician orders. During an interview on 9/23/2021 at 11:15 AM, the Director of Nursing (DON) stated it was identified recently that CCP's were not being completed and implemented. It was up to the Registered Nurse Unit Manager (RNUM) to implement and update the care plans for the residents. Resident #73: Resident #73 was admitted to the facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 2/29/2021 documented the resident was usually understood, could usually understand, and had moderately impaired cognitive skills for daily decision making. Review of the resident's medical record did not include documentation that a Comprehensive Care Plan (CCP) for discharge planning was developed. During an interview on 9/21/2021 at 11:24 AM, the Administrator stated that in February 2021 Resident #73's family and representatives were provided notice of a facility-initiated discharge. The family declined a lateral transfer to another facility and decided to discharge to home with home care services instead. A progress note titled Interdisciplinary Team (IDT) dated 4/29/2021 at 2:44 PM, documented the IDT met with the resident's wife, daughter, and Ombudsman and discussed the residents needs at length with the family to ensure accommodations can be made and patient can be safely discharged home in the care of his family. discharge date set on or before 5/13/2021. Social Worker (SW) will continue to follow and facilitate discharge with family. A facility document titled Discharge Summary Effective Date 5/10/2021 and Signed Date 5/13/2021 documented Resident #73 will be discharged to home with wife and Home Care of (named) and private aide services. Durable Medical Equipment (DME) needed for this discharge is Hoyer, hospital bed, high back wheelchair with elevated leg rests, hand rolls, and trapeze bar. Primary Care Physician (PCP) appointment scheduled for May 21,2021 at 10:45 AM. Social Worker (SW) faxed home care referral to Home Care of (named) for nursing assessment and therapy needs. Home Care (named) Agency will do a home visit and safety assessment on May 14, 2021. Transportation set up with (named) for a pickup time of 2:00 PM. Scripts for DME have been faxed to pharmacy. Patient discharging with facilities high back wheelchair, will return high back wheelchair when their new one is delivered from the pharmacy. A Social Services progress note dated 5/13/2021 at 3:18 PM, documented Social Worker(SW) faxed discharge summary and Medical Director (MD) orders to PCP and to (named) Home Care Agency. During an interview on 9/23/2021 at 10:43 AM, the Director of Social Services (DSS) stated a discharge planning care plan was not developed for Resident #73. The DSS stated the resident was admitted for long term care and would not expect a discharge care plan to have been initiated. The DSS stated, the facility-initiated discharge happened quickly and the DSS did not think to initiate a new care plan for discharge planning. The DSS stated a discharge care plan should have been developed and implemented. During an interview on 9/23/21 at 11:42 AM, Registered Nurse (RN) #4 stated discharge planning starts on admission and discharge care plans should be developed, implemented, reviewed, and revised quarterly and as needed. RN #4 stated a discharge planning care plan was not developed for Resident #73 and the care plan should have been developed upon admission. During an interview on 9/23/2021 at 11:48 AM, the Administrator stated there was not a discharge planning care plan developed for Resident #73, and a discharge planning care plan should have been developed for the facility initiated the discharge. 10NYCRR 483.21(b)(1)

Based on record reviews and interviews during the recertification survey, the facility did not ensure the residents and resident representatives were notified in writing of the reason for the transfer/discharge to the hospital in a language they understood for 2 (Resident #'s 57 and 60) of 3 residents reviewed for hospitalization s. Specifically, for Resident #'s 57 and 60, the facility did not ensure the residents or residents representatives were notified in writing of the reason for the transfer/discharge to the hospital in a language they understood. This is evidenced by: The facility Policy and Procedure titled Transfer/Discharge Notice dated 2/2019, documented the purpose of the policy was to ensure residents and their representatives were notified of impending transfers and discharges and must include the following in the transfer/discharge notice in a language and format that the resident can understand: the reason for transfer/discharge, the effective date of the transfer/discharge, the location of the transfer/discharge, a statement of the resident's appeal rights with all pertinent contact information and the contact information for the local Office of the State Long-Term Care Ombudsman. Resident #57: Resident #57 was admitted to the facility with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 8/9/2021, documented the resident was cognitively intact, could understand others and could make self understood. A nursing progress note dated 7/25/2021 at 4:23 PM, documented the resident was extremely diaphoretic (perspiration or sweating) and would be transferred to the emergency room for evaluation. A nursing progress note dated 7/25/2021 at 5:41 PM, documented the emergency room nurse informed the facility the resident was admitted to the hospital due to not being alert and somewhat unresponsive. A record review, did not reveal documentation that the resident and the resident representative were provided with a written transfer/discharge notification upon the resident's transfer to the hospital. Resident #60: Resident #60 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 8/13/2021, documented the resident had severely impaired cognition, could understand others and could make self understood. A nursing progress note dated 7/14/2021 at 9:39 AM, documented the resident was very lethargic and the resident was sent to the emergency room . A nursing progress note dated 7/24/2021 at 4:26 AM, documented the resident was very difficult to arouse and speech was extremely elongated with each response. The resident was sent to the hospital. A nursing note date dated 9/2/2021 at 3:25 PM, documented the resident was sent to the emergency room due to being lethargic, clammy, and not responding verbally. A record review did not reveal documentation that the resident and the resident representative were provided with written transfer/discharge notifications upon the resident's transfers to the hospital. Interview: During an interview on 9/23/2021 at 12:02 PM, the Administrator stated the Administrator had assumed the responsibility for providing the transfer/discharge notices upon a resident's transfer to the hospital due to the position being vacant. The Administrator stated the Administrator did not provide the transfer/discharge notices to the residents and the resident representatives. The Administrator stated the Administrator verbally communicated with the families and the hospital discharge planners and the Ombudsman's received a daily census so they were aware of the transfers/discharges. 10NYCRR 415.39(H)(1)(III)(a-c)

Based on interviews and record reviews during the recertification survey, the facility did not ensure written notice of the facility's bed hold policy was provided to the residents and the resident representatives for 2 (Resident #'s 57 and #60) of 3 residents reviewed for hospitalization . Specifically, for Resident #'s 57 and #60, the facility did not ensure there was documented evidence the residents and the resident representatives received written notice of the facility's bed hold policy when the residents were transferred to the hospital. This was evidenced by: The facility Policy and Procedure titled Policy Regarding Bed Reservations for Temporary Absences not dated, documented a copy of the bed hold notice would be sent with the resident at the time of hospitalization or leave of absence and it would be sent to the responsible party within 1 business day. Resident #57: Resident #57 was admitted to the facility with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 8/9/2021, documented the resident was cognitively intact, could understand others and could make self understood. A nursing progress note dated 7/25/2021 at 4:23 PM, documented the resident was extremely diaphoretic (perspiration or sweating) and would be transferred to the emergency room for evaluation. A nursing progress note dated 7/25/2021 at 5:41 PM, documented the emergency room nurse informed the facility that the resident was admitted to the hospital because the resident was not alert and was somewhat unresponsive. Review of the resident's record did not include documentation that the resident and the resident representative received a written notice of the facility's bed hold policy when the resident was transferred to the hospital. Resident #60: Resident #60 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 8/13/2021, documented the resident had severely impaired cognition, could understand others and could make self understood. A nursing progress note dated 7/14/2021 at 9:39 AM, documented the resident was very lethargic and was sent to the emergency room . A nursing progress note dated 7/24/2021 at 4:26 AM, documented the resident was very difficult to arouse and speech was extremely elongated with each response. The resident was sent to the hospital. A nursing note date dated 9/2/2021 at 3:25 PM, documented the resident was sent to the emergency room due to being lethargic, clammy, and not responding verbally. Review of the resident's record did not include documentation that the resident and the resident received a written notice of the facility's bed hold policy when the resident was transferred to the hospital. Interview: During an interview on 9/23/2021 at 12:02 PM, the Administrator stated the Administrator had assumed responsibility for providing the bed hold policy to residents and resident representatives upon transfer to the hospital due to the position being vacant at this time. The Administrator stated the Administrator had not provided the bed hold policy in writing to the residents and the resident representatives upon their transfers to the hospital. The Administrator stated the Administrator verbally communicated with the families and the hospital discharge planners. 10NYCRR 415.3(h)(4)(i)(a)

