Every finding on record at Rochester Center for Rehabilitation and Nursing

Based on observations, interviews, and record review, the facility failed to ensure residents receiving enteral nutrition, (tube placed in the stomach via the abdomen to receive nutritional support) were provided treatment and services in accordance with physician orders and professional standards of practice to prevent complications for three (3) of four (4) residents reviewed (Resident #5, Resident #7, and Resident #9). Specifically, Resident #5 did not receive prescribed enteral nutrition and hydration for multiple days and was hospitalized ; Resident #7 and Resident #9 had significant inconsistencies in the administration of prescribed enteral nutrition and hydration without physician orders, clinical justification, or documented refusals. This deficient practice resulted in actual harm, that was not Immediate Jeopardy, for Resident #5 who developed dehydration (a condition caused by insufficient fluid intake resulting in fluid imbalance), hypotension (low blood pressure), and new onset atrial fibrillation with rapid ventricular response (an irregular and often rapid heart rhythm that can lead to poor blood flow) requiring hospital transfer, intravenous fluid resuscitation (the rapid administration of fluids directly into the bloodstream to treat shock or severe low blood volume caused by sepsis or dehydration), and admission to the intensive care unit.The findings include:The facility policy Enteral Feeding Administration dated 02/25/2026 documented enteral nutrition would be administered per physician orders, evidence based clinical practices, resident rights, and federal regulation.1. Resident #5 had diagnoses including aspiration pneumonia (a lung infection caused by inhaling food, liquid, or stomach contents into the lungs), gastrostomy (a medical device inserted through the abdomen directly into the stomach to deliver nutrition, fluids, and medications), and hemiplegia/hemiparesis (paralysis or weakness affecting one (1) side of the body) following cerebral infarction (a type of stroke caused by blockage of blood flow to the brain affecting the right dominant side). The Minimum Data Set Assessment (a resident assessment tool) dated 12/05/2025 documented Resident #5 was cognitively intact.Review of the Comprehensive Care Plan on 04/16/2026 revealed Resident #5 required tube feeding related to dysphagia (difficulty swallowing). Interventions included to administer tube feeding and water flushes per Registered Dietician recommendation and physician orders. Review of Physician Orders dated 03/13/2026 included nothing by mouth and enteral nutrition Isosource 1.5 at 70 milliliters per hour beginning at 8:00 AM for a total volume of 840 milliliters daily, with verification of total volume infused and documentation of total volume delivered. Orders also included administration of 30 milliliters of water before and after feeding and 100 milliliters of water every four (4) hours six (6) times a day.Review of the March 2026 Medication Administration Record revealed no documented administration of enteral nutrition on 03/16/2026, 03/17/2026, and 03/18/2026 with the amount documented as zero (0). Additional entries included blank boxes with no indication if enteral nutrition or hydration was administered or held. Water flush documentation was also incomplete with missing entries on 03/12/2026, 03/16/2026, and 03/17/2026 at 8:00 AM, 10:30 AM, and 1:00 PM.Review of a nursing progress note dated 03/19/2026, Licensed Practical Nurse #1 documented Resident #5 did not receive enteral nutrition per order on 03/18/2026 day shift. At approximately 9:00 PM on 03/18/2026, Licensed Practical Nurse #1 obtained an order to initiate enteral nutrition; however, Resident #5 expressed distress and requested transfer to the hospital.Review of hospital records dated 03/18/2026 revealed Resident #5 was transported from the facility to the emergency department for reports of missed enteral nutrition and concern for dehydration. Resident #5 presented with hypotension, tachycardia (elevated heart rate), and clinical findings (including elevated laboratory values) consistent with dehydration. Medical evaluation documented dehydration and new onset atrial fibrillation with rapid ventricular response requiring intravenous fluid resuscitation, and admission to the intensive care unit. Resident #5 was later discharged to another skilled nursing facility. During an interview on 04/16/2026 at 11:28 AM, Licensed Practical Nurse #1 stated Resident #5 did not receive enteral nutrition prior to the start of their evening shift on 03/18/2026 and the resident begged them to go to the hospital.During a telephone interview on 04/16/2026 at 2:14 PM, Physician Assistant #1 stated Resident #5 had not been receiving enteral nutrition at appropriate times and was transferred to the hospital on [DATE] to evaluate a change in condition.2. Resident #7 had diagnoses including dysphagia (difficulty swallowing), cerebral palsy (a neurological disorder affecting movement and muscle coordination), hyperosmolality and hypernatremia (elevated concentration of sodium and other substances in the blood due to fluid imbalance), and spastic quadriplegia (muscle stiffness and weakness affecting all four (4) limbs). The Minimum Data Set assessment dated [DATE] documented Resident #7 was cognitively intact and required enteral nutrition.Review of the Comprehensive Care Plan on 04/16/2026 revealed Resident #7 required tube feeding related to dysphagia. Interventions included to administer tube feeding and water flushes per Registered Dietician recommendation and physician orders. Review of Physician Orders dated 03/10/2026 included nothing by mouth and enteral nutrition Peptomen 1.5 at 70 milliliters per hour beginning at 4:00 PM for a total volume of 1000 milliliters to be delivered daily. Orders also included administration of 200 milliliters of water every eight (8) hours three (3) times a day and 50 milliliters of water before and after tube feeding administration, with instructions to verify infusion each shift, and document total volume infused.Review of the March 2026 and April 2026 Medication Administration Records revealed, based on the physician order, if enteral nutrition was initiated at 4:00 PM as prescribed, the expected volume infused by 11:00 PM would be approximately 490 milliliters. Documented volumes at 11:00 PM varied significantly and ranged from 560 milliliters to 1000 milliliters. There were multiple blank entries (no documentation of volume infused and/or nurse signatures). For the order to administer 200 milliliters of water every eight (8) hours three (3) times a day, there were no documented administrations on 03/20/2026 at 2:00 PM, 03/29/2026 at 6:00 PM and 8:00 PM, 04/03/2026 at 6:00 PM, and 04/05/2026 at 6:00 PM and 8:00 PM. Additional review of physician orders, progress notes, and intake/output records included no documented evidence of orders to hold or adjust enteral nutrition or hydration, clinical justification for inconsistent volumes, or resident refusal. There was no alternate documentation to support administration when the Medication Administration Record was incomplete (blank entries) or inconsistent (variable documentation).During an observation on 04/08/2026 at 4:05 PM, Resident #7's enteral feeding was not running and the feeding bag hanging near the bed was empty and dated 04/07/2026. At 5:02 PM, the feeding was still not running. At 5:33 PM, Licensed Practical Nurse #7 initiated the feeding and stated the second nurse assigned to the unit was not coming in.3. Resident #9 had diagnoses including dysphagia (difficulty swallowing), gastrostomy status (presence of a feeding tube inserted into the stomach), and convulsions (sudden, involuntary muscle contractions often associated with seizure activity). The Minimum Data Set, dated [DATE] documented the resident had severely impaired cognition and required enteral feeding. Review of the Comprehensive Care Plan on 04/16/2026 revealed Resident #9 required tube feeding related to dysphagia. Interventions included to administer tube feeding and water flushes per Registered Dietician recommendation and physician orders. Review of Resident #9's physician orders dated 04/11/2026 included nothing by mouth and enteral nutrition Nutren 1.5 at 65 milliliters per hour beginning at 5:00 PM for a prescribed total daily volume of 1315 milliliters. Orders also included administration of water via enteral tube through both automatic flushes at a rate of 30 milliliters per hour with a total volume of 500 milliliters and 150 milliliters of water flushes six (6) times a day. Orders required verification of infusion each shift, confirmation of total volume delivered through pump settings, and documentation of total volume infused.Review of the February 2026, March 2026, and April 2026 Medication Administration Records revealed, based on physician orders, the expected volume at 7:00 AM would be approximately 910 milliliters of enteral nutrition and approximately 420 milliliters of water flush. Documented enteral nutrition volumes at 7:00 AM varied significantly and ranged from 113 milliliters to 1315 milliliters. Documented water flush volumes varied widely ranging from 120 milliliters to 1035 milliliters. There were multiple blank entries across all shifts.Additional review of physician orders, progress notes, and intake/output records included no documented evidence of orders to hold or adjust enteral nutrition or hydration, clinical justification for inconsistent volumes, or resident refusal. There was no alternate documentation to support administration when the Medication Administration Record was incomplete or inconsistent.During an interview on 04/17/2026 at 9:09 AM, the Director of Nursing stated documentation contained blank entries and they could not confirm if Residents #5, #7, and #9 received enteral nutrition and hydration as ordered. The Director of Nursing acknowledged staffing concerns and system issues.During an interview on 04/16/2026 at 12:22 PM, Nurse Practitioner #1 stated there were significant communication gaps between nursing staff and the provider, and staff did not consistently notify the provider when medications, treatments, or enteral feedings were late or not administered. Nurse Practitioner #1 stated they expect physician orders to be carried out as written and to be notified if care is not provided as ordered. Nurse Practitioner #1 stated no nursing staff had notified them of missed or late enteral feedings or hydration, nor had staff expressed concern residents were not being fed or receiving enteral nutrition as prescribed. Nurse Practitioner #1 stated failure to administer enteral nutrition and hydration as ordered could result in dehydration, aspiration, and clinical decline.During an interview on 04/17/2026 at 12:25 PM, the Medical Director stated there were significant system concerns within the facility, including missed medications and enteral feedings, and lack of oversight to ensure ordered care was provided. The Medical Director stated they had been notified of missed medications but were not provided details regarding what was missed and expressed concern regarding the absence of a clear process to identify and address missed care. The Medical Director stated if enteral feeding pumps are not set up correctly or if feedings are not administered as ordered, residents may not receive prescribed nutrition and hydration, which could result in dehydration, aspiration, and potentially death. The Medical Director stated current staffing levels, including one (1) nurse for 40 to 42 residents, were not sufficient to ensure safe care. Title 10 New York Codes, Rules and Regulations 415.12(g)(2) and 415.12(j)