Based on observation, record review and interview during the recertification survey and an abbreviated survey (Case #NY 698), the facility did not ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 (Resident #'s 21 and 322) of 4 residents reviewed for ADL's. Specifically, for Resident #21, who was dependant on staff for ADL Care, the facility did not ensure incontinence care was provided in accordance with the resident's care plan on 9/21/2021, did not ensure the resident's hair was brushed daily and did not ensure the resident's fingernails were cleaned and trimmed, and for Resident #322, the facility did not ensure the resident received assistance with shaving. This is evidenced by: The Policy and Procedure (P&P) titled Activities of Daily Living (ADLs), not dated, documented residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The P&P documented appropriate care and services would be provided for residents who were unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance for: Hygiene (bathing, dressing, grooming, and oral care) and Elimination (toileting). Resident #21: Resident #21 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 6/25/2021, documented the resident had moderately impaired cognition, could usually understand others and could usually make self understood. Finding #1: The facility did not ensure incontinence care was provided in accordance with the resident's care plan on 9/21/2021. The Comprehensive Care Plan (CCP) for Activities of Daily Living dated 12/17/2020, documented Toilet use: the resident required an extensive assist by 1 staff for check and change every 2 hours or as needed. The CCP for Potential for Pressure Ulcer Development dated 9/10/2021, documented the resident was frequently incontinent of bowel and bladder and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The interventions included to follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] The CCP for Bladder and Bowel Incontinence dated 9/16/2021, documented the resident was incontinent and to check the resident 2 times a shift and as required for incontinence. Change clothing PRN (as needed) after incontinence episodes. During observations on 9/21/2021 at: -9:35 AM: Resident #21 was dressed and sitting in the wheelchair next to the bed in the resident's room. -10:52 AM: A staff member went into Resident #21's room and brought the resident to the visitation room to visit with a visitor. The resident was not changed prior to the visit. -11:00 AM: Resident #21 was observed visiting with a visitor in the visitation room. -11:17 AM: The visit with the visitor ended. Resident #21 was brought back to the bedroom. -11:24 AM: The staff member who brought the resident back to the bedroom put the call light on and left the room. The Administrator entered the room. -11:25 AM: The Administrator left the room, and a CNA and nurse entered the resident's room. The call was turned off. -11:26 AM: The resident's bedroom door was open; the resident did not receive incontinence care by the nurse or CNA. The nurse and CNA left the room within 1 minute of entering. -12:35 PM: A Certified Nursing Assistant (CNA) entered the resident's room and brought the resident in the wheelchair to the dining room for lunch. The resident did not receive incontinence care prior to lunch. -1:27 PM: A CNA brought the resident out of the dining room to the resident's room and a nurse gave the resident medication in the doorway of the resident's room. -1:29 PM: The CNA brought the resident back to the dining room for lunch. -1:51 PM: Resident #21 remained in the dining room. -2:01 PM: Resident #21 was brought back to the resident's room after lunch. The staff member left room and the resident was not provided with incontinence care. The resident remained in the wheelchair. -2:03 PM: The evening shift started coming onto the unit for change of shift at 2:00 PM. Resident #21 was in the resident's room in the wheelchair. -2:10 PM: The observation concluded. The resident was not provided with incontinence care from 9:35 AM to 2:10 PM. The Certified Nurse Assistant (CNA) Accountability for ADL care documented the resident received urinary incontinence care on 9/21/2021 at 8:36 AM, 6:24 PM, and 11:11 PM. A progress note dated 8/10/2021 documented the resident had new superficial MASD area to sacrum. The note documented the resident was turned and positioned while in bed and should be checked frequently for soiled Depends (incontinence briefs). A review of progress notes from 9/1/2021-9/21/2021 did not include documentation the resident declined incontinence care. During a confidential interview on 9/19/2021 at 9:02 AM, the interviewee stated Resident #21 required more frequent changes due to incontinence. The interviewee stated the Director of Nursing (DON) was aware Resident #21 needed to be changed more often, but nothing was ever done about it. The interviewee stated the resident had a red area on the resident's buttock because the resident would go to the bathroom in the resident's pants and did not get changed timely. During an interview on 9/22/2021 at 9:33 AM, Certified Nursing Assistant (CNA) #1 stated for residents who were incontinent, incontinence care was provided every hour if the CNAs were able to, but the facility policy was to provide incontinence care every 2 hours. CNA #1 stated for the residents who could not ring their call bell or ask to go to the bathroom, the CNAs were constantly changing them throughout the shift, so it worked out to be every 2 hours. During an interview on 9/22/2021 at 9:59 AM, CNA #2 stated Resident #21 did not refuse care. CNA #2 stated Resident #21 was a heavy wetter and was incontinent. CNA #2 stated Resident #21 would wet through the resident's clothes if the resident was not changed. CNA #2 stated CNA #2 would change Resident #21 after breakfast so the resident did not leak through the resident's clothing and then would check the resident again before lunch and would change the resident if needed. CNA #2 stated the residents were supposed to be changed every 2-4 hours for incontinence care. During an interview on 9/23/2021 at 8:42 AM, CNA #3 stated Resident #21 received incontinence care once in the morning and before or after lunch so that the resident received incontinence care twice during the shift. CNA #3 stated the CNA was assigned to Resident #21 on 9/21/2021 and stated CNA #3 did not provide incontinence care twice in the shift to Resident #21. The CNA stated the resident was asked if the resident wanted to lay down, but the resident did not want to lay down, so the resident was not changed twice during the day shift. CNA #3 stated Resident #21 could not consistently tell the staff when the resident needed to be changed so the staff would check the resident's pants to see if the resident wet through. CNA #3 stated Resident #21 was always wet though and the staff usually had time to change the resident two times a shift if they changed the resident with morning care and then again before lunch. CNA #3 stated lunch ran into the evening shift so the staff on day shift did not have time to change residents after lunch. During an interview on 9/23/2021 at 9:18 AM, Register Nurse (RN) #2 stated Resident #21 should be changed at least every 2 hours. RN #2 reviewed Resident #21's care plan for Bladder and Bowel Incontinence and stated RN #2 saw where the care plan documented the resident was to be changed 2 times. RN #2 stated the interdisplinary team reviewed the CCPs together and that was where the discrepancy between the ADL and Bladder and Bowel Incontinence care plans should have been picked up. RN #2 stated incontinence care should be every 2 hour and that was the standard for incontinence care. RN #2 stated the nurse on the medication (med) cart directly oversaw the CNAs. RN #2 was often on a med cart and stated the RN thought a nurse would notice if the resident had not been received cared for a length of time. RN #2 stated the RN frequently told staff and encouraged the staff to go check on Resident #21 because the resident urinated often. RN #2 stated all the nurses oversaw the CNAs and the care they provided. During an interview on 9/23/2021 at 10:28 AM, the Director of Nursing (DON) stated the facility policy was to check and change resident every 2 to 4 hours and as needed for incontinence care. The DON stated Resident #21 was checked and changed every 2 to 4 hours and had not heard that the resident had not been being changed. The DON stated none of the unit managers or nurses had come to the DON with concerns that residents were not being changed as they should be according to facility policy. Finding #2: The facility did not ensure Resident #21, who was dependent for ADL care, received daily hair brushing and routine nail care. The P&P titled Maintaining Skin Integrity dated 9/2018, documented residents shall be provided good skin care according to individual need. This included: Keep resident nails clean and trim to prevent self-injury, and infection; Keep skin dry and free of urine and feces; and Keep residents' hair clean and combed. The Comprehensive Care Plan (CCP) for Activities of Daily Living (ADLs) dated 12/17/2020, documented personal hygiene: the resident required limited assist by 1 staff with personal hygiene. During an observation on: -9/19/2021 at 12:30 PM, the resident was in the wheelchair and the resident's hair was sticking straight up in the front. The resident's fingernails were long and had a black substance that appeared to be thick hardened dirt underneath them. -9/21/2021 at 9:35 AM, the resident was dressed and out of bed in the wheelchair and the resident's hair was sticking straight up in the front. The resident's fingers were long and had a black substance that appeared to be thick hardened dirt underneath them. At 10:52 AM, a staff member brought the resident to the visitation room to visit with a family member and the resident's hair was still sticking up. At 11:00 AM, the resident's visitor was observed brushing the resident's hair. The resident's hair was no longer sticking up after being brushed. -9/22/2021 at 8:25 AM, the resident was out of bed eating breakfast with the resident's hands. The resident's fingernails were long and had a black substance that appeared to be thick hardened dirt underneath them. The substance under the resident's nails was not fresh food from the resident's breakfast. A review of progress notes from 9/1/2021-9/21/2021 did not include documentation the resident declined to have the resident's hair brushed or fingernails cleaned. During a confidential interview on 9/19/2021 at 9:02 AM, the interviewee stated Resident #21's fingernails were disgusting and the resident ate with the resident's hands. The interviewee stated Resident #21's hair was never brushed or combed. The interviewee stated the resident had always been a very neat and clean individual, and the resident wore the resident's hair short and combed, not sticking up. The resident would not have wanted the resident's hair to look like it did when it stuck up and was not combed. During an interview on 9/22/2021 at 9:33 AM, Certified Nursing Assistant (CNA) #1 stated every resident received a shower once a week and as part of the shower the resident had nail care done. CNA #1 stated if the CNAs could not get to the nail care, Activities would also do the residents' nails. CNA #1 stated CNAs were supposed to clean, cut, and file the residents' fingernails with their weekly shower. CNA #1 stated part of morning care was to brush the residents' hair. During an interview on 9/22/2021 at 9:59 AM, CNA #2 stated every resident received a shower once a week but the residents were washed up every morning. CNA #2 stated Activities cleaned and trimmed the residents' nails unless the residents specifically asked the CNAs to do it. CNA #2 stated the CNAs did not typically do fingernails and stated nails were not done with showers. CNA #2 stated CNAs were supposed to brush the residents' hair every morning. During an interview on 9/23/2021 at 9:18 AM, Registered Nurse (RN) #2 stated RN #2 had noticed a couple residents with dirty nails and with hair not brushed. RN #2 stated hair brushing was provided daily, and nails were done at least weekly and as needed. Staff should document if a resident refused and should let a nurse know. RN #2 stated all the nursing staff oversaw that the residents were receiving the care they should be. During an interview on 9/23/2021 at 10:28 AM, the Director of Nursing (DON) stated fingernails were cleaned and trimmed on the resident shower day, once weekly and hair brushing was done daily and as a needed. The DON stated CNA oversight was done by the medication nurses to make sure resident care was provided, and then the chain of command was followed. The med (medication) nurse would go to the nurse manager, then to the Assistant DON, or DON. The DON stated none of the Unit Managers or nurses had come to the DON with concerns that ADL care was not being done. Resident #322: The resident was admitted on with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS (Minimum Data Sett-an assessment tool) dated 9/1/21 documented the resident was without cognitive impairment, understood and understands. It documented the resident required extensive assistance for personal hygiene and total assistance for bathing. The Visual/Bedside Kardex Report dated 9/22/2021 for Resident #322 documented the resident required set up for grooming and hygiene with one staff assistance and for bathing the resident required extensive assistance with two staff members assistance. It did not include documentation for shaving the resident. The documentation survey report dated September 21, documented personal hygiene included combing hair, brushing teeth, shaving, and washing and drying face and hands. It documented the resident received limited to extensive assistance by one staff member with personal hygiene two to three times daily from 9/1/2021 through 9/22/2021. The Comprehensive Care Plan (CCP) for Activities of Daily Living (ADLs) dated 8/25/2021, documented for grooming/hygiene, the resident required set up for grooming and hygiene by one staff and for bathing the resident required extensive assistance by two staff. During observations on 9/19/2021 at 12:40 PM, 9/21/2021 at 9:05 AM, 9/21/2021 at 3:42 PM, 9/22/2021 at 11:08 AM and 9/23/2021 at 10:43 AM, the resident was unshaven with facial hair on cheeks, chin, upper neck, and upper lip. A review of progress notes from 9/1/2021-9/21/2021 did not include documentation the resident declined to be assisted with shaving. During an interview on 9/19/2021 at 12:45 PM, Resident #322 reported they preferred to be shaved daily. Resident #322 stated they would attempt to shave themselves if the staff would give them a razor. Resident #322 stated prior to the illness, they consistently were clean shaven. During an interview on 9/22/2021 at 11:08 AM, Certified Nurse Assistant (CNA) #5 stated residents were shaved weekly during their shower. CNA #5 stated Resident #322 was not shaved with their shower today or last week and stated the resident did not like to be in the shower for longer than absolutely necessary as the resident complained of being cold with a shower. CNA #5 stated Resident #322 did not refuse to be shaved, and she didn't know what the facility process was when a resident did not get shaved in the shower. During an interview on 9/23/21 at 10:43 AM, Registered Nurse Unit Manager (RNUM) #3 stated when residents received their weekly shower, they would have their hair washed, their nails filed and cleaned, and the resident would be shaven. RNUM #3 stated they were aware residents were not consistently provided assistance with a shower, shaving and nail care. RNUM #3 stated the resident should receive the level assistance with shaving they were care planned for, and if a resident was not shaved during a shower, they would be shaved in their room as requested and tolerated. During an interview on 9/23/21 at 11:36 AM, the DON stated residents should be shaved as part of their personal hygiene. The DON stated the unit manager should ensure staff provided all residents personal hygiene assistance including shaving as the resident allowed. The DON stated the CCP should be updated when a resident with resident specific information regarding shaving and personal hygiene. 10NYCRR415.12(a)(3)

Based on observation, record review, and interviews during the recertification survey, the facility did not ensure acceptable parameters of nutrition were maintained for 1 (Resident #32) of 2 residents reviewed for nutrition. Specifically, for Resident #32, the facility did not ensure the resident's weight was documented and monitored in accordance with professional standards of practice and meal intakes were adequately documented and monitored. Additionally, the facility did not ensure a nutritional supplement was provided in accordance with professional standards. This is evidenced by: Resident #32: Resident #32 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 7/27/2021 documented the resident had severely impaired cognition, could usually understand others and could usually make self understood. The Comprehensive Care Plan (CCP) for Nutritional Maintenance Problem dated 8/5/2021, documented the resident had severe protein and calorie malnutrition. Interventions included: Provide supplements as ordered: Med Pass 2.0 (a fortified nutritional shake) 120 cubic centimeter (cc) 3 times a day (TID) with the resident's medication pass (added to the CCP on 8/10/2021); and Provide and serve diet as ordered. Monitor intake and record every meal. The CCP did not document the frequency of weights for the resident. Finding 1: The facility did not ensure the resident's weight was documented and monitored in accordance with professional standards of practice. The Policy and Procedure (P&P) titled Weights dated 9/2018, documented each resident's weight would be carefully monitored on a regular basis (monthly or weekly) so that appropriate timely interventions may be initiated. Interventions would be initiated as needed to track unplanned significant weight variances of 5% weight loss/gain in 30 days, 7.5% weight loss/gain in 90 days, or 10% weight loss/gain in 180 days. Each resident was to be weighed upon admission weekly x 4 weeks and monthly thereafter unless otherwise specified. The Dietitian/Designee must notify the nurse managers to verify any weight variance of 5 pounds or more by reweight. A review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #32's weights were as documented: -7/28/2021- 110.5 lbs. - Admission weight -8/04/2021- 114.0 lbs. -8/11/2021- 108.6 lbs. (weight variance of 5.4 pounds; a re-weight was not obtained per facility policy) -8/18/2021- Blank (weekly weight was not obtained per facility policy) -9/01/2021- 109.8 lbs. -9/08/2021 -105.0 lbs. (-7.9% weight loss over 30 days) A Weight Change Note dated 8/11/2021, written by the Food Services Director, documented Resident #32's weight was 108.6 and was a 4.7% loss in a week. The note documented the current weight was more in line with the resident's admission weight and the resident remained on weekly weights. A review of progress notes from 8/1/2021 to 9/20/2021 did not include documentation the resident refused to be re-weighed following the weight obtained on 8/11/2021 and did not include documentation the resident refused to be weighed on 8/18/2021. During an interview on 9/22/2021 at 9:33 AM, Certified Nursing Assistant (CNA) #1 stated every week the CNAs received a list of weights to do for residents who either needed a weekly weight or monthly weight. CNA #1 stated the CNAs knew which residents needed to be weighed because the Unit Manager assigned the weights to them. The CNAs were responsible for obtaining the weights that were assigned to them. During an interview on 9/22/2021 at 9:59 AM, CNA #2 stated some residents were weighed monthly and some were weighed weekly. CNA #2 stated the CNAs were provided with a list every Monday of residents who needed to be weighed. The CNAs were responsible for obtaining the weights but did not document the weights in the computer. The CNAs documented the weights they obtained on paper and the Food Services Director (FSD) would input the weights into the computer. During an interview on 9/23/2021 at 9:29 AM, Registered Nurse (RN) #2 stated the staff on the unit obtained the resident's monthly weights and weekly weights. The weights were assigned to the CNAs. The process was that the CNAs would obtain the residents' weights, write the weights on paper, and then dietary would put the weights into the computer. RN #2 stated the frequency of weights should be on the care plan because RN #2 stated RN #2 did not know how often Resident #32 was weighed. RN #2 stated the FSD gave a list to the unit of which residents needed to be weighed and the staff went by that list. RN #2 stated the FSD would also give the unit a list of who needed to be re-weighed, but stated the FSD had been out of work for a few weeks. During an interview on 9/23/2021 at 10:00 AM, the Administrator stated Administrator assumed responsibilities of the FSD position while the FSD was on leave. The Administrator stated the Registered Dietitian (RD) consulted with the facility's FSD and did not work full time at the facility. The Administrator stated Resident #32 was on weekly weights, but that the resident refused at times to be weighed. The Administrator reviewed the FSD's weight book and stated the resident was not on weekly weights. The Administrator stated residents were weighed weekly for 4 weeks upon admission, and then monthly after that. The Administrator stated there should have be a reweight obtained after the 5-pound difference on 8/11/2021. The Administrator reviewed the weight book for 8/18/2021 and stated there was not a weight documented for Resident #32. For 8/18/2021, there was not documentation that the resident was or was not weighed or that the resident had refused to be weighed. The Administrator stated the physician should also write a note when a resident had weight loss. The Administrator stated the FSD monitored the residents' weights and the FSD and RD communicated regularly. The Administrator did not know the RD's role regarding the consultations provided to the FSD. On 9/23/2021 at 10:30 AM, Food Services Director (FSD) #4 and Dietitian #8 were not available for interview. Finding 2: The facility did not ensure meal intakes were adequately documented and monitored. The facility Policy and Procedure (P&P) titled Nutrition and Hydration Policy dated 2/2019, documented it was the policy of the facility to monitor those residents who were identified as at risk for dehydration and malnutrition. The P&P documented Nursing/Designee monitored CNA documentation for fluid and food consumption and alerts. Certified Nursing Assistant (CNA) for Nutrition- Meal Intake from 9/15/2021 to 9/21/2021 documented the resident ate: - 26%-100% of breakfast 2 out of 7 days (5 out of 7 days there was no documentation of the percentage of the meal the resident ate). - 26%-100% lunch 3 out of 7 days. (4 out of 7 days there was no documentation of the percentage of the meal the resident ate). - 26%-100% dinner 5 out of 7 days. (2 out of 7 days there was no documentation of the percentage of the meal the resident ate). A Weight Change Note dated 8/11/2021, written by the Food Services Director, documented the resident's weight was 108.6 and was a 4.7% loss in a week. The resident's intake varied with meals from 25% to 100%. A review of progress notes from 9/15/2021 to 9/21/2021, did not include documentation the resident refused to eat a meal. During an interview on 9/22/2021 at 9:33 AM, Certified Nursing Assistant (CNA) #1 stated it was the CNAs' responsibility to document meal intake for the residents. CNA #1 stated the CNAs documented how much the residents ate and drank at each meal. CNA #1 stated the CNAs were to document the percentage eaten at each meal. During an interview on 9/22/2021 at 9:59 AM, CNA #2 stated it was the CNAs' responsibility to document what a resident ate and the CNAs also documented if a resident refused and reported it to the nurse. During an interview on 9/23/2021 at 9:29 AM, RN #2 stated the CNAs were responsible for documenting the percentage eaten by a resident at meals and the CNAs have an option to document if they provided a snack to the resident. RN #2 stated CNA documentation as whole was an issue, not just with meal intake. During an interview on 9/23/2021 at 10:00 AM, the Administrator stated the Administrative staff had identified CNA documentation as an issue. The Administrator stated the CNAs were responsible for meal documentation. The Administrator stated the Assistant Director of Nursing was monitoring CNA documentation, including meal intake documentation. Finding 3: The facility did not ensure a nutritional supplement was provided in accordance with professional standards. The Policy and Procedure (P&P) titled Oral Nutritional Supplements dated 11/1/2017, documented to provide oral supplements to residents who were deemed to be at increased nutritional risk despite provision of adequate nutrients as provided by the physician ordered diet and/or meal modifications made by the clinical nutrition staff. The RD/Designee would identify residents who would potentially benefit from a change in plan of care, including addition or changes in food or beverage, fortified foods or nutritional supplements. The RD/Designee would determine any monitoring criteria and implement as indicated. The RD/Designee would evaluate the effectiveness of changes to the plan of care, including nutritional supplements, with each subsequent nutritional assessment as part of the complete plan of care, at a minimum quarterly. A review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Weight Change Note dated 8/11/2021, written by the Food Services Director, documented the resident's