Based on interviews and record review, the facility failed to ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for residents in the facility. Specifically, staffing levels were insufficient to meet resident care needs, the facility did not consistently meet its own identified minimum staffing levels, and the facility failed to implement sufficient contingency staffing measures to address known staffing shortages, resulting in missed medication administrations, delayed medication administration, and inability to complete ordered treatments.The findings include: The Facility assessment dated [DATE] documented the facility was licensed for 124 beds with a daily census of 120 to 122 residents. The Facility Assessment included staffing would be adjusted based on resident acuity and included a minimum staffing plan of two (2) nurses on the first floor during day shift from 7:00 AM to 3:00 PM, one (1) nurse during evening shift from 3:00 PM to 11:00 PM, and one (1) nurse during night shift from 11:00 PM to 7:00 AM. The second and third floors each required one (1) nurse on day shift from 7:00 AM to 3:00 PM, one (1) nurse on evening shift from 3:00 PM to 11:00 PM, and one (1) nurse on night shift from 11:00 PM to 7:00 AM, for a total of 10 nurses per 24 hours.During the entrance conference on 03/03/2026 at 8:45 AM, the Administrator stated the facility census was 121 residents.Review of medication administration audits from 02/01/2026 to 04/16/2026 revealed 17 days in which 20 or more residents had missed medication administrations.Review of time punch records for nursing staff on the 17 identified days revealed two (2) evening shifts and nine (9) night shifts in which three (3) or fewer nurses were working in a facility with approximately 120 residents. There were 13 days in which nursing staff punched in more than one (1) hour late and four (4) days in which nursing staff punched out more than one (1) hour early, resulting in reduced staffing levels for significant portions of scheduled shifts.Review of medication administration audits from 02/01/2026 to 04/16/2026 revealed multiple residents experienced delayed medication administration: Resident #10 had 282 medications administered more than one (1) hour late in February 2026, 327 medications administered more than one (1) hour late in March 2026, and 117 medications administered more than one (1) hour late from 04/01/2026 to 04/16/2026. Resident #5 had 188 medications administered more than one (1) hour late in February 2026, 170 medications administered more than one (1) hour late in March 2026, and 43 medications administered more than one (1) hour late from 04/01/2026 to 04/16/2026. Resident #8 had 83 medications administered more than one (1) hour late in February 2026, 249 medications administered more than one (1) hour late in March 2026, and 75 medications administered more than one (1) hour late from 04/01/2026 to 04/16/2026.During an interview on 03/04/2026 at 11:11 AM, Licensed Practical Nurse #4 stated during evening shift on the third floor there was one (1) nurse and two (2) certified nursing assistants assigned to 42 residents and there were occasions with only one (1) certified nursing assistant available. Licensed Practical Nurse #4 stated when assigned alone they were unable to complete required resident care tasks and reported medications were not administered to portions of the unit.During an interview on 04/15/2026 at 1:50 PM, Licensed Practical Nurse #5 stated there was frequently one (1) nurse assigned to the unit and they were unable to complete ordered treatments due to administering medications.During an interview on 04/16/2026 at 11:04 AM, Licensed Practical Nurse #6 stated medication administration required the entire shift and no break was taken.During an interview on 04/16/2026 at 1:46 PM, Licensed Practical Nurse #2 stated they had been the only nurse assigned to a unit on multiple occasions and were unable to complete wound care without additional nursing staff. Licensed Practical Nurse #2 stated there were instances when a nurse would punch in to work, leave the facility for several hours, and returned later before the end of the shift. During an interview on 04/16/2026 at 2:14 PM, Physician Assistant #1 stated they had been made aware of instances where entire resident units did not receive medications and reported significant medications were not administered.During an interview on 04/17/2026 at 9:09 AM, the Director of Nursing stated each unit was expected to have two (2) nurses during day and evening shifts and one (1) nurse during night shift; however, there were occasions when only one (1) nurse was assigned per unit during day and evening shifts. The Director of Nursing stated each unit had 40 to 42 residents and there was currently one (1) unit manager in the facility.During an interview on 04/17/2026 at 12:25 PM, the Medical Director stated one (1) nurse assigned to 40 to 42 residents was not safe.During an interview on 04/22/2026 at 2:22 PM, the Scheduling Coordinator stated they were responsible for staffing each unit to ensure adequate coverage and were unaware of staffing concerns. During an interview on 04/22/2026 at 2:34 PM, the Administrator stated they were aware of residents not receiving medications through reports from residents, families, staff, internal audits, and corporate oversight and acknowledged nurses were not always able to administer medications or complete care within expected timeframes. The Administrator stated staffing levels followed minimum corporate requirements and acknowledged difficulty retaining unit managers.Title 10 New York Codes, Rules and Regulations 415.13(a)

Based on observations, interviews, and record review, the facility failed to ensure medications were administered in accordance with physician orders, resulting in clinically significant medication errors, for 11 of 11 residents reviewed (Residents #1, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13). Specifically, Resident #8 received duplicate dosing of a controlled medication (drugs regulated due to their potential for abuse, misuse, or dependence), and several residents experienced omissions of ordered medications, and/or medications administered outside the ordered timeframe and there was no documented evidence a medical provider was notified. These failures included high-risk medications such as insulin (used to treat high blood sugar levels), anticoagulants (blood thinner), anti-seizure medications, cardiac medications (used to treat heart conditions), antibiotics (used to treat infections), and narcotics (controlled medications used to treat severe pain). The findings include: The facility policy Medication Administration dated December 2019 documented medications were to be administered in a safe and timely manner and in accordance with physician orders, including required timeframes. The facility policy Medication Administration - Documentation dated January 2019 documented medication administration must be recorded immediately after administration and must include reasons medications were not administered.1. Resident #8 had diagnoses including heart disease, diabetes, and left lower leg amputation. The Minimum Data Set (a resident assessment tool) dated 03/13/2026 documented Resident #8 was cognitively intact.Review of current physician orders revealed Resident #8 was prescribed the following: Oxycodone (a controlled medication used to treat pain) five (5) milligrams three (3) times daily, ordered on 01/08/2026 and discontinued on 04/13/2026. Oxycodone five (5) milligrams every eight (8) hours, ordered on 04/10/2026. Gabapentin (a medication used to treat nerve pain) 300 milligrams twice daily, ordered on 04/10/2026. Lispro insulin (a short-acting insulin used to treat high blood glucose levels) per sliding scale (a method of insulin administration where the dose is calculated based on a person's blood sugar level at that specific moment) every morning and at bedtime, ordered on 04/10/2026. Ipratropium-albuterol (an inhaled medication used to treat respiratory conditions) twice daily, ordered on 04/10/2026. Symbicort (a combination inhaler medication used to treat respiratory conditions) two (2) puffs twice daily, ordered on 04/10/2026.Review of Resident #8's Medication Administration Record from 03/01/2026 through 04/15/2026 revealed the following: Oxycodone five (5) milligrams was not administered thirteen (13) times during March 2026 and five (5) times between 04/01/2026 and 04/15/2026. Between 04/10/2026 and 04/13/2026, Resident #8 had two (2) active oxycodone orders and received doses under both orders, resulting in administration of a controlled medication in excess of the ordered frequency. During this timeframe, morning blood glucose monitoring and lispro insulin administration, scheduled between 7:00 AM and 10:00 AM, were not completed on three (3) occasions and on seven (7) occasions were completed/administered outside the ordered timeframe, including administration between 1:00 PM and 2:58 PM. On 03/28/2026 and 04/09/2026, blank entries (undocumented, empty spaces for specific dates and times where a medication signature, initial, or refusal code should have been recorded) on the Medication Administration Record indicated Resident #8 did not receive evening medications, including duloxetine (an antidepressant medication), propranolol (a medication used to treat heart conditions and blood pressure), blood glucose monitoring with lispro insulin, Lantus insulin (a long-acting insulin used to treat high blood glucose levels), acetaminophen (a medication used to treat pain and fever), gabapentin, Symbicort, tamsulosin (a medication used to treat urinary symptoms), melatonin (a medication used to assist with sleep), and ipratropium-albuterol.Review of Medication Administration Audits (system-generated audits from the electronic health record used to verify medication safety, compliance, and accuracy) from 02/01/2026 to 04/19/2026 identified Resident #8 had 411 occurrences where their medications were administered over one (1) hour late. Review of the Narcotic Count Sheet (a log used to track controlled medications) entries for Resident #8 revealed missing documentation for 8 occurrences in February 2026, 13 occurrences in March 2026, and 5 occurrences between 04/01/2026 and 04/10/2026. Between 04/11/2026 and 04/15/2026, Resident #8 received seven (7) additional doses of oxycodone with some doses administered three (3) hours apart, resulting in administration of a controlled substance medication in excess of the ordered frequency.Review of the facility records did not include documented evidence a medical provider was notified when medications were omitted or administered outside the ordered timeframe for Resident #8.During an interview on 04/15/2026 at 11:30 AM, Resident #8 stated they had yet to receive their medications scheduled for that morning. Resident #8 stated medications were frequently not administered as scheduled and reported delays in receiving medications, including morning medications at times received after 3:00 PM.During an interview on 04/16/2026 at 12:22 PM, Nurse Practitioner #1 stated Resident #8 should have had only one (1) active oxycodone order and the original order should have been discontinued.2. Resident #10 had diagnoses including diabetes, heart failure (a chronic condition where the heart cannot pump blood efficiently, causing fatigue, shortness of breath, and fluid retention), and respiratory failure (occurs when the lungs cannot adequately transfer oxygen to the blood or remove carbon dioxide, causing severe shortness of breath or low oxygen levels). The Minimum Data Set, dated [DATE] documented Resident #10 was cognitively intact. Review of current physician orders dated 04/11/2026 revealed Resident #10 was prescribed the following: Duloxetine (an antidepressant medication) 120 milligrams daily Lovenox (an anticoagulant medication used to prevent blood clots) 40 milligrams every twelve (12) hours Insulin Aspart (a short-acting insulin used to treat high blood glucose levels) eight (8) units before meals with sliding scale coverage Insulin Glargine (a long-acting insulin used to treat high blood glucose levels) 35 units twice daily Melatonin three (3) milligrams at bedtime Metoprolol Succinate (a medication used to treat high blood pressure) 50 milligrams daily Torsemide (a medication used to treat fluid retention) 20 milligrams daily Trazodone (an antidepressant medication) 50 milligrams at bedtimeReview of Resident #10's Medication Administration Records revealed: On 02/28/2026, 03/28/2026, and 04/09/2026, blank entries indicated Resident #10 did not receive evening medications, including blood glucose monitoring with insulin aspart, insulin glargine, Lovenox, melatonin, and trazodone. Between 03/11/2026 and 03/31/2026, there were seven (7) occurrences where morning medications were not administered (blank entries), including blood glucose monitoring with insulin aspart, insulin glargine, Lovenox, duloxetine, metoprolol, and torsemide.Review of Medication Administration Audits from 02/01/2026 to 04/19/2026 identified Resident #10 had 726 occurrences where their medications were administered over one (1) hour late.Review of the facility records did not include documented evidence a medical provider was notified when medications were omitted or administered outside the ordered timeframe for Resident #10.During an interview on 04/22/2026 at 11:22 AM, Resident #10 stated medications were not administered consistently and reported delays in receiving medications, including morning medications at times received after 1:00 PM. Resident #10 stated blood glucose monitoring and insulin administration often were not completed prior to meals.3. Resident #9 had diagnoses including seizure disorder (with recent seizure activity on 02/05/2026 and 02/28/2026), diabetes, and history of cerebrovascular accident (a condition where blood flow to the brain is interrupted). The Minimum Data Set, dated [DATE] documented the resident had severely impaired cognition.Review of current physician orders dated 04/11/2026 revealed Resident #9 was prescribed the following: Zonisamide (an anti-seizure medication used to control seizures) 1000 milligrams daily Amlodipine Besylate (a medication used to treat high blood pressure) five (5) milligrams daily Carvedilol (a medication used to treat high blood pressure) 25 milligrams twice daily Apixaban (an anticoagulant medication used to prevent blood clots) five (5) milligrams twice daily Levetiracetam (an anti-seizure medication used to control seizures) 1500 milligrams every twelve (12) hours Sertraline (an antidepressant medication) 50 milligrams daily Valproate Sodium (an anti-seizure medication used to control seizures) 375 milligrams three (3) times dailyReview of Resident #9's Medication Administration Records revealed: Between 02/06/2026 and 04/06/2026, there were eleven (11) occurrences where morning medications were not administered (blank entries), including anti-seizure medications and anticoagulant medication. Between 02/02/2026 and 04/11/2026, there were eleven (11) occurrences where evening medications were not administered (blank entries), including carvedilol, apixaban, levetiracetam, and valproate Sodium. Review of Medication Administration Audits from 02/01/2026 to 04/19/2026 identified Resident #9 had 331 occurrences where their medications were administered over one (1) hour late.Review of the facility records did not include documented evidence a medical provider was notified when medications were omitted or administered outside the ordered timeframe for Resident #9.4. Resident #12 had diagnoses including osteomyelitis (a bone infection), right ankle and foot, acquired absence of right great toe, and hypertension (high blood pressure). The Minimum Data Set, dated [DATE] documented Resident #12 was cognitively intact. Review of current physician orders revealed Resident #12 was prescribed the following: Amoxicillin-potassium clavulanate (an antibiotic medication used to treat infection) 875-125 milligrams every twelve (12) hours from 02/27/2026 through 03/13/2026, ordered on 02/27/2026. Hydralazine (a medication used to treat high blood pressure) 25 milligrams every eight (8) hours, ordered on 04/10/2026. Carvedilol 25 milligrams daily, ordered on 04/15/2026. Torsemide 40 milligrams daily, ordered on 04/15/2026. Gabapentin 100 milligrams three (3) times daily, ordered on 04/10/2026.Review of Resident #12's Medication Administration Records revealed: Between 02/27/2026 and 03/06/2026, there were six (6) occurrences where evening doses of Amoxicillin-Potassium Clavulanate were not administered. Between 03/01/2026 and 03/17/2026, there were six (6) occurrences where hydralazine was not administered. On 03/31/2026, blank entries indicated Resident #12 did not receive evening medications, including carvedilol, torsemide, and gabapentin.Review of the facility records did not include documented evidence a medical provider was notified when medications were omitted or administered outside the ordered timeframe for Resident #12.During an interview on 04/16/2026 at 12:22 PM, Nurse Practitioner #1 stated residents had reported medications were not administered as ordered and confirmed they had not been notified of medications that were omitted or administered outside ordered timeframes.During an interview on 04/17/2026 at 12:25 PM, the Medical Director stated medications must be administered as ordered. The Medical Director stated if residents do not receive prescribed medications they could die and the facility was potentially causing harm. During an interview on 04/16/2026 at 2:14 PM, Physician Assistant #1 stated nursing staff were expected to notify providers when medications were not administered and reported this did not consistently occur.During an interview on 04/22/2026 at 2:34 PM, the Administrator stated they were aware residents had not received medications through reports from residents, families, staff, internal audits, and corporate oversight, acknowledged nurses were not always able to administer medications within expected timeframes, and stated residents should receive their medications as prescribed. The Administrator stated nurses should have notified their supervisors and the medical providers when medications were omitted or administered outside ordered timeframes. Title 10 New York Codes, Rules and Regulations 415.12(m)(2)

Based on observations, interviews, and record review, the facility failed to ensure it was administered in a manner which enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility failed to ensure administrative systems, including staffing oversight, medication administration monitoring, and quality assurance processes, were implemented and functioning to identify and correct deficient practices, resulting in a pattern of noncompliance across multiple areas of care, including sufficient nursing staffing, medication administration, and enteral nutrition management.The findings include:The facility policy Quality Assurance and Performance Improvement Program reviewed 04/28/2025 documented the program was designed to support continuous evaluation of facility systems, ensure care delivery systems function consistently and accurately, identify issues and concerns, and develop and implement plans to correct identified areas. The facility policy Quality Assurance and Performance Improvement Committee last reviewed December 2022 documented the committee would meet monthly and additional meetings would be conducted as needed to address identified concerns. The facility policy Medication Administration dated December 2019 documented medications were to be administered in a safe and timely manner in accordance with physician orders. The Facility assessment dated [DATE] documented staffing would be adjusted based on resident acuity and included minimum staffing levels for each unit and shift. The facility was licensed for 124 beds with a daily census of approximately 120 to 122 residents during the survey period. Residents residing in the facility required services including medication administration, enteral nutrition (delivery of liquid nutrition through a tube into the stomach or intestine), wound care, and assistance with activities of daily living.Review of facility records identified systemic failures in care delivery. For additional information, see Centers for Medicare and Medicaid Services Form 2567, reference F725 (Sufficient Nursing Staffing), which identified the facility did not consistently meet minimum staffing levels and did not implement sufficient contingency staffing measures, resulting in missed medication administrations, delayed medication administration, and inability to complete ordered treatments. Review of medication administration audits from 02/01/2026 to 04/16/2026 identified 17 days in which 20 or more residents had missed medication administrations. Review of time punch records identified multiple shifts in which three (3) or fewer nurses were present in a facility with approximately 120 residents.For additional information, see Centers for Medicare and Medicaid Services Form 2567, reference F760 (Free of Significant Medication Errors), which identified clinically significant medication errors for 11 of 11 residents reviewed, including omissions of medications, medications administered outside ordered timeframes, and duplicate dosing of a controlled medication (medications regulated due to potential for misuse or dependence), with no documented evidence a medical provider was notified. Review of medication administration audits from 02/01/2026 to 04/19/2026 identified hundreds of occurrences of medications administered more than one (1) hour late for individual residents.For additional information, see Centers for Medicare and Medicaid Services Form 2567, reference F693 (Tube Feeding Management), which identified failure to administer prescribed enteral nutrition, including lack of documented evidence residents received prescribed feeding volumes, and an adverse outcome in which a resident required hospital transfer and treatment for dehydration.For additional information, see Centers for Medicare and Medicaid Services Form 2567, reference F868 (Quality Assurance and Performance Improvement), which identified the facility failed to ensure the Quality Assurance and Performance Improvement committee met at least quarterly, with a lapse of approximately five (5) months between meetings and lack of medical provider participation.During an interview on 04/16/2026 at 2:14 PM, Physician Assistant #1 stated they were aware of instances in which entire resident units did not receive medications and reported significant medications were not administered.During an interview on 04/17/2026 at 12:25 PM, the Medical Director stated one (1) nurse assigned to 40 to 42 residents was not safe and residents must receive medications as ordered.During an interview on 04/22/2026 at 2:34 PM, the Administrator stated they had been in the role since 02/09/2026 and acknowledged awareness of staffing concerns and missed or late medication administration. The Administrator stated residents and families reported not receiving medications and internal audits and corporate oversight identified missed medications. The Administrator stated reports were available on a dashboard and were expected to be reviewed by unit managers daily; however, there was only one (1) Director of Nursing available at times and unit manager positions were not consistently filled. The Administrator stated there were periods without an Assistant Director of Nursing, nurse managers, and nursing supervisors, and acknowledged difficulty maintaining staffing levels due to multiple staff departures. The Administrator stated the facility relied on agency staffing and ongoing recruitment efforts to address staffing shortages. The Administrator stated Quality Assurance and Performance Improvement meetings were conducted in March 2026 and after identification of issues related to enteral nutrition; however, the Medical Director was not present and there was no designated medical provider in attendance. The Administrator stated issues related to missed medications were sometimes identified through resident complaints, family reports, or external communication rather than through a consistent internal monitoring process.Title 10 New York Codes, Rules and Regulations 415.26