weight was 108.6 and was a 4.7% loss in a week. The note documented Med Pass 2.0 120cc TID added last week per dietician recommendation. A Weight Change Note dated 8/29/2021, written by the Dietitian, documented to follow the resident's acceptance to interventions and success halting further weight loss. During an interview on 9/22/2021 at 9:23 AM, Licensed Practical Nurse (LPN) #1 stated there would be an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #1 stated the Dietitian would recommend the supplement, the physician would order it, and then the nurses would administer it and sign on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #1 stated the Dietitian monitored if the residents were accepting the Med Pass 2.0 by looking at the documentation on the MAR. The nurses would also let the Unit Manager know if the resident was not accepting it and the unit manager would communicate with the Dietitian. During an interview on 9/22/21 09:54 AM, Registered Nurse (RN) #1 stated Resident #32 was not one of the residents who received Med Pass 2.0. RN #1 stated the recommendation for Med Pass 2.0 would come from the Dietitian and then a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/23/2021 at 9:29 AM, RN #2 stated dietary monitored nutritional supplements. The process was that a dietary slip would be filled out with the recommendation for the supplement, dietary would tell the RN, and the RN would obtain an order from the physician for the Med Pass 2.0. RN #2 reviewed Resident #32's record and stated something must have been missed with the turnover in staff since there was not a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 9/23/2021 at 10:00 AM, the Administrator stated the Administrator assumed the responsibilities of the FSD position while the FSD was on leave. The Administrator stated the facility did monitor nutritional supplements but, in this case, the recommendation for the Med Pass 2.0 did not get to the physician orders. The Administrator stated the Dietitian would make the recommendation, the nurse would put the order in and then the med nurses would provide and document the supplement on the MAR. The Administrator stated it was the responsibility of the FSD to monitor the nutritional supplements that the residents received. The Administrator did not know the process used to monitor or track the acceptance of nutritional supplements. On 9/23/2021 at 10:30 AM, Food Services Director (FSD) #4 and Dietitian #8 were not available for interview. 10NYCRR415.12(i)(1)

Based on observations, record review, and interviews during a recertification survey the facility did not ensure that its medication error rates were not 5 percent or greater. Specifically, for 25 medication administration opportunities there were 19 errors resulting in a medication error rate of 76%. This is evidenced by: The facility Policy and Procedure titled Administration of Medication-General dated ,d+[DATE], documented Administration of medications will occur utilizing the following eight rights: 1. Right Time; a. assist with administration of medications at the indicated time or within sixty (60) minutes before or sixty (60) minutes after the indicated time. b. Ensure that medications labeled to be taken with food are given at mealtime or with a snack. c. Complete a medication error report if medication is not taken within sixty (60) minute timeframe, 2. Right Resident, 3. Right Medication, 4. Right Dose of Medication, 5. Right Route, 6. Right Documentation, 7. Right Reason, and 8. Right Response. Resident #27: Resident #27 was admitted to the facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- an assessment tool) dated [DATE], documented the resident was cognitively impaired, had clear speech, understands, and was understood by others. During an observation on [DATE] at 9:38 AM, Registered Nurse (RN) #1 administered morning medications that were scheduled on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The medications administered were: [MEDICATION(S)] 300 milligrams (mg) by mouth three times a day for pain, [MEDICATION(S)] 500 micrograms (mcg) by mouth daily for [CONDITION(S)], [MEDICATION(S)] 25 mg by mouth daily for [CONDITION(S)], [MEDICATION(S)] 4 mg by mouth daily for [CONDITION(S)], [MEDICATION(S)] 500 mg by mouth daily for [CONDITION(S)] ([DATE]- [DATE]), [MEDICATION(S)] 10 mg by mouth daily for [CONDITION(S)], [MEDICATION(S)] 20 mg by mouth daily for gastroesophageal reflux disorder (GERD), [MEDICATION(S)] (KCL) 20 milliequivalents (MEQ) by mouth daily for replacement therapy, Aspirin 81 mg by mouth daily for [CONDITION(S)], [MEDICATION(S)] 150 mg by mouth two times a day for history of [CONDITION(S)] (DVT), [MEDICATION(S)] 25 mg by mouth daily for depression, [MEDICATION(S)] 40 mg by mouth daily for [CONDITION(S)] ([DATE]- [DATE]), [MEDICATION(S)] Aerosol ,d+[DATE].5 MCG/ACT inhalation aerosol 2 puffs inhale orally two times a day for [CONDITION(S)], and [MEDICATION(S)] 18 mcg capsule inhale 1 capsule orally daily for [CONDITION(S)]. During an interview on [DATE] at 9:52 AM, Registered Nurse (RN) #1 stated the staff do their best to administer the morning medications within the 2-hour timeframe, but sometimes things happen with our residents that need immediate attention, and the nurse is pulled away from the medication cart. RN #1 stated the charge nurse and supervisors are aware that medications are sometimes administered late, this was being monitored and reeducation would be provided when a specific nurse was consistently running late. Resident #42: Resident #42 was admitted to the facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- an assessment tool) dated [DATE] documented the resident was cognitively intact, had clear speech, understands, and was understood by others. During an observation on [DATE] at 9:37 AM, Licensed Practical Nurse (LPN) #2 administered morning medication that were scheduled on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The medications administered were: [MEDICATION(S)] 5 mg by mouth daily for constipation, [MEDICATION(S)] (Vitamin D3) 1000-unit tablets; 2 tablets by mouth daily for supplement, [MEDICATION(S)] 5 mg by mouth two times a day for [CONDITION(S)], [MEDICATION(S)] 10 mg by mouth daily for depression, and [MEDICATION(S)] extended release (ER) capsule 360 mg by mouth daily for hypertension ([CONDITION(S)]). During an interview on [DATE] at 9:37 AM, LPN #2 stated this was LPN #2's fourth shift working in this facility and had not developed a routine yet. LPN #2 stated the standard of practice is medications are supposed to be administered within 1 hour of the scheduled time. During an interview on [DATE] at 10:01 AM, Registered Nurse Unit Manager (RNUM) #2 stated staff have not reported that medications were administered late. RNUM #2 stated staff are expected to ask for help when falling behind and administering medications late. RNUM #2 also a medication error report should be completed when medications are administered later than 1 hour of scheduled time. During an interview on [DATE] at 10:26 AM, RN #5 stated staff are expected to notify the supervisor and the physician when medications are administered late, this should be documentation in the resident's record and a medication error report should be completed. RN #5 also this concern was identified on both units and approximately 2 weeks ago medication administration audits were initiated. During an interview on [DATE] at 12:07 PM, the Director of Nursing (DON) stated medications should be administered 1 hour before to 1 hour after the scheduled time. The DON stated that since the waivers have expired in [DATE] observations have been made of medications being administered late, medication audits with staff reeducation have already been started and will continue. 10NYCRR 415.12(m)(1)

Based on interview and record review conducted during the COVID-19 Infection Control Focus Survey completed on 3/11/2021, the facility did not inform residents by 5:00 PM the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other for 2 (Resident #'s 1 and #2) of 2 residents reviewed for notification. Specifically, the facility did not ensure Resident #'s 1 and #2 were provided with verbal or written notification when a resident and/or staff tested positive for COVID-19. This is evidenced by: On 3/9/21, the Hospital Electronic Response Data System (HERDS) report listed the following information: Facility census 67, COVID-19 positive residents 7, Residents on isolation 67. The Center of Medicare and Medicaid Services (CMS) guidance titled, Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes (Ref: QSO-20-29-NH), dated May 6, 2020, provided that as part of a skilled nursing facility's COVID-19 reporting requirements, facilities must Inform residents, their representatives, and families of those residing in facilities by 5:00 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. Such requirements were made effective May 8, 2020 in regulatory amendments to 42 CFR 483.80 pursuant to 85 Fed. Reg. , . The Policy and Procedure titled, Effective Communication with Residents & Families during COVID-19 Pandemic, last updated on 5/4/2020, documented to inform residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. During an interview on 3/10/21 at 8:30 AM, the Director of Nursing/Infection Control Preventionist (DON/ICP) reported there were currently 7 COVID-19 positive residents in the facility and 2 staff on quarantine due to a COVID-19 positive test results. Resident #1: The resident was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 1/16/21, documented the resident was cognitively intact, could understand others, and could make him/herself understood. During an interview on 3/10/21 at 9:05 AM, Resident #1 stated he/she had been told in the past that there was a COVID-19 positive resident in the facility, but stated he/she did not know if there any positive COVID-19 residents currently in the facility. Resident #1 stated he/she did not know if there were staff positive for COVID-19. Resident #1 stated he/she assumed there were COVID-19 positive residents in the facility since the staff were still wearing gowns when they entered his/her room but was not certain. During a record review on 3/10/21, Resident #1's medical record did not include documentation that the resident was notified when a resident or staff tested positive for COVID-19. Resident #2: The resident was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 2/21/21, documented the resident was cognitively intact, could understand others, and could make him/herself understood. During an interview on 3/10/21 at 10:15 AM, Resident #2 stated he/she had only been notified about COVID-19 in the building when they tested positive. During a record review on 3/10/21, Resident #2's medical record did not include documentation that the resident was notified when a resident or staff tested positive for COVID-19. During an interview on 3/10/21 at 1:20 PM, the Social Worker stated she was responsible for notifying families when there was a new COVID-19 positive staff member or resident. She stated she did not usually notify the residents in the facility of new COVID-19 cases and there was no method for tracking which residents were and were not notified when there was a new COVID-19 positive case. During an interview on 3/10/21 at 2:20 PM, the Administrator stated Administration, Social Work and the nursing staff verbally tell the residents when there was a new COVID-19 positive staff member or resident. The Administrator stated the resident notification process had become informal because the facility was notifying the residents so frequently with all the recent cases of COVID-19. The Administrator stated since the resident notification became informal, the resident notification probably was not documented as well as it should have been. 10NYCRR 400.2