Based on record review and interview, the facility failed to ensure the Quality Assessment and Assurance committee met at least quarterly, in accordance with regulatory requirements. Specifically, the facility had a lapse of approximately five (5) months between scheduled meetings.The findings include:Review of the facility's Quality Assurance and Performance Improvement Program reviewed 04/28/2025 included the purpose, which was to support the continuous evaluation of facility systems with the objectives of ensuring care delivery systems function consistently, accurately, and incorporate current and evidence-based practice standards, where available; preventing deviation from care processes, to the extent possible; identifying issues and concerns with facility systems, as well as identifying opportunities for improvement; and developing and implementing plans to correct and/or improve identified areas.Review of the facility's Quality Assurance and Performance Improvement Committee policy last reviewed December 2022 indicated the committee will meet monthly at an appointed time, and special meetings may be called by the coordinator as needed to address issues that cannot be held until the next regularly scheduled meeting.Review of the facility's Quality Assurance and Performance Improvement Meeting Minutes and Sign-In Sheets for meetings held on 05/29/2025, 09/26/2025, 10/31/2025, and 03/24/2026 revealed a lapse of approximately five (5) months between the meeting held on 10/31/2025 and the meeting held on 03/24/2026. Additionally, there was an approximate four (4) month interval between the meetings held on 05/29/2025 and 09/26/2025.Further review of the meeting attendance records revealed no medical provider was in attendance at the meeting held on 03/24/2026.During an interview on 04/22/2026 at 2:34 PM, the Administrator stated they had been in the role since February 2026 and confirmed a Quality Assurance and Performance Improvement meeting was held at the end of March 2026. The Administrator did not identify any additional meetings held between October 2025 and March 2026.Title 10 New York Codes, Rules and Regulations 415.27(c)(1)

Based on observations and interviews conducted during the Recertification Survey from 01/06/2025 to 01/14/2025, for three (first, second, and third floors) of three resident-use floors and one of one basement, the facility did not provide housekeeping or maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, exhaust ventilation was not functional, ready stand lifts were dirty, there was wall and window damage, chairs were in disrepair, a microwave oven was dirty, an exit stairwell was dirty, and an exit door was not tight fitting into the door frame. The findings are: Observations on 01/07/2025 from 9:05 AM to 9:33 AM included the exhaust ventilation on the third floor was not functioning in the staff bathroom, bathrooms of resident rooms #319 and #322, and the soiled utility room. Significant foul odors were noted in each of these rooms and when a piece of paper was placed against the exhaust grates, no air draw was observed. During an interview at this time, the Maintenance Director stated the exhaust on the third floor was not working and it has been hard getting an electrician to make repairs. Observations on 01/07/2025 at 9:21 AM included a large section of the wall behind the bed in resident room [ROOM NUMBER] was damaged and a drawer at the base of the wardrobe in this room was missing. Observations on 01/07/2025 at 9:45 AM included two sit-to-stand lifts (mechanical lifts used to transfer residents) in the corridor outside resident rooms #201 and #219 were heavily soiled with brown residue, crumbs, and debris on the footrests. Observations on 01/07/2025 at 9:50 AM included three chairs in the second-floor dining room were chipped, cracked, and the cushions and armrests were damaged. Observations on 01/07/2025 at 10:00 AM included the interior of the microwave oven in the second-floor clean utility room was heavily soiled with food splatter and debris. Observations on 01/07/2025 at 10:10 AM included the inside of the first floor south exit stairwell had a large amount of spiderwebs and dead bugs on the floor. Observations on 01/07/2025 at 10:50 AM included an approximately one to one and a half-inch gap below and around the lower edge of the exit discharge door from the first floor leading to the back parking lot near the medical waste storage room. Observations on 01/10/2025 at 12:47 PM included duct tape and heat tape around the windows in resident room [ROOM NUMBER] was peeling off and cold air could be felt coming through small openings around the edges of the windows. Additionally, in this room there was an approximately two-foot by one-foot section of the wall behind the bed closest to the window that was cracked, peeling, and damaged. 10 NYCRR: 415.29, 415.29(c), 415.29(e)(3), 415.29(h)(1)(2), 415.29(i)(1), 415.29(j)(1)

Based on interviews and record reviews conducted during the Recertification Survey from 01/06/2025 to 01/14/2025, for six (Residents #34, #36, #44, #70, #71, and #92) of six residents reviewed, the facility did not ensure that concerns voiced by residents during Resident Council meetings related to resident care and life in the facility were responded to and a rationale given for the response. Specifically, during a special Resident Council meeting, multiple residents voiced multiple care concerns that they felt had not been followed up on. Review of the previous six months of meeting minutes did not include any follow ups, resolution, or a rationale for lack of resolution to the resident's concerns. This is evidenced by the following: During a special Resident Council meeting on 01/07/2025 at 2:00 PM, with six residents present, it was reported that appropriate silverware was not provided to residents for meals instead utensils that were plastic, miniature in size, and often broke in half while using. Residents reported lack of linens, not being allowed to go outside without permission, roommate issues, being treated by staff in an undignified manner, and call lights not being answered timely (up to one hour). Residents reported the facility did not follow up on their concerns (when brought up in the Resident Council meetings) and they were not given an explanation as to why they had not been addressed. Review of the previous six months of meeting minutes revealed residents had voiced issues such as a shortage of linen, regular use of plastic silverware during meals, cold food temperatures, lack of permission to go outside unescorted, staff using inappropriate language (swearing), and missing clothing. The meeting minutes did not include any follow-up done by the facility related to the resident's voiced concerns. During an interview on 01/08/2025 at 10:05 AM, the Director of Recreation stated complaints were addressed, but they did not document this anywhere. The Director of Recreation also stated they did not manually or electronically maintain records of resident concerns, follow-ups, or updates, but that it was facility protocol that minutes from the previous months should be reviewed at the beginning of every meeting before opening the meeting for new concerns. Concerns that are voiced at the meeting should be followed up on and a concern/response form filled out by the designated staff representative and addressed to the corresponding department heads to provide a resolution. Additionally, residents who expressed a concern should be provided with a resident notification summary form, providing a summary of concern stated and the resolution given by the department head. The Director of Recreation was unable to provide any documented evidence that the concerns recorded in the previous six meeting minutes had been followed up on. During an interview on 01/14/2025 at 1:45 PM, the Administrator stated that when concerns are expressed during Resident Council meetings the directors present at the meetings should document the concerns and follow ups and outcomes discussed at the next meeting. The Administrator stated that the follow up process is not currently documented anywhere that they were aware of. 10 NYCRR 415.5 (c)(6)

Based on observation, interviews, and record review conducted during the Recertification Survey from 01/06/2025 to 01/14/2025 the facility did not ensure they established and maintained an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 (Residents #34, #45, and #99) of 24 of residents reviewed. Specifically, appropriate Personal Protective Equipment (PPE) was not worn by nursing staff in residents' room that were identified by the facility as requiring Enhanced Barrier Precautions while preforming high contact care to residents. Additionally, observations of multiple facility staff who had declined the influenza vaccine were not wearing face masks while in resident care areas during the current influenza season as determined by the Department of Health. The facility policy Enhanced Barrier Precautions, dated 05/30/2024, documented Enhanced Barrier Precautions would be initiated and implemented for residents as applicable in accordance with federal and/or state regulations and/or in accordance with Centers for Disease Control guidance to reduce the risks of transmission of Multiple Drug-Resistant Organisms. Enhanced Barrier Precautions is applicable for resident with any of the following: a. Infection or colonization with a Multiple Drug-Resistant Organisms. b. Wounds (e.g. any type of wound requiring a dressing) c. Indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.) Issue 1 1. Resident #34 had diagnoses that included cerebral palsy, peripheral vascular disease, and non-pressure related chronic ulcers/wounds. The Minimum Data Set Resident Assessment, dated 10/02/2024, documented the resident was cognitively intact. Review of Resident #34's current Comprehensive Care Plan, created 07/12/2024, revealed the resident was at risk for infection and multi drug-resistant organisms (MDRO) and was on Enhanced Barrier Precautions due to multiple wounds to both lower extremities (calf, ankles, feet). Staff were to wear Personal Protective Equipment (gown and gloves) when providing high contact resident care including dressing, bathing/showering, transferring, linen change, providing personal hygiene, changing briefs, and wound care. During an observation on 01/08/2025 at 12:14 PM, Resident #34 had an Enhanced Barrier Precaution sign hanging at eye level at the entrance to their room. Licensed Practical Nurse #3, wearing gloves but no gown, provided wound care to Resident #34 that included wounds on both lower extremities. Wound care included removal of soiled dressings, cleansing the wounds, applying creams, and redressing wounds. 2. Resident #45 had diagnoses that included encephalopathy (disease of the brain that may cause confusion), urinary retention (unable to void), and benign prostatic hyperplasia (enlarged prostate). The Minimum Data Set Resident Assessment, dated 12/12/2024, documented the resident had severely impaired cognitive function and a stage 3 (full thickness tissue loss) pressure ulcer. Review of Resident #45 Comprehensive Care Plan, dated 12/05/2024, revealed the resident had an alteration in skin integrity related to an actual pressure ulcer and an indwelling urinary catheter. The Comprehensive Care Plan did not include that Resident #45 was on Enhanced Barrier Precautions. During an observation on 01/10/2025 at 10:10 AM, the Director of Nursing, Registered Nurse Supervisor #2, and Certified Nursing Assistant #5 entered Resident #45 room. An Enhanced Barrier Precaution sign was hanging at the entrance to Resident #45's room. Certified Nursing Assistant #5 and Registered Nurse #2, wearing gloves but no gowns, repositioned the resident and removed their clothing. The Director of Nursing, wearing gloves but no gown, removed the wound/ulcer dressing and measured and assessed the wound/ulcer with their gloved hands. During an interview on 01/10/2025 at 11:03 AM, the Director of Nursing stated Personal Protective Equipment including gown, gloves, and mask should be worn in residents' rooms who are on Enhanced Barrier Precautions. The Director of Nursing stated they should have worn full Personal Protective Equipment in Resident #45 room when assessing and dressing the pressure ulcer. 3. Resident #99 had diagnoses that included a stroke, dysphagia (unable to swallow) requiring a feeding tube, and a stage 3 pressure ulcer. The Minimum Data Set Resident Assessment, dated 12/18/2024, documented the resident was severely impaired of cognitive function and had a pressure ulcer and a feeding tube (surgically inserted tube directly into the stomach via the abdomen to administer nutrition). Review of Resident #99's current Comprehensive Care Plan, dated 07/12/2024, revealed the resident was on Enhanced Barrier Precautions due to a colonized multi drug-resistant organism (MDRO) methicillin resistant staphylococcus aureus (MRSA) and for staff to wear Personal Protective Equipment (gown and gloves) when providing high contact care to residents including dressing, bathing/showering, transferring, providing hygiene, changing briefs, device care (feeding tube), and wound care. During an observation on 01/10/2025 at 4:52 PM, Licensed Practical Nurse #3 entered Resident #99's room without performing hand hygiene and applied gloves but no gown. There was no Enhanced Barrier Precaution signage outside of Resident #99's room and no Personal Protective Equipment was easily accessible outside the resident's room. Licensed Practical Nurse #3 checked the resident's blood glucose (using a finger prick to test the resident's blood glucose level) and then administered tube feeding. During an interview on 01/13/2024 at 10:04 AM, Register Nurse Manager #2 stated residents with catheters, feeding tubes, or anything that is a possible point of entry for an infection should be placed on Enhanced Barrier Precautions. Registered Nurse Manager #1 stated with any hands-on care provided to residents, staff should wear gowns, gloves, and masks. Registered Nurse Manager #1 stated that Resident #99 was on Enhanced Barrier Precautions related to having a gastrostomy (feeding) tube. Registered Nurse Manager #2 stated they were not aware who was responsible for placing Enhanced Barrier Precaution signage or placing Personal Protective Equipment by residents' rooms. During an interview on 1/14/25 at 9:55 AM, Licensed Practical Nurse Manager #3 stated they provide wound care to residents on Enhanced Barrier Precautions and should wear Personal Protective Equipment (gown and gloves), but the gowns are so hot, they do not always wear the gowns. During an interview on 01/13/2025 at 10:49 AM, the Director of Nursing stated any resident with a wound or a feeding tube should be on Enhanced Barrier Precautions. The Director of Nursing stated the Assistant Director of Nursing who was the Infection Preventionist recently quit. The Director of Nursing stated Resident #99 should have been on Enhanced Barrier Precautions. Issue 2 The facility policy Influenza Vaccine, dated 08/22/2024, documented that staff will provide consent or declination for the influenza vaccine each year. Individuals refusing the vaccination may be required to wear a standard face mask in resident care areas throughout influenza season, as defined and required by the state Department of Health. Review of the employee influenza, pneumococcal, and covid-19 vaccination status list provided by the facility listed 10 randomly picked employees from all departments and their vaccination status. Nine of the ten employees listed included they had declined the flu vaccine. During an observation and interview on 01/13/2025 at 4:23 PM on 2nd floor residential care unit, Certified Nursing Assistant #8 was in the dining room with six residents and was not wearing a face mask. Certified Nursing Assistant #8 stated they had declined the flu vaccine this year and knew that they should wear a mask in resident care areas during influenza season, but were not aware that influenza season had started. During an observation and interview on 01/13/2025 at 4:31 PM on the 3rd floor residential care unit, License Practical Nurse #1 was at the medication cart outside the main dining room and was not wearing a mask. Licensed Practical Nurse #1 stated they were unsure if they got the influenza vaccine this year. Review of the signed declination form declining the influenza vaccine with License Practical Nurse #1 at this time, License Practical Nurse #1 stated they should be wearing a mask. During an interview on 1/14/2025 at 9:32 AM, the Regional Director of Clinical Services stated staff are trained on Infection Control policies including Enhanced Barrier Precautions during orientation, with any policy change, or for education to meet a correctional plan. The Regional Director of Clinical Services stated an automated text message and voice message is sent out to all employees notifying them of influenza season. Employees that decline the influenza vaccine should be wearing a face mask in resident care areas. 415.19(a)(b)(1-3)

NY00352644 NY00348465 Based on observations, interviews, and record review conducted during the Recertification Survey from 01/06/2025 to 01/14/2025, for three (Residents #9, #47, and #96) of 15 residents reviewed, the facility did ensure that each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, all residents were observed being served meals using disposable cutlery (plastic utensils) and dishware (paper/plastic plates) and stated it was ongoing. This was evidenced by the following: Review of the facility policy, Quality of Life/Dignity, dated 05/28/2024, documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents shall be treated with dignity and respect at all times. 1. Resident #9 had diagnoses including anxiety, depression, and obesity. The Minimum Data Set Resident Assessment, dated 10/20/2024, documented the resident was cognitively intact, had no behaviors, and required set up assistance with eating. Review of the Comprehensive Care Plan, dated 09/13/2024, revealed Resident #9 had a nutritional problem or potential nutritional problems related to being at risk for malnutrition and inadequate intake. The care plan did not include a need for disposable dishware or utensils During an observation on 01/06/2025 at 12:57 PM, Resident #9 received plastic utensils and beverages (coffee, juice, and water) were in plastic cups during the lunch meal. During an interview on 01/06/2025 at 1:07 PM, Resident #9 stated their meals were served on paper plates with plastic utensils which made eating difficult because they could not cut their food well and it fell off the utensils casusing the food to get cold faster. 2. Resident #96 had diagnoses including depression, obesity, and emphysema. The Minimum Data Set Resident Assessment, dated 12/10/2024, documented the resident was cognitively intact, had no behaviors, and required partial/moderate assistance with eating. Review of the Comprehensive Care Plan, dated 08/26/2024, Revealed resident #96 had a nutritional problem or potential nutritional problem related to being at risk for malnutrition, significant weight gain, depression, and obesity. The care plan did not include a need for disposable cutlery and/or dishware. During an observation on 01/06/25 at 1:12 PM, Resident #96's meal was served with plastic cups, utensils, and paper plates. In an immediate interview the resident stated their food usually came on a paper or plastic plate and made them feel like they were in jail which was dehumanizing. 3. Resident #47 had diagnoses including dementia, diabetes, and schizophrenia. The Minimum Data Set Resident Assessment, dated 11/27/2024, documented the resident was rarely/never understood, had no behaviors, and required substantial/maximal assistance with eating. Review of the current Comprehensive Care Plan, dated 04/17/2024, revealed Resident #47 had a potential for altered nutrition related to at risk for malnutrition, significant weight loss and dysphagia (difficulty swallowing). Interventions included, but were not limited to, regular diet with ground minced moist consistency and thin liquids. The care plan did not include a need for disposable cutlery and/or dishware. During an observation on 01/08/2025 at 9:54 AM, Resident #47 was eating breakfast independently in the dining room with a pureed consistency meal on a paper plate and plastic utensils on their tray. The resident's meal ticket did not include disposable cutlery or dishware. During an observation on 01/06/2025 at 8:51 AM, breakfast tray line was in progress, with service to the second and third units. Plastic utensils were being placed on resident meal trays and there were no metal utensils on the tray line. During an interview on 01/06/2025 at 8:55 AM, Dietary Aide #1 stated plastic utensils were being used because there were not enough metal utensils. During an interview on 01/06/2025 at 9:30 AM, [NAME] #1 stated plastic and paper products were being used because there was not enough metal utensils. They stated when metal utensils, cereal bowls, and coffee mugs were in stock, the items went out and never came back. [NAME] #1 stated residents may have been hoarding them or they were getting thrown out. During an interview on 01/13/2025 at 3:21 PM, Food Service Director #1 stated the facility used the paper plates and plastic utensils because they have a few residents who had something in their urine. They had a list of the residents whose diet plans included to have disposable products. At that time, Food Service Director #1 provided a list of three residents (Residents #78, #87, and #94) that required paper/plastic dishware. During an interview on 01/14/2025 at 12:36 PM, Director of Nursing #1 stated it was brought to their attention there was a large quantity of paper plates and plastic utensils used throughout the building (at mealtimes) and were only aware of one resident who was to receive paper products for a behavioral issue. They were not aware of any other reason for residents to be receiving paper or plastic. During an interview on 01/14/2025 at 1:45 PM, Administrator #1 stated they were not aware that multiple residents had received paper products and plastic utensils. 10 NYCRR 415.5(a)