Based on record review and staff interview during abbrieviated surveys (Case # NY 871), the facility did not ensure the facility provided the necessary care and services to attain or maintain the highest practicable physical well-being in accordance with the comprehensive assessment and plan of care. Specifically, for Resident #2, who has a history of falls, who was found lying on her right side in the hallway adjacent to her walker and chair after an unwitnessed fall on 12/13/15. Review of the care plan revealed that a previous fall on 10/12/15 was not documented on the care plan. Documented care planned interventions for falls were unclear as to which were current and when they were added, or if discontinued, when and why the interventions were no longer effective. There were no interventions added after the 12/13/15 fall. Nurse's notes reveal that the resident experienced a possible change in condition, and there is no documented evidence that the resident was assessed by a Registered Nurse or that the resident's physician was notified. Eleven hours later, the resident was found face down on the floor calling from her bedroom. The resident was transferred to the hospital, diagnosed with [REDACTED]. This is evidenced by: Resident #2: The resident was admitted to the facility on [DATE], diagnosed with [REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident with severe cognitive impairment. The same MDS documented that the resident's transfer ability (moving between surfaces including to/from bed, chair, wheelchair etc.) was an extensive assist of 1. The Policy and Procedure titled Fall Prevention dated 2/19/09, documented it is the policy of the facility to ensure that each resident receives adequate supervision and assistive devices to prevent accidents. The purpose of the policy was to identify and initiate individualized interventions focusing on prevention in the least restrictive manner. To prevent falls among residents identified to be at risk, the facility will conduct thorough fall investigations and insures the ongoing development and implementation of proactive, individualized interventions. The procedure included that after a resident falls, the incident will be reviewed by the interdisciplinary team for root cause analysis and development of proactive interventions. The management follow-up process is documented to include a review of the previous interventions in place and a plan for further interventions. The team will conduct a root cause analysis of the incident and look at all factors. The Comprehensive Care Plan for Falls initiated on 7/13/14, documented falls for 2015 on 1/17, 2/15, 3/19, 8/1, 8/4, 12/13 and 12/18/15 (the date 10/12/15 does not appear on the care plan). There are numbered interventions 1 - 20 and two interventions with the number 21. Some of the interventions are crossed out, labeled discontinued and most entries are undated. Under the evaluation and comments, documentation on 8/5/15 No independent ambulation. The Accident and Incident (A&I) Report dated 10/12/15 at 9:10 am, documented that the resident went to sit in a chair, missed and was assisted to her wheelchair with the assistance of two staff. The A&I Root cause is documented poor safety awareness due to dementia and preventative measure noted as redirection when in unsafe situation. It is further documented that the care plan was updated. (The care plan does not reflect this fall.) The MDS dated [DATE], assessed the resident's transfer ability (moving between surfaces including to/from bed, chair, wheelchair etc.) was an extensive assist of 1. The attached Fall Risk Assessment documented; Resident's history of falls in the past 6 months as greater than 2 for a maximum score of 6 for this category. Total score is documented as 25 and a score of 12 or greater indicates a risk for fall. The Nursing Assistant Care Sheet dated 11/15/15, documented that the resident was a fall risk, independent with ambulation, required close supervision for transfers, was confused frequently, had short-term memory loss and impaired decision making. A Nurse's note dated 12/12/15 (this is an error in documentation, date should be 12/13/15) at 4:00 pm, documented that the resident was observed to be lying on her right side in the hallway adjacent to her walker and chair. The resident stated she was trying to sit in the chair and missed, care plan updated, family and physician notified. The A&I Report dated 12/13/15 at 2:45 pm, documented the resident had an unwitnessed fall and was observed lying adjacent to her walker and a chair. The A&I root cause is documented progressive dementia, significant decrease in falls and preventative interventions is documented as continue plan of care. A Nurse's note dated 12/14/15 at 9:00 am, documented that the resident's fall was reviewed by the interdisciplinary team. Dementia - progressive/ unaware of safety precautions. Significant decrease in falls, continue plan of care. A Nurse's note dated 12/17/15 at 2:00 pm, LPN (licensed practical nurse) #1 documented writer noted resident is having increased confusion, anxiety and garbled speech . RN (registered nurse) aware. Will continue to monitor. The A&I Report dated 12/18/15 at 12:30 am, documented the resident had an unwitnessed fall and was found face down on the floor with a laceration over her right eye on forehead. Explanation is documented as resident gets up at night and usually able to get walker then staff see her and takes care of resident and brings back to bed. It appears resident didn't utilize her walker lost balance and fell forward. It is further documented that the resident was assessed, cleaned and dressed [MEDICAL CONDITION], nose bleed stopped on own and resident was sent to the emergency room for evaluation. A Nurse's note dated 12/18/15 at 1:00 am, documented the resident got up to use the bathroom, resident was face down on the floor, bleeding from her nose and a laceration on her forehead over right eye. Resident's family and physician notified and resident was transferred to the hospital. A Nurse's note dated 12/18/15 at 9:10 am, documented that the fall was reviewed by the interdisciplinary team. Resident often seeks independence, resident remains out of facility at this time. Apply skid strips to the right side of her bed, continue plan of care when resident returns to the facility. The Hospital Summary for the resident's admission of 12/18/15, documented that the resident with advanced dementia sustained a mechanical fall. The resident received a CT (computerized tomography) of the head which showed subarachnoid hemmorhage (bleeding between the brain and the tissues that cover it) in the right frontal area. The resident was transferred to another hospital, stabilized and returned to the local hospital. It is documented that as a result of her fall, the resident sustained [REDACTED]. It is further documented she is going to be discharged back to her nursing home, but I think she needs to have a bed alarm and chair alarm and rubber mat on the floor to decrease the risk of fall and injury. The Director of Nursing (DON) Investigation dated 12/21/15, documented a Fall with (Significant crossed out) Injury. It documented that at 12:30 am, resident was in room sleeping, seen 5 minutes before by nursing supervisor. Per supervisor's assessment, resident got out of bed and ambulated a few steps and fell forward onto head/face - transferred to acute hospital diagnosed with [REDACTED]. admitted to acute care hospital and then transferred to another hospital to rule out a [MEDICAL CONDITION]. It documented, per staff interviews, common for resident to get out of bed and found ambulating with or without her walker during the night and has been known to remove her skid socks. The resident's medical record was reviewed and documented a history of falls but a significant decline in the number of falls in the past several months. Multiple interventions begun or discontinued including alarms, not used at present. Interventions included skid socks, skid strips, redirect if in an unsafe situation, independent to one assist for transfers, which are unpredictable. Ending stages of dementia, constant moving, and redirection can be difficult. Per the CNAs, removed skid socks and doesn't like to wear them, incomplete thoughts. Per RN assessment resident possibly moved/tripped over her walker. Care plan was followed and resident can/will remove skid socks. During an interview on 12/31/15 at 10:10 am, the Registered Nurse Manager (RNM) stated the resident is assigned to her unit. The RNM stated that the resident had a previous fall on 10/21/15 and for Resident #2, having not had a fall since August, that was a long time for her. The RNM stated that the resident lacks safety awareness. The RNM reviewed the nurse's note dated 12/12/15, regarding the resident's fall that is identical to the A&I on 12/13/15 and stated that is just a documentation of the date error, the fall was on 12/13/15. The RNM reviewed the nursing note dated 12/17/15 by LPN #1 and stated that LPN #1 had informed her of her observations and we discussed that maybe a recent decrease in medication was to blame. The RNM stated that she did assess the resident on 12/17/15 and found her to be at her baseline. The NM reviewed the nursing notes and stated that an assessment note is not in the resident's medical record. The RNM stated that the resident has been known to get up during the night and would walk the halls all day long. The RNM reviewed the resident's comprehensive care plan for falls and stated that it was difficult to determine when interventions were initiated or discontinued because they are not dated and they should be. The RNM was asked to identify the interventions in place at the time of the falls on 10/21, 12/13 and 12/18 and the RNM stated I have not idea how to tell when they were added or discontinued based on this. During an interview on 12/31/15 at 12:00 pm, The DON stated that after a fall, the incident will be discussed with the interdisciplinary team. The DON stated that she was aware that Resident #2 was found on the floor behind the nurse's station, although resident's are not allowed in that area. The DON stated that the resident is independent with ambulation so we have to keep her safe while ambulating. The DON stated that she was aware that the resident was found on the floor in the hallway on 12/13/15 and looked into the incident. The DON reviewed the resident's comprehensive care plan for falls and stated that the resident had alarms somewhere along the way and they were discontinued, but that she could not recall when because it is not documented on the care plan. The DON also stated that there were no changes made to the care plan after the 12/13/15 fall because it didn't seem that anything was indicated at that time. The DON stated for some reason, there were no alarms, I think we were trying to maintain her independence. I personally use alarms as a last resort because alarms only alert staff that she is up and moving and do not prevent falls. If staff see the resident in an unsafe situation, they try to keep her safe. During an interview on 2/12/16 at 2:45 pm, LPN #1 stated that she was the resident's primary LPN. LPN #1 stated that on 12/17/15, she noticed that the resident had increase in confusion and anxiety and wanted to be right at her side throughout the shift. LPN #1 stated that during the time that she was with resident, she noticed that the resident's speech was garbled. LPN #1 stated that the resident began speaking with just pieces of words, and some of her sentences weren't making any sense, which was not the resident's norm. LPN #1 stated that she reported to the RN. LPN #1 stated that she found out the following day that the resident had fallen. LPN #1 stated that she was not entirely surprised, because she felt as though the resident was declining. During a follow-up interview on 2/16/16 at 10:00 am, the DON stated that in review of the resident's falls after the 12/18/15 incident, the facility determined that although the resident's care card documented that resident's transfers should be with close supervision, she was not actually being supervised for transfers. The DON stated that maybe that termonolgy should not have been used because what was intended was to closely monitor her as they do all resident's in the facility. The DON stated that after the 12/18/15 fall, she reviewed the nursing note on 12/17/15 that documented increased confusion, anxiety and garbled speech and spoke with the RN who stated that the resident appeared to be at baseline, but did not document her assessment findings. The DON stated that she would expect a complete nursing assessment to be documented in the resident's chart. 10NYCRR415.12