Based on interviews and record review conducted during the Recertification Survey from 01/06/2025 to 01/14/2025, for four (Resident #31, #53, #99 and #220) of seven residents reviewed, the facility did not ensure that a comprehensive assessment of residents' needs, strengths, goals, life history, and preferences were conducted per the regulatory timeframes using the Centers for Medicare and Medicaid Services specified Resident Assessment Instrument (RAI) process. Specifically, Residents #53 and #220 did not have their comprehensive admission assessments completed within 14 calendar days of admission, and Resident #99 did not have their comprehensive assessment completed within 14 calendar days of the assessment reference date. This is evidence by the following: The State Operations Manual and the Resident Assessment Instrument (Minimum Data Set Resident Assessment) Manual 3.0 include facilities, at a minimum, are required to complete a comprehensive assessment (Minimum Data Set Resident Assessment) of each resident within 14 calendar days after admission to the facility. Additionally, the Resident Assessment Instrument Manual 3.0 included annual comprehensive assessments are required to be completed no later than 14 days after the assessment reference date. The facility policy Minimum Data Set (MDS) Completion and Submission, dated August 2024, included the facility would conduct and submit resident assessments in accordance with federal and state submission timeframes. An admission assessment completion date would be the admitted plus 13 calendar days. An annual assessment completion date would be the assessment reference date plus 14 calendar days. 1. Resident #53 was admitted to the facility on [DATE] with diagnoses including anxiety, diabetes, and post-traumatic stress disorder. The admission Minimum Data Set Resident Assessment, dated 11/21/2024, was not completed until 12/05/2024 (21 calendar days after admission). 2. Resident #220 was admitted to the facility on [DATE] with diagnoses including acute kidney failure, chronic obstructive pulmonary disease (a long-term lung disease that makes it hard to breathe), and malignant neoplasm (cancer) of the bladder. The admission Minimum Data Set Resident Assessment, dated 12/27/2024, was not completed until 01/07/2025 (18 calendar days after admission). 3. Resident #99 had diagnoses that included stroke, diabetes, and pressure ulcers. The annual Minimum Data Set Resident Assessment, dated 12/18/2024, was not completed until 01/07/2025 (20 calendar days after the Assessment Reference Date). During an interview on 01/14/2025 at 9:03 AM with Minimum Data Set Coordinator #1 and Minimum Data Set Coordinator #2, Minimum Data Set Coordinator #1 stated their role consisted of reading and gathering (resident information) to complete sections of the Minimum Data Set Resident Assessments. Minimum Data Set Coordinator #1 stated they had 14 days to finish an admission Minimum Data Set Resident Assessment and had 21 days (from admitted ) to submit the assessments to the Centers for Medicare and Medicaid. Minimum Data Set Coordinator #1 stated once all the sections were completed, they would email the corporate Registered Nurse Minimum Data Set Coordinator, who would review, complete, sign, and submit the assessments. During review at this time, Minimum Data Set Coordinator #1 stated Resident #53's admission Minimum Data Set Resident Assessment, dated 11/21/2024, and Resident #99's annual Minimum Data Set Resident Assessment, dated 12/18/2024, were not completed timely and did not know why. Minimum Data Set Coordinator #2 stated corporate staff were responsible for opening (initiating) and submitting all the Minimum Data Set Resident Assessments to the Centers for Medicare and Medicaid. Minimum Data Set Coordinator #1 stated the timely completion and submission of assessments had an impact on resident care because they helped to build a resident's care plan. During an interview on 01/14/2025 at 12:36 PM, Director of Nursing #1 stated the Minimum Data Set Nurse Coordinators did not report to them and they did not know when the assessments should be completed or submitted. During an interview on 01/14/2025 at 1:45 PM, Administrator #1 stated they were not aware of any issues related to Minimum Data Set Resident Assessments not being completed timely. 10 NYCRR 415.11(a)(3)(i)

Based on interviews and record review conducted during the Recertification Survey from 01/06/2025 to 01/14/2025, the facility did not ensure each resident received the influenza or the pneumococcal immunizations (vaccine) for two (Resident #8 and #74) of five residents reviewed. Specifically, the facility was unable to provide any evidence the residents or their representatives had been provided educational material, been offered, or declined the immunizations. The facility policy Infection Control-Influenza Vaccine/Pneumococcal Vaccine, dated 11/24/2024, documented that all residents and/or the resident representative will be offered and provided influenza vaccine and pneumococcal vaccine. Residents have the opportunity to refuse the vaccine. A resident's refusal of the vaccine shall be documented on the informed consent for influenza vaccine and pneumococcal vaccine and placed in the resident's medical record and will include that the resident or resident's representative was provided education regarding the benefits and potential side effects of the vaccine. 1. Resident #8 had diagnoses that included dementia, encephalopathy (disease of the brain that can cause confusion), hypertension, and atrial fibrillation (irregular heartbeat). The Minimum Data Set Resident Assessment, dated 11/06/2024, documented that Resident #8 had severely impaired cognition and listed their spouse as their Health Care Proxy. Review of Resident #8 electronic medical record revealed under immunizations the pneumococcal vaccine had been refused. The facility was unable to provide any documentation that educational material regarding the benefits and potential side effects of the vaccine had been provided to the resident's Health Care Proxy or a declination of the vaccine completed and signed or refused. 2. Resident #74 had diagnoses that included hypertension, atrial fibrillation, and neuromuscular dysfunction of the bladder. The Minimum Data Set Resident Assessment, dated 10/09/2024, documented Resident #74 was cognitively intact. Review of Resident #74's electronic medical record revealed under immunizations that the influenza and pneumococcal vaccines had been refused. The facility was unable to provide any documentation that educational material regarding the benefits and potential side effects of the vaccine had been offered to Resident #74 or a declination of the vaccines had been completed and signed or refused. During an interview on 1/14/2025 at 12:10 PM, Licensed Practical Nurse Manager #1 stated they did not take part in the influenza vaccination initiative this season, it was the Assistant Director of Nursing who did. Licensed Practical Nurse Manager #1 stated they were not sure how declinations of the vaccines are managed. During an interview on 1/10/2025 at 11:03 AM, the Regional Director of Clinical Services (acting Infection Preventionist) stated an automated call is made from the facility to all residents Health Care Proxy's that influenza vaccines are being offered and the Unit Managers were responsible to reach out to residents and resident's Health Care Proxys for consent or declination. 10 NYCRR 415.19(a)(3)

Based on observations and interviews conducted during the Recertification Survey from 01/06/2025 to 01/14/2025, the facility did not ensure that all drugs and biologicals were properly stored in accordance with State and Federal Laws for three (Unit Three medication cart North, Unit Three medication cart South, Unit Two medication cart North) of three medication carts reviewed. Specifically, multiple medication carts contained several insulin pens labeled by pharmacy to refrigerate until opened that were unopened and stored in the medication carts and a vial of insulin stored in the medication cart that was not opened. Additionally, two nicotine patches were observed stuck to the shower room wall and an opened insulin was observed at a resident's bedside. This evidenced by the following: The facility policy Medication Storage, dated January 2019, documented that medication will be stored in a manner that maintains the integrity of the product, ensures the safety of the residents, and is in accordance with Department of health guidelines. During observation on 01/06/2025 at 9:20 AM, in resident room [ROOM NUMBER]b there was an opened vial of insulin (needle attached) on the resident's bedside stand. Resident #70 stated the nurse must have left it there. During an immediate interview, Licensed Practical Nurse #7 stated they had become distracted and forgot to grab the insulin pen when leaving the room. During an observation on 01/07/2025 at 10:35 AM, the Unit Three medication cart North contained four insulin pens that were unopened and unrefrigerated. All four pens had pharmacy instruction labels on them to refrigerate until opened. Three of the insulin pens had resident identifiers on them. During an interview at the time, Licensed Practical Nurse #1 stated each resident-specific medication should have a label that included resident identifiers, and insulin should be labeled with an open and expiration date or remain refrigerated until ready for use. During an observation on 01/07/2025 at 10:51 AM, the Unit Three medication cart South contained four insulin pens labeled with resident identifiers that were unopened, unrefrigerated, and labeled with orange pharmacy stickers that read refrigerate until opened. In addition, the cart contained an unopened oral solution of gabapentin (anti-seizure medication) that was labeled with resident identifiers and an orange pharmacy sticker that read refrigerate until opened. During an immediate interview, Licensed Practical Nurse #2 stated opened insulin should be refrigerated until ready for use and it should be dated once opened. During observations on 01/07/2025 11:25 AM, the Unit Two medication cart South contained a vial of insulin that was unopened and unrefrigerated. During an interview on 01/08/2025 at approximately 2:00 PM, Licensed Practical Nurse Manager #1 stated the protocol for medication storage and labeling is to refrigerate medications that specify the requirement, and that once it is opened, it should be dated. Licensed Practical Nurse Manager #1 stated that Licensed Practical Nurses should locate a manager for advisement on unlabeled and improperly stored medications and that cart audits should include checks for this. During an observation on 01/13/2025 in the Unit Two shower room, there were two used nicotine patches, dated 12/09/2024 and 12/30/2025, stuck to the shower wall. During an immediate interview, Licensed Practical Nurse Manager #1 stated they were unaware of why anyone would leave the patches there and proceeded to pull three more used patches off the wall. Licensed Practical Nurse Manager #1 stated the patches should be discarded by whomever removed them from the resident in the sharps containers on the medication carts. Licensed Practical Nurse Manager #1 also stated it was most likely the Certified Nursing Assistants removing them during resident showers. 10 NYCRR 415.18 (e) (1-4)