Based on observation, staff interview, and medical record review during an abbreviated survey (complaint #NY 625), the services provided or arranged by the facility did not meet professional standards of quality for one (Resident # 1) of three (# 2, # 3) residents reviewed for care and services. Specifically, Resident #1 was admitted to the facility for rehabilitation on [DATE]. On [DATE] resident was noted to have a rash to his abdominal folds and groin area, physician (MD) order was received for [MEDICATION NAME] cream every shift. The treatment was rendered as ordered by the MD through the end of May. The treatment for [REDACTED]. On [DATE], the weekly shower skin check revealed pink/purple groin, put cream on, LPN Nurse Manager aware; there was no RN assessment or notification to the physician and no subsequent nurse notes in regards to the rash on the abdominal folds and groin until [DATE]. Resident was admitted to the hospital and expired two days later. This resulted in actual harm which was not Immediate Jeopardy. This was evidenced by: Resident # 1 The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident had no cognitive deficit with a Brief Interview for Mental Status (BIMS) score of 15, according to the Minimum Data Set ((MDS) dated [DATE]. Nursing Admission assessment dated [DATE] documented for skin areas on the body, self inflicted scratches on both hips, dry skin areas to both lower legs, bruise to the coccyx. There was no documentation of any rash or other skin issues to his lower abdomen or groin. Comprehensive Care Plan (CCP) dated [DATE] and titled "Alteration in skin integrity" documented under the heading "Problem," yeast rash abdomen and groins. On [DATE] abscess/cyst to right upper buttock, noted by physician (MD). On [DATE] both abdominal and groin areas were irritated and bleeding. Documented under the heading "Actions," on [DATE], [MEDICATION NAME] cream (used to treat fungal infections of the skin) every shift (qshift) and as needed (prn) with hygiene to abdominal folds and groins; Keflex (used to treat infections caused by bacteria) 500 milligrams (mg), start on [DATE], monitor right buttock daily for changes; [DATE] monitor both areas, soap and water wash, A&D ointment (Ointment is specially formulated with two active ingredients, [MEDICATION NAME] and [MEDICATION NAME], that form a protective barrier to help seal out irritating wetness)/ABD pads (large fluffy dressing) every shift (qshift) and as needed (prn). Nurse note dated [DATE] at 3:30 pm documented, order for [MEDICATION NAME] cream q shift and prn with hygiene to abdominal folds, groins for yeast rash. MD order dated [DATE] at 3:30 pm documented [MEDICATION NAME] cream to abdominal folds and groins qshift and prn with hygiene until resolved. MD progress note dated [DATE] documented, "resident has class 4 renal (kidney) failure. Has chronic leg [MEDICAL CONDITION] gets [MEDICAL TREATMENT] 2 times per week, Tuesday, Thursday and Saturday. Has slight vesicular [MEDICAL CONDITION] (vesicular lesion is a blister on the skin or another organ), on left leg recently burst, will try to keep legs elevated." There was no mention of rash to groin or abdominal area. Treatment Administration Record (TAR) dated [DATE] documented (listing of all procedural orders with designated areas for nurses to initial when treatment completed) [MEDICATION NAME] cream to abdominal fold and groins with hygiene, every shift and prn, dated [DATE]. Documentation revealed designated boxes to be initialed by nurse for each shift was completed from [DATE] through [DATE], with the exception of [DATE] which was left blank. Nurse notes dated [DATE] through [DATE] revealed there was no mention of the rash to groins and/or abdominal folds. Review of the TAR dated [DATE] revealed there was no treatment for [REDACTED]. Review of physician orders [REDACTED]. Weekly shower documentation, provided to the DOH investigator by the "Shower CNA" who stated during an interview on [DATE] at 1:45 pm, that the nurses come to look at the residents skin after she showers the resident, the nurses initial the weekly shower form. Shower CNA writes what the nurses say under the comment section and then initials the comment. Shower CNA stated the groin and abdominal fold area was always bad and the redness did not go away, the comments that are written "no change" mean that the redness was the same. The comments written by the Shower CNA are as follows: [DATE], red in groin area, notified Mike (evening shift Registered Nurse Supervisor). [DATE], nurse says no change. [DATE], red in groin. [DATE], no change. [DATE], pink on bottom callus of right foot. [DATE], pink/purple groin, put cream on LPN Nurse Manager (LPNNM) aware. (There was no documentation of an RN assessment or MD notification). On [DATE], the groin and fold areas were red and open. Both legs remained swollen. (There was no documentation of an RN assessment or MD notification). MD order dated [DATE] documented Keflex 500 mg, po, bid times 7 days for abscess cyst right upper butt. Nurse note dated [DATE] at 6:00 am documented, Writer made aware of resident having reddened areas between groin by CNA. Assessment revealed the resident to have small amounts of frank red blood to folds in groin bilaterally with purple discoloration noted as well. Writer left areas open to air and will have MD assess today during rounds. Note was signed by a Registered Nurse Supervisor (RNS). MD orders dated [DATE] at 2:03 pm documented, soap and water wash, A&D ointment, ABD pad, every shift and prn to both abdominal folds and groins. Nurse's note dated [DATE] at 12:45 am documented, "patient requested and received [MEDICATION NAME] (pain medication) ,[DATE] mg at 12:45 am for complaints (c/o) groin pain." There was no documentation of assessment of the groins/abdominal folds. Nurse's note dated [DATE] at 9:46 pm documented, resident medicated with [MEDICATION NAME] ,[DATE] at 21:46 for pain in groin. There was no documentation of assessment of the groins/abdominal folds. Nurse's note dated [DATE] at 5:00 am documented, the resident requested and received [MEDICATION NAME] ,[DATE] for c/o back pain results pending. Dressing to inguinal area changed per MD order, some scant sanguineous (red drainage from trauma to a blood vessel) drainage noted on each side. Note was signed by a Registered Nurse (RN). Nurse's note dated [DATE] at 9:40 pm documented, administered [MEDICATION NAME] ,[DATE] at 8:50 pm per patient request, for c/o groin pain. Nurse's note dated [DATE] at 5:40 am documented, [MEDICATION NAME] ,[DATE] given at 4:00 am with moderate effect for c/o groin pain. Dressing changed to inguinal area as MD ordered. Moderate amount of serosanguineous (containing or relating to both blood and the liquid part of blood (serum), foul smelling discharge, drainage noted bilaterally. Patient tolerated treatment well, experienced restless night due to discomfort regardless of position changes. There was no documentation of MD notification of the changes in the rash and the complaints of pain to the groin. Nurse's note dated [DATE] at 1:45 pm documented, resident's cs (capillary sample blood test for glucose level) down to 27 (low blood sugar) at [MEDICAL TREATMENT] center, resident fainted, given intravenous IV, (infusion of liquid substances directly into a vein) [MEDICATION NAME] of [MEDICATION NAME] 50%, fed snack, cs up to 171. Return to nursing home cs 73. There was no documentation of MD notification of the low blood sugar. Nurse's note dated [DATE], with no time documented, late entry, resident exhibited no signs or symptoms of [DIAGNOSES REDACTED] (low blood sugar) entire shift (2:00 pm through 10:00 pm) on [DATE]. Ate 100% of dinner and given crackers at bedtime. Dressing changed with moderate amount of serosanguineous drainage noted. There was no documentation of MD notification of the low blood sugar or rash to groins/abdominal folds. Nurse's note dated [DATE] at 12:00 am documented, Licensed Practical Nurse (LPN) called writer, resident sugar low was giving graham crackers; assessed resident speech slurred, re-checked cs 41, gave po icing, LPN called MD to get order to send to emergency room . At 12:05 am resident became more confused and lethargic, re-checked cs 42, gave 1 mg [MEDICATION NAME] (raises the concentration of glucose in the bloodstream) intramuscular (needle injection into the muscle) right deltoid (upper arm muscle). 911 called arrived 12:08 am. MD orders dated [DATE] at 11:50 pm documented, order to send out via emergency squad, low blood sugar/lethargic. Hospital Discharge Summary dated [DATE] documented, "Time of Death," 7:50 pm. "Primary Diagnosis," Death. "Secondary Diagnosis," Multiorgan failure; [MEDICAL CONDITION], status [REDACTED]. [MEDICAL CONDITION] secondary to [MEDICAL CONDITION]; [MEDICAL CONDITION] in both thigh areas with Proteus mirabilis (Proteus organisms are implicated as serious causes of infections in humans); nonischemic dilated [DIAGNOSES REDACTED] (any disease of the heart muscle that causes the walls of the heart to stretch and weaken); [MEDICAL CONDITION] stage 4 (advanced kidney damage). Documented under "Hospital Course," the patient was admitted to Intensive care unit (ICU) on [MEDICATION NAME] (antibiotic useful for the treatment of [REDACTED]. The patient eventually went into septic shock and then required [MEDICATION NAME] drip (The predominant actions of [MEDICATION NAME] are on the cardiovascular system) as well as [MEDICATION NAME] (Treats circulation problems caused by [MEDICAL CONDITION], heart failure, kidney failure, low blood pressure, or surgery). He had advanced [MEDICAL CONDITION] and went also into [MEDICAL CONDITION] which then required endotracheal intubation. The patient eventually was extubated and he was made Do Not Resuscitate (DNR) and Do Not Intubate (DNI) and he was changed into comfort care only. He expired on [DATE] at 7:50 pm. Policy & Procedure (P&P) titled, Resident Skin Monitoring/Tracking dated [DATE] documented, resident skin will be monitored weekly for issues and areas as outlined below. Documented under "Protocol," on admission/readmission to the facility the resident is designated a specific day/shift when they will receive their weekly tub bath/shower. This day will be noted in the treatment book as well as on the tub schedule by the nurse. Each resident on his/her tub day will receive a head to toe observation by a nurse. Any concerns will be brought to the attention of the Registered Nurse (RN) for follow-up and assessment. The observation will be documented in the individual's medical record. The RN will then do an assessment of the area of concern, update the attending physician and family and initiate appropriate treatment and interventions in the treatment book as well as documentation in the individual's medical record which will include cause if known. The area of concern will continue to be monitored at least weekly until the area is resolved. During an interview on [DATE] at 9:45 am the Director of Nursing (DON) stated that she reviewed Resident # 1's chart after the discharge to the hospital and she did not find any problems with the care the resident received in the facility. During an interview on [DATE] at 1:05 pm CNA # 1 stated that [MEDICATION NAME] cream is applied by the nurses only. The CNAs find skin issues, write on a piece of paper and give to the nurse, there is no special form for CNAs to write skin issues on. CNA # 1 stated that Resident # 1 did refuse care from the CNAs a lot, not sure if nurses were putting on the cream. Resident did have a shower done weekly by the "Shower aide" who would get the nurses to look at the residents skin. During an interview on [DATE] at 1:20 pm CNA # 2 stated that Resident was on their assignment approximately two times per week. Resident # 1 would give a hard time of bathing, very little washing. CNA # 2 remembered the abdominal folds being red, nurses would do the creams that were ordered. During an interview on [DATE] at 1:40 pm LPN # 1 stated that any new skin issues should be checked by the RN. The nurses would apply the skin creams to areas and document in the nurse notes. When LPN # 1 first saw the rash to the abdominal folds and groins she thought is was sometime in June, and it was red, moist and dull looking. The resident refused care a lot, but LPNs not responsible to document the care refusals. On shower days the nurses look at the residents skin and document negative findings on the skin. The progression or decline of an area should be documented in the nurse notes. Once the area is resolved the nurse would discontinue the order, write a progress note and discontinue the treatment on the TAR. During an interview on [DATE] at 1:45 pm the Shower CNA stated that her primary job is to do the showers on all the residents. The nurse do the skin checks on the shower days and she calls for them when the resident is ready to be observed. Shower CNA stated that the redness to the groins and abdominal folds were always red and never went away. During an interview on [DATE] at 1:55 pm the LPNNM stated that Resident # 1 was treated with [MEDICATION NAME] for a fungal rash. The [MEDICATION NAME] was ordered for every shift and as needed until resolved. If the rash had resolved it should be discontinued on the TAR and documented in the nurse notes. The end of month turnover of the TAR to the next month's TAR should be reviewed by two nurses and initialed. Did not know what happened with Resident # 1's [MEDICATION NAME] treatment and why it was not carried over to June. Nurses look at residents skin on shower days and should sign the shower sheet and the TAR. Skin issues are usually noted by the CNAs who notify the nurses. New skin areas of concern should be assessed by an RN. During an interview on [DATE] at 2:30 pm Registered Nurse Manager (RNM) stated that the CNA would report a rash to nurse and it would require an RN assessment. Cream would be ordered and placed in the TAR, documented on 24 hour report sheet as a new rash and should be monitored by the three shifts. If there is no change in the rash after a period of time the MD should have to look at it. RNM had no memory of being notified of Resident # 1's groin and abdominal folds. After Resident # 1 went to the emergency room the hospital called and said that the resident [MEDICAL CONDITION] from the abdominal and groin wounds. RNM stated that the DON was investigating the situation. During an interview on [DATE] at 9:05 am the MD # 1 stated that he began working with the facility in mid [DATE]. MD # 1 stated he vaguely remembered the name of Resident # 1, that he goes into the facility on ce per week and the Medical Director does the same. The doctors address any matters that are reported to them by the nurses. MD should be notified of changes in a rash and if he was aware of it he would have included it in his notes. During an interview on [DATE] at 11:40 am CNA # 3 stated in the beginning of [DATE] Resident # 1's groin was always red, then it started looking dark red, almost black and he went to the hospital a few days after that. CNA # 3 stated that the Shower Aide on day shift said to keep an eye on the groins/abdominal area but she could not remember exactly when that was. During an interview on [DATE] at 3:25 pm the Medical Director (Med Dir) stated he remembered there was a concern with the abscess on his backside and he had seen the resident. On that day (see [DATE] nurse note) of looking at the abscess the staff tried to stand Resident # 1 and he had great difficulty. Med Dir remembers speaking with the nurse about the rash to the groin and was told by the nurse that it was a small area, it was difficult to be seen that day due to his difficulty in standing. Medical Director had no memory of being notified of the worsening rash as documented by the Shower Aide on [DATE]. He thought the other physician had seen the resident on [DATE] and ordered the A&D and ABD pads. He had no memory of being notified of the subsequent pain or foul smelling drainage from the groins or abdominal folds. Med Dir stated a physician should have been notified of the changes in the groin/abdominal folds. 10NYCRR415.11(c)(3)(ii)

Based on observation, record review, and staff interviews during an abbreviated survey (complaint #NY 625), the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one ( Resident #1) of three residents reviewed for necessary care and services. Specifically, Resident #1 was admitted to the facility for rehabilitation on [DATE]. On [DATE] resident was noted to have a rash to his abdominal folds and groin area, physician (MD) order was received for [MEDICATION NAME] cream every shift. The treatment was rendered as ordered by the MD through the end of May. The treatment for [REDACTED]. On [DATE], the weekly shower skin check revealed pink/purple groin, put cream on, LPN Nurse Manager aware; there was no RN assessment or notification to the physician and no subsequent nurse notes in regards to the rash on the abdominal folds and groin until [DATE]. Resident was admitted to the hospital and expired two days later. This resulted in actual harm which was not Immediate Jeopardy. This was evidenced by: Resident # 1 The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident had no cognitive deficit with a Brief Interview for Mental Status (BIMS) score of 15, according to the Minimum Data Set ((MDS) dated [DATE]. Nursing Admission assessment dated [DATE] documented for skin areas on the body, self inflicted scratches on both hips, dry skin areas to both lower legs, bruise to the coccyx. There was no documentation of any rash or other skin issues to his lower abdomen or groin. Comprehensive Care Plan (CCP) titled "Alteration in skin integrity" documented under the heading "Problem," [DATE], yeast rash abdomen and groins; [DATE] abscess/cyst to right upper buttock, noted by physician (MD); [DATE], irritated bleeding areas both abdominal areas, groin areas. Documented under the heading "Actions," [DATE], [MEDICATION NAME] cream (used to treat fungal infections of the skin) every shift (qshift) and as needed (prn) with hygiene to abdominal folds and groins; Keflex (used to treat infections caused by bacteria) 500 milligrams (mg), start on [DATE], monitor right buttock daily for changes; [DATE] monitor both areas, soap and water wash, A&D ointment (Ointment is specially formulated with two active ingredients, [MEDICATION NAME] and [MEDICATION NAME], that form a protective barrier to help seal out irritating wetness)/ABD pads (large fluffy dressing) every shift (qshift) and as needed (prn). Nurse note dated [DATE] at 3:30 pm documented, order for [MEDICATION NAME] cream qshift and prn with hygiene to abdominal folds, groins for yeast rash. MD order dated [DATE] at 3:30 pm documented [MEDICATION NAME] cream to abdominal folds and groins qshift and prn with hygeine until resolved. MD progress note dated [DATE] documented, "resident has class 4 renal (kidney) failure. Has chronic leg [MEDICAL CONDITION] gets [MEDICAL TREATMENT] 2 times per week, Tuesday, Thursday and Saturday. Has slight vesicular [MEDICAL CONDITION] (vesicular lesion is a blister on the skin or another organ), one left leg recently burst, will try to keep legs elevated." There was no mention of rash to groin or abdominal area. Treatment Administration Record (TAR) dated [DATE] documented (listing of all procedural orders with designated areas for nurses to initial when treatment completed) [MEDICATION NAME] cream to abdominal fold and groins with hygiene, every shift and prn, dated [DATE]. Documentation revealed designated boxes to be initialed by nurse for each shift was completed from [DATE] through [DATE], with the exception of [DATE] which was left blank. Nurse notes dated [DATE] through [DATE] revealed there was no mention of the rash to groins and/or abdominal folds. Review of the TAR dated [DATE] revealed there was no treatment for [REDACTED]. Review of physician orders [REDACTED]. Nurse note dated [DATE] documented, resident complains of worsening bilateral lower extremity pain inner thighs and posterior lower legs, affecting transfers and ambulation. MD orders dated [DATE] at 3:00 pm documented, obtain Xray ( of lumbar spine (the five vertebrae between the rib cage and the pelvis) due to concern over discomfort with walking, change in transfer and ambulation. Nurse note dated [DATE] at 2:50 pm documented, to have a lumbar spine Xray due to changes noted. Xray result dated [DATE] at 12:04 pm documented under the heading "impression," there is narrowing of the L3-L4 disc in the endplates (top and bottom portions of the vertebral bodies that interface with the vertebral discs) demonstrate mixed lytic and sclerotic heterogeneous density (representing recent bleeds are present within the mass) that could represent early destruction of the endplates. This raises the possibility of discitis (infection in the intervertebral disc space) and adjacent osteo[DIAGNOSES REDACTED] (an infection in a bone). Recommend emergent Medical Resonant Imaging (MRI, a test that uses a magnetic field and pulses of radio wave energy to make pictures of organs and structures inside the body) of the lumbosacral spine with gadolinium contrast (When injected into the body, gadolinium contrast medium makes certain tissues, abnormalities or disease processes more clearly visible on a MRI scan). MD order dated [DATE] at 2:40 pm documented, Cat scan (an imaging method that uses x-rays to create pictures of cross-sections of the body) of L3/L4 due to infection of L3/L4 as soon as possible (ASAP). Nurse note dated [DATE] at 2:30 pm documented, received call from radiologist to have urgent/ASAP MRI. Unable to have MRI, order changed to Cat scan due to pacemaker, so resident out for a Cat scan at 2:40 pm. Cat scan report dated [DATE] at 4:19 pm documented under the heading "Impression," marked endplate irregularity is present at L3-L4 without any evidence of paraspinal inflammation or [MEDICATION NAME] mass. Due to the lack of any adjacent inflammation I would favor this being [MEDICAL CONDITION] in etiology rather than infectious. For a more definitive evaluation a follow-up gallium scan is suggested. Lateral recess stenosis (Spinal stenosis is a narrowing of the open spaces within your spine, which can put pressure on your spinal cord and the nerves) is present bilaterally at L4, L5. Nurse note dated [DATE] at 2:20 am documented, Certified Nurse Aide (CNA) reported blood in resident's pad (incontinence product), assessed resident, no sign of rectal bleeding, ruptured cyst above anus draining not (illegible word), scant amount of blood no pus noted. Weekly shower documentation, provided to the DOH investigator by the "Shower CNA" who stated during an interview on [DATE] at 1:45 pm, that the nurses come to look at the residents skin after she showers the resident the nurses initial the weekly shower form. Shower CNA writes what the nurses say under the comment section and then initials the comment. Shower CNA stated the groin and abdominal fold area was always bad and the redness did not go away, the comments that are written "no change" mean that the redness was the same. The comments written by the Shower CNA are as follows: [DATE], red in groin area, notified Mike (evening shift Registered Nurse Supervisor). [DATE], nurse says no change. [DATE], red in groin. [DATE], no change. [DATE], pink on bottom callus of right foot. [DATE], pink/purple groin, put cream on LPN Nurse Manager (LPNNM) aware. (There was no documentation of an RN assessment or MD notification). [DATE], groin and fold red and open, legs swollen. (There was no documentation of an RN assessment or MD notification). Nurse note dated [DATE] at 11:20 am documented, MD assessed with [REDACTED]. New order for Keflex (antibiotic) 500 mg by mouth (po) twice per day (bid) times 7 days, to start today, monitor area daily. Per radiology request to have Gallium study (nuclear medicine test uses a