Based on observations, interviews, and record review conducted during the Recertification Survey from 01/06/2025 to 01/14/2025, for one (Resident #99) of one resident reviewed, the facility did not ensure a resident maintained acceptable parameters of nutritional status and was offered sufficient fluid intake to maintain proper hydration and health. Specifically, the facility could not provide documented evidence for a resident that required total nutrition and hydration via a gastrostomy tube (the delivery of nutrients through a feeding tube directly into the stomach also referred to as an enteral feeding) was provided nutritional and hydration care and services consistent with the resident's comprehensive assessment. Additionally, Resident #99's Medication Administration Record was missing documentation and had documentation that did not correlate with medical orders or the Registered Dietitian recommendations for tube feed and water flush administration. This was evidenced by the following: Review of the facility policy Enteral Feedings, dated February 2023, included when administering enteral nutrition therapy (tube feeding), the nurse should verify the physician order and documentation was to include, but not limited to, the type and amount of the enteral feeding. Review of the facility policy Intake and Output, dated December 2019, documented Clinical Services personnel would maintain a record of intake and output in keeping with physician orders for residents requiring monitoring. The nurse should verify the physician's order, review the resident's care plan to assess for any special needs, total the amounts of all liquids consumed, and record all fluid intake on the intake record. Resident #99 had diagnoses that included dysphagia (swallowing difficulty), malnutrition, and diabetes. The Minimum Data Set Resident Assessment, dated 10/30/2024, documented the resident had severe cognitive impairment, had weight loss, and was not on a physician-prescribed weight-loss regimen, had a feeding tube, and received 51% or more of total calories and 501 cubic centimeters per day or more fluid intake per day by tube feeding. Current physician's orders included, but were not limited to: - Enteral Feed Order, initiated on 12/11/2024, Glucerna 1.5 via enteral gastrostomy tube bolus (the administration of a limited volume of enteral formula over brief periods of time) 474 milliliters to be administered three times a day at 9 AM, 1 PM, and 5 PM. - Enteral Feed Order, initiated on 12/11/2024, Glucerna 1.5 via enteral gastrostomy tube bolus 237 milliliters to be administered one time a day at 9 PM - Enteral Feed Order, initiated on 12/11/2024, administer 150 milliliters of water every six hours via enteral tube four times a day. - Enteral Feed Order, initiated on 12/11/2024, administer 80 (water) milliliters before and after tube feeding administration four times daily. Review of the current Comprehensive Care Plan, initiated 08/09/2024, revealed Resident #99 had a nutritional problem related to severe malnutrition, a gastrostomy tube in place, received tube feeding, and had significant weight loss times six months. Interventions included, but were not limited to, administer tube feeding and water flushes per Registered Dietitian recommendation and medical doctor orders, Glucerna 1.5 calories via enteral tube gastrostomy tube 474 milliliters to be administered at 9 AM, 1 PM, 5 PM, and 237 milliliters at 9 PM, total tube feeding to equal 1659 milliliters, and flush with 80 (water) milliliters before and after bolus feeds (640 milliliters) and 150 milliliters every six hours (600 milliliters). Total fluids to equal 2500 milliliters. Review of Resident #99's December 2025 Medication Administration Record revealed the following: - On 12/13/2024 and 12/14/2024 at 6 AM, there were blanks (no documentation that it was administered) in the record for 150 milliliters of water. - On 12/17/2024 at 9 PM, there was a blank in the record for Glucerna 1.5 administer 237 milliliters and 80 (water) milliliters before and after tube feed administration. - For the Enteral Feed Order, initiated on 12/11/2024, administer 80 milliliters before and after (total 160 milliliters) tube feeding administration four times daily; it was documented that 80 milliliters was administered at 9 AM for 17 of 20 opportunities, at 1 PM for 16 of 20 opportunities, at 5 PM for 12 of 21 opportunities, and at 9 PM for 10 of 21 opportunities. On 12/30/2024, it was documented that zero milliliters was administered. - For the Enteral Feed Order, initiated on 12/11/2024, Glucerna 1.5 via enteral gastrostomy tube bolus 474 milliliters to be administered three times a day at 9 AM, 1 PM, and 5 PM; it was documented that 237 milliliters was administered at 9 AM for seven of 20 opportunities (on 12/16/2024 it was documented that 447 milliliters was administered), at 1 PM for eight of 19 opportunities, and at 5 PM for five of 20 opportunities. Review of Resident #99's January 2025 Medication Administration Record from 01/01/2025 to 01/08/2025, revealed the following: - For the Enteral Feed Order, initiated on 12/11/2024, administer 80 milliliters before and after (total 160 milliliters) tube feeding administration four times daily; it was documented that 80 milliliters was administered at 9 AM for five of eight opportunities, at 1 PM for four of eight opportunities, at 5 PM for three of seven opportunities, and at 9 PM for three of seven opportunities. - For the Enteral Feed Order, initiated on 12/11/2024, Glucerna 1.5 via enteral gastrostomy tube bolus 474 milliliters to be administered three times a day at 9 AM, 1 PM, and 5 PM; it was documented that 237 milliliters was administered at 5 PM for two of seven opportunities. During an observation and interview on 01/10/2025 at 8:47 AM, Licensed Practical Nurse #1 stated (while demonstrating) the process for documenting Resident #99's fluid intake was done by entering the milliliter amount in the electronic health record for each separate enteral feeding order. Licensed Practical Nurse #1 stated all intake documentation was completed in the electronic health record. During interviews conducted on 01/13/2025 at 10:49 AM and 1:33 PM, Director of Nursing #1 stated they thought the Registered Dietitian would be responsible for monitoring fluid intake records, but needed to clarify. They stated there was no clinical nutrition support currently in the facility and a remote Registered Dietitian was being utilized. At 1:33 PM, Director of Nursing #1 stated the Registered Dietitian monitored the intake records and managed tube feeding orders. During an interview on 01/14/2025 at 10:55 AM, Registered Nurse Manager #1 stated the nurses documented the total amount administered on the electronic Medication Administration Record for residents who received tube feeds and water flushes. If the amount documented was less than or more than what was ordered, there could be adverse effects such as electrolyte imbalances, dehydration, and diarrhea. Registered Nurse Manager #1 stated they would expect the volume of tube feed and flushes be documented accurately because the documentation would assist providers with addressing a resident's medical concern. During a telephone interview on 01/13/2025 at 3:43 PM, Registered Dietitian #1 stated they only worked remotely to cover until the facility filled the Registered Dietitian position. There was no clinical nutrition support on-site and they monitored fluid intakes for residents who received tube feeds by reviewing the electronic Medication Administration Record documentation. Registered Dietitian #1 stated they would expect if a resident was to receive 80 milliliters (water) before and after the tube feed, a total of 160 milliliters should be documented. If two, 237 milliliters cartons of enteral feeding were administered, a total of 474 milliliters should be documented. Registered Dietician #1 stated they reviewed Resident #99's tube feed intakes monthly and when the December 2024 Medication Administration Record was reviewed, they did not notice any discrepancies for the tube feed or flushes. During a follow-up telephone interview on 01/14/2025 at 12:28 PM, Registered Dietician #1 reviewed the December 2024 Medication Administration Record and stated they noticed the discrepancies and assumed the nurses were following the medical orders. During an interview on 01/14/25 at 1:45 PM, Administrator #1 stated they were not aware tube feeds and flushes were not being documented according to the physician's orders. 10 NYCRR 415.12(i)(1)

Based on observations, interviews, and record review conducted during the Recertification Survey from 01/06/2025 to 01/14/2025, for one (Resident #45) of one resident reviewed, the facility did not ensure the resident received the necessary care, treatment, and services consistent with professional standards of practice to promote healing, prevent new pressure ulcers from developing, and/or prevent existing pressure ulcers from worsening. Specifically, Resident #45 did not receive a thorough wound assessment upon re-admission to the facility after a hospitalization with a pressure ulcer and no pressure ulcer care or treatments were documented as provided for multiple days. This is evidenced by the following: The facility policy Wound Identification and Wound Rounds, last revised 11/06/2023, included the facility will identify, assess, and manage residents with pressure injuries, skin alterations, impairments, or wounds in accordance with current standards of practice. New admissions and re-admissions will have a complete body examination to identify any pressure injuries, skin alterations, impairments, or wounds. Upon discovery of a skin impairment, the registered nurse completes a skin assessment, including documentation of size, depth, stage if applicable, and appearance of the skin impairment. The licensed nurse will notify the health care provider and obtain a treatment order utilizing the Centers Wound Care Guidelines. The wound nurse/designee, wound care provider, and registered dietician are notified of pressure ulcer or skin impairment and the resident is scheduled for weekly wound rounds. Resident #45 was recently readmitted to the facility following a hospital stay with diagnoses that included high blood pressure, diabetes, and heart failure. The Minimum Data Set Resident Assessment, dated 12/12/2024 (prior to recent hospitalization ), documented Resident #45 was cognitively intact, at risk for pressure ulcers, and had a pressure ulcer at that time. Review of the hospital After Visit Summary (a document that summarizes a patient's hospital stay and is given to them at time of discharge that includes medications, treatments, and recommendations from the hospital) revealed Resident #45 had a wound to the left trochanter (hip) and recommendations for wound care treatment. Review of Resident #45's Comprehensive Care Plan, effective 12/05/2024, revealed the resident had a pressure injury (ulcer) and included interventions for staff to evaluate the wound weekly and monitor the dressing daily. There was no evidence the care plan had been revised to include a pressure ulcer following Resident #45's recent re-admission from the hospital. During an interview on 01/06/2025 at 3:11 PM, Resident #45 stated they had a pressure ulcer on their left hip and were not receiving dressing changes to it. Review of physician's orders from hospital discharge on 01/07/2025 revealed no orders for wound care to the left trochanter. The Admission/Readmission Evaluation Part One Skin Assessment, signed on 01/03/2025 by Registered Nurse #2, documented that Resident #45 had a stage two pressure ulcer to the left trochanter (hip). The assessment did not include the size, depth, appearance or treatment of the pressure ulcer. During an observation of morning care with Certified Nursing Assistant #9 on 01/08/2025 at 9:29 AM, Resident #45 had an unlabeled and undated adhesive dressing to the left trochanter. Licensed Practical Nurse #9 was notified and removed the dressing which revealed an open area approximately two inches by one inch with a moderate amount of yellow drainage. During an interview at this time, Licensed Practical Nurse #9 stated they did not know what was under the dressing on Resident #45 and did not know if the resident had any ordered treatments to the left hip. During an interview on 01/08/2025 at 2:50 PM with Certified Nursing Assistant #1 and Certified Nursing Assistant #2, Certified Nursing Assistant #2 stated certified nursing assistants should notify the nurse of any new wounds when care was provided and that they were not assigned to Resident #45. During an interview on 01/08/2025 at 3:56 PM, Licensed Practical Nurse #8 stated certified nursing assistants should notify them of any new skin impairments and they should then notify the registered nurse. If nursing saw an undated dressing, they should check the orders for what treatment to provide and if there was no order, they should notify the nursing supervisor or manager to get an order for wound care treatment. During an interview on 01/10/2025 at 9:09 AM, Registered Nurse #2 stated they were responsible for reviewing the hospital's After Visit Summary for residents who were admitted or readmitted from the hospital, and they should review the orders and recommendations from the hospital with the medical provider and enter new orders into the electronic medical record, including wound care recommendations and orders. Once the resident is admitted they completed the initial skin assessments and a thorough assessment of any identified skin impairments and document that information in the electronic medical record. Registered Nurse #2 stated they completed the readmission skin assessment for Resident #45, documented the pressure ulcer to the left trochanter, and did not complete a skin assessment on the wound but should have. They stated they reviewed the After Visit Summary with the medical provider, but must have overlooked the wound care recommendations, and no wound care orders had been placed at the time of re-admission. During an interview on 01/10/2025 at 9:41 AM, the Director of Nursing stated the After Visit Summary should have been reviewed and any hospital recommendations for wound care should have been entered into the electronic medical record, a thorough skin assessment should have been completed at the time of admission or re-admission, and if a skin impairment was identified, it should have been assessed and documented in the electronic medical record. If an undated and unlabeled dressing was identified by a certified nursing assistant or licensed practical nurse, it should have been reported, a new dressing placed, and if there is no order, the medical provider should have been contacted for wound care orders. 10 NYCRR 415.12(c)(2)

Based on observations, interviews, and record review conducted during the Recertification Survey from 01/06/2025 to 01/14/2025 for one (Resident #21) of nine residents reviewed, the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #21 did not receive assistance with shaving and fingernail care as requested. This is evidenced by the following. The facility policy Activities of Daily Living Care and Support, revised 03/13/2024, included activities of daily living care and support will be provided for residents who are unable to carry out activities of daily living independently, with the consent of the resident and in accordance with the resident's assessed needs, personal preferences, and individualized plan of care including grooming. Nail care should be provided as needed for the resident. Facial hair will be groomed as per resident's preference and/or assessed needs. Resident #21 had diagnoses that included a stroke, hemiplegia (paralysis on one side of the body), and high blood pressure. The Minimum Data Set Resident Assessment, dated 11/06/2024, documented Resident #21 was cognitively intact and needed assistance with personal hygiene. Review of the Resident #21's Comprehensive Care Plan, revised 11/11/2024, and the current Kardex (care plan used by Certified Nursing Assistants for daily care) revealed Resident #21 had an activities of daily living self-care performance deficit and required assistance from staff for personal hygiene. Review of the resident's Treatment Administration Report in the electronic medical record revealed Resident #21 received a shower on 01/05/2025 at 2:13 PM. During an observation on 01/06/2024 at 3:35 PM, Resident #21 had long fingernails on both hands with several broken and jagged nails and several days of beard growth. During an interview at this time, Resident #21 stated they wanted to be shaved and have their fingernails cut, they had asked nursing staff for a shave and fingernails to be cut, but no one had helped them. During an observation on 01/08/2025 at 10:11 AM, Resident #21's facial hair remained unshaved and their fingernails remained uncut and dirty. During an interview on 01/08/2025 at 2:50 PM with Certified Nursing Assistant #1 and Certified Nursing Assistant #2, Certified Nursing Assistant #2 stated they should complete shaving and fingernail care on shower days and as needed. During an interview on 01/08/2025 at 3:56 PM, Licensed Practical Nurse #8 stated resident grooming was typically completed by the certified nursing assistants and grooming, including shaving and fingernail care, were reviewed for completion during skin checks which were scheduled on shower days. During an interview on 01/08/2025 at 4:10 PM, Licensed Practical Nurse Manager #2 stated activities of daily living including personal hygiene and grooming should be completed on shower day, as needed, per preference, and per request. Certified Nursing Assistants should be providing the care, and the nurses should be checking to make sure it was completed. During an observation of Resident #21 at this time, Licensed Practical Nurse Manager #2 stated Resident #21's nails were very long, should have been trimmed, and Resident #21 should have received a shave per their request or during their shower. 10 NYCRR 415.12(a)(3)

Based on observations, interviews, and record review conducted during the Recertification Survey from 01/06/2025 to 01/14/2025, for three (Residents #53, #104, and #220) of 26 residents reviewed, the facility did not develop and/or implement the comprehensive person-centered care plans for each resident that included measurable objectives and timeframes to meet all the resident's medical, nursing, mental, and psychosocial needs. Specifically, Resident #53's Comprehensive Care Plan did not include goals and interventions related to the resident's post-traumatic stress disorder diagnosis. Resident #220's Comprehensive Care Plan did not include goals and interventions related to care of the resident's nephrostomy tube (tube inserted into the kidney that drains urine directly into a drainage bag and bypassing the bladder). Resident #104 had a physician's order for compression (ACE) wraps (a dressing used to help reduce swelling in an extremity) to be applied to the left arm in the morning and removed at bedtime. There were multiple observations of Resident #104 not wearing the compression wraps despite documentation by staff that they were applied. This is evidenced by the following: The facility policy Care Plans - Comprehensive, dated 08/02/2024, included that the interdisciplinary team, in conjunction with the resident and his/her family or legal representative, would develop and implement a comprehensive, person-centered care plan for each resident. The care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 1. Resident #53 had diagnoses of post-traumatic stress disorder, anxiety, and diabetes. The Minimum Data Set Resident Assessment, dated 11/21/2024, included the resident had moderately impaired cognition and had a diagnosis of post-traumatic stress disorder. The Care Area Assessment form (area of the Minimum Data Set Resident Assessment that analyzes areas that require care planning) triggered from the 11/21/2024 Minimum Data Set Resident Assessment included that Resident #53 had a psychiatric disorder (including post-traumatic stress disorder) that should be considered for care planning. The form was not signed or dated when it was completed. Review of the resident's current Comprehensive Care Plan revealed no information related to Resident #53's post-traumatic stress disorder diagnosis including goals or interventions for management. Review of Resident #53's Kardex (care plan used by the Certified Nursing Assistants for daily care) included to monitor/record occurrence of target behavior symptoms but did not include what target behavior symptoms to monitor for or interventions. During an interview on 01/07/2025 at 10:56 AM, Resident #53 stated they had a diagnosis of post-traumatic stress disorder and would often get moody and easily upset, which is why they requested mental health services. During an interview on 01/13/2025 at 11:57 AM, Licensed Practical Nurse #2 stated they would know if a resident had a post-traumatic stress disorder by reading (progress) notes (in the resident's electronic medical record), but would not know what triggers they had unless they talked to the resident. Licensed Practical Nurse #2 stated they did not know of any residents (currently) that had been diagnosed with post-traumatic stress disorder. Licensed Practical Nurse #2 stated Resident #53 was screaming at the top of their lungs (the other night), threatened to leave the facility, and stated they were not feeling right mentally. During an interview on 01/13/2025 at 1:08 PM, Licensed Practical Nurse Manager #2 stated the care plans should include interventions on how to care for a resident related to their diagnosis(es). Licensed Practical Nurse Manager #2 stated they believed Resident #53 had been diagnosed with post-traumatic stress disorder, had begun yelling about a week prior, and subsequently the resident stated they were having mental health issues. Licensed Practical Nurse Manager #2 stated Resident #53's care plan did not include their post-traumatic stress disorder diagnosis or related interventions, but should have. Licensed Practical Nurse Manager #2 stated they did not have much involvement with care plans but that it would be important for the diagnosis and interventions to be on Resident #53's care plan so staff would know how to assist the resident if they were upset or displaying certain behaviors. During an interview on 01/14/2025 at 10:49 AM, Registered Nurse #2 stated care plans were generated based on the resident's admission assessments that included auto-populated information (unsure from where) which they then reviewed/changed. Registered Nurse #2 stated the care plans should include diagnoses, goals, and related interventions. A diagnosis of post-traumatic stress disorder should absolutely be on a resident's care plan including goals and interventions to direct staff on how to provide care and ensure the resident's safety. During an interview on 01/14/2025 at 12:36 PM, Director of Nursing #1 stated a resident's care plan should include a post-traumatic stress diagnosis and related interventions to ensure they were taken care of psychologically and maintain good mental hygiene. 2. Resident #220 had diagnoses of acute kidney failure, chronic obstructive pulmonary disease (a long-term lung disease that makes it hard to breathe), and malignant neoplasm of the bladder (cancer) requiring a nephrostomy tube. The Minimum Data Set Resident Assessment, dated 12/27/2024, included the resident had moderately impaired cognition and required moderate assistance for personal hygiene. The Care Area Assessment section of the Minimum Data Set Resident Assessment included Resident #220 triggered for an indwelling catheter and should be care planned for it. Review of the Comprehensive Care Plan, dated 12/23/2024, revealed no information related to Resident #220's nephrostomy tube, care of or any other interventions to assist the resident with nephrostomy tube needs. In a progress note, dated 01/08/2025, Nurse Practitioner #2 documented Resident #220 would need home care and assistance with flushing the nephrostomy tube. During an observation and interview on 01/08/2025 at 10:32AM, Resident #220 stated they had not heard about any plans for a care plan meeting and had not received any teaching about care for the nephrostomy tube which was covered with a dressing at this time. Resident #220 stated facility staff were flushing it. Review of Resident #220's January 2025 Treatment Administration Record revealed inconsistent documentation that the nephrostomy tube was being flushed as ordered by the physician. During an interview on 01/14/2025 at 10:35 AM, Licensed Practical Nurse Manager #2 stated that a Registered Nurse or the Director of Nursing developed the Comprehensive Care Plans and Resident #220 should have had nephrostomy tube care in their care plan. During an interview on 01/14/2025 at 10:43AM, the Director of Nursing stated the Comprehensive Care Plan starts at the time of admission, can be updated at any time, and Resident #220's Comprehensive Care Plan should have included nephrostomy tube care. 3. Resident #104 had diagnoses that included stroke, hemiparesis (paralysis on one side of the body) affecting their left side, and swelling in the left arm. The Minimum Data Set Resident Assessment, dated 11/27/2024, included Resident #104 had moderate cognitive impairment and an impairment in one arm and one leg. Review of Resident #104's Comprehensive Care Plan, dated 08/02/2024, revealed the resident had a fluid deficit related to edema with a goal to receive adequate fluids and maintain good skin turgor. Interventions did not include compression wraps to their left arm. Physician orders, dated 12/25/2024, included for staff to place an ACE (compression dressing used to help reduce swelling) wrap on the resident's left arm in the morning and remove at bedtime for