special camera to take pictures of specific tissues in the body after a radioactive [MEDICATION NAME] (radionuclide or radioisotope) makes them visible) done due to concerns over L3/L4 (lower discs' of the lumbar spine), being scheduled at present. MD orders dated [DATE] documented Gallium study due to change in lumbar spine, transfer and ambulation status. MD progress note dated [DATE] documented, patient with some rectal bleed and exudate. (illegible sentence). peri rectal abscess. Keflex 500 mg bid times 7 days. There was no mention of rash to groins/abdominal folds. MD order dated [DATE] documented Keflex 500 mg, po, bid times 7 days for abscess cyst right upper butt. Nurse note dated [DATE] at 1:30 pm documented, out for Gallium study at present, care card and care plan changed due to change in overall status. Resident is non-ambulatory with two assist for transfer at present, to be cut from Physical Therapy (PT) today. There was no mention of rash to groins/abdominal folds. Report of Gallium study dated [DATE] at 12:53 pm documented under the heading : "Impression," No abnormal rediopharmaceutical accumulation, specifically in the region of the L3-L4 disc. The changes at the L3-L4 disc therefore, likely are [MEDICAL CONDITION]. Nurse note dated [DATE] at 6:00 am documented, Writer made aware of resident having reddened areas between groin by CNA. Assessment revealed Resident to have small amounts of frank red blood to folds in groin bilaterally with purple discoloration noted as well. Writer left areas open to air and will have MD assess today during rounds. Note was signed by a Registered Nurse Supervisor (RNS). MD orders dated [DATE] at 2:03 pm documented, soap and water wash, A&D ointment, ABD pad, every shift and prn to both abdominal folds and groins. Nurse note dated [DATE] at 12:45 am documented, patient requested and received [MEDICATION NAME] (pain medication) ,[DATE] mg at 12:45 am for complaints (c/o) groin pain. There was no documentation of assessment of the groins/abdominal folds. Nurse note dated [DATE] at 9:46 pm documented, resident medicated with [MEDICATION NAME] ,[DATE] at 21:46 for pain in groin. There was no documentation of assessment of the groins/abdominal folds. Nurse note dated [DATE] at 5:00 am documented, resident requested and received [MEDICATION NAME] ,[DATE] for c/o back pain results pending. Dressing to inguinal area changed per MD order, some scant sanguineous (red drainage from trauma to a blood vessel) drainage noted on each side. Note was signed by a Registered Nurse (RN). Nurse note dated [DATE] at 9:40 pm documented, administered [MEDICATION NAME] ,[DATE] at 8:50 pm per patient request, for c/o groin pain. Nurse note dated [DATE] at 5:40 am documented, [MEDICATION NAME] ,[DATE] given at 4:00 am with moderate effect for c/o groin pain. Dressing changed to inguinal area as MD ordered. Moderate amount of serosanguineous (containing or relating to both blood and the liquid part of blood (serum), foul smelling discharge, drainage noted bilaterally. Patient tolerated treatment well, experienced restless night due to discomfort regardless of position changes. There was no documentation of MD notification of the changes in the rash and the complaints of pain to the groin. Nurse note dated [DATE] at 1:45 pm documented, resident's cs (finger stick capillary test) down to 27 (low blood sugar) at [MEDICAL TREATMENT] center, resident fainted, given intravenous (IV, infusion of liquid substances directly into a vein) [MEDICATION NAME] of [MEDICATION NAME] 50%, fed snack, cs up to 171. Return to nursing home cs 73. There was no documentation of physician notification of the low blood sugar. Nurse note dated [DATE], with no time documented, late entry, resident exhibited no signs or symptoms of [DIAGNOSES REDACTED] (low blood sugar) entire shift (2:00 pm through 10:00 pm) on [DATE]. Ate 100% of dinner and given crackers at bedtime. Dressing changed with moderate amount of serosanguineous drainage noted. There was no documentation of MD notification of the low blood sugar or rash to groins/abdominal folds. Nurse note dated [DATE] at 12:00 am documented, Licensed Practical Nurse (LPN) called writer, resident sugar low was giving graham crackers; assessed resident speech slurred, re-checked cs 41, gave po icing, LPN called MD to get order to send to emergency room . At 12:05 am resident became more confused and lethargic, re-checked cs 42, gave 1 mg [MEDICATION NAME] (raises the concentration of glucose in the bloodstream) intramuscular (needle injection into the muscle) right deltoid (upper arm muscle). 911 called arrived 12:08 am. MD orders dated [DATE] at 11:50 pm documented, order to send out via emergency squad, low blood sugar/lethargic. Hospital Discharge Summary dated [DATE] documented, "Time of Death," 7:50 pm. "Primary Diagnosis," Death. "Secondary Diagnosis," Multiorgan failure; [MEDICAL CONDITION], status [REDACTED]. walls of the heart to stretch and weaken); [MEDICAL CONDITION] stage 4 (advanced kidney damage). Documented under "Hospital Course," the patient was admitted to Intensive care unit (ICU) on [MEDICATION NAME] (antibiotic useful for the treatment of [REDACTED]. The patient eventually went into septic shock and then required [MEDICATION NAME] drip (The predominant actions of [MEDICATION NAME] are on the cardiovascular system) as well as [MEDICATION NAME] (Treats circulation problems caused by [MEDICAL CONDITION], heart failure, kidney failure, low blood pressure, or surgery). He had advanced [MEDICAL CONDITION] and went also into [MEDICAL CONDITION] which then required endotracheal intubation. The patient eventually was extubated and he was made Do Not Resuscitate (DNR) and Do Not Intubate (DNI) and he was changed into comfort care only. He expired on [DATE] at 7:50 pm. Policy & Procedure (P&P) titled, Resident Skin Monitoring/Tracking dated [DATE] documented, resident skin will be monitored weekly for issues and areas as outlined below. Documented under "Protocol," on admission/readmission to the facility the resident is designated a specific day/shift when they will receive their weekly tub bath/shower. This day will be noted in the treatment book as well as on the tub schedule by the nurse. Each resident on his/her tub day will receive a head to toe observation by a nurse. Any concerns will be brought to the attention of the Registered Nurse (RN) for follow-up and assessment. The observation will be documented in the individual's medical record. The RN will then do an assessment of the area of concern, update the attending physician and family and initiate appropriate treatment and interventions in the treatment book as well as documentation in the individual's medical record which will include cause if known. The area of concern will continue to be monitored at least weekly until the area is resolved. During an interview on [DATE] at 9:45 am the Director of Nursing (DON) stated that she reviewed Resident # 1's chart after the discharge to the hospital and she did not find any problems with the care the resident received in the facility. During an interview on [DATE] at 1:05 pm CNA # 1 stated that [MEDICATION NAME] cream is applied by the nurses only. The CNAs find skin issues, write on a piece of paper and give to the nurse, there is no special form for CNAs to write skin issues on. CNA # 1 stated that Resident # 1 did refuse care from the CNAs a lot, not sure if nurses were putting on the cream. Resident did have a shower done weekly by the "Shower aide" who would get the nurses to look at the residents skin. During an interview on [DATE] at 1:20 pm CNA # 2 stated that Resident was on their assignment approximately two times per week. Resident # 1 would give a hard time of bathing, very little washing. CNA # 2 remembered the abdominal folds being red, nurses would do the creams that were ordered. During an interview on [DATE] at 1:40 pm LPN # 1 stated that any new skin issues should be checked by the RN. The nurses would apply the skin creams to areas and document in the nurse notes. When LPN # 1 first saw the rash to the abdominal folds and groins she thought is was sometime in June, and it was red, moist and dull looking. The resident refused care a lot, LPNs not responsible to document the care refusals. On shower days the nurses look at the residents skin and documents negative findings of skin in the progress notes. The progression or decline of an area should be documented in the nurse notes. Once the area is resolved the nurse would discontinue the order, write a progress note and discontinue the treatment on the TAR. During an interview on [DATE] at 1:45 pm the Shower CNA stated that her primary job is to do the showers on all the residents. Shower CNA calls for the nurse to do the skin check when the resident is ready to be observed. Shower CNA stated that the redness to the groins and abdominal folds were always red and never went away. During an interview on [DATE] at 1:55 pm the LPNNM stated that Resident # 1 was treated with [MEDICATION NAME] for a fungal rash. The [MEDICATION NAME] was ordered for every shift and as needed until resolved. If the rash had resolved it should be discontinued on the TAR and documented in the nurse notes. The end of month turnover of the TAR to the next month's TAR should be reviewed by two nurses and initialed. Did not know what happened with Resident # 1's [MEDICATION NAME] treatment and why it was not carried over to June. Nurses look at residents skin on shower days and should sign the shower sheet and the TAR. Skin issues are usually noted by the CNAs who notify the nurses. New skin areas of concern should be assessed by an RN. During an interview on [DATE] at 2:30 pm Registered Nurse Manager (RNM) stated that the CNA would report a rash to nurse and it would require an RN assessment. Cream would be ordered and placed in the TAR, documented on 24 hour report sheet as a new rash and should be monitored by the three shifts. If there is no change in the rash after a period of time the MD should have to look at it. RNM works closely with the LPNNM and is responsible to do the RN assessments, he had no memory of being notified of Resident # 1's groin and abdominal folds. After Resident # 1 went to the emergency room the hospital called and said that the resident [MEDICAL CONDITION] from the abdominal and groin wounds. RNM stated that the DON was investigating the situation. During an interview on [DATE] at 9:05 am the MD # 1 stated that he began working with the facility in mid [DATE]. MD # 1 stated he vaguely remembered the name of Resident # 1, that he goes into the facility on ce per week and the Medical Director does the same. The doctors address any matters that are reported to them by the nurses. MD should be notified of changes in a rash and if he was aware of it he would have included it in his notes. During an interview on [DATE] at 11:40 am CNA # 3 stated in the beginning of [DATE] Resident # 1's groin was always red, then it started looking dark red, almost black and he went to the hospital a few days after that. CNA # 3 stated that the Shower Aide on day shift said to keep an eye on the groins/abdominal area but she could not remember exactly when that was. During an interview on [DATE] at 3:25 pm the Medical Director (Med Dir) stated he remembered there was a concern with the abscess on his backside and he had seen the resident. On that day (see [DATE] nurse note) of looking at the abscess the staff tried to stand Resident # 1 and he had great difficulty. Med Dir remembers speaking with the nurse about the rash to the groin and was told by the nurse that it was a small area, it was difficult to be seen that day due to his difficulty in standing. Medical Director had no memory of being notified of the worsening rash as documented by the Shower Aide on [DATE]. He thought the other physician had seen the resident on [DATE] and ordered the A&D and ABD pads. He had no memory of being notified of the subsequent pain or foul smelling drainage from the groins or abdominal folds. Med Dir stated a physician should have been notified of the changes in the groin/abdominal folds. 10 NYCRR 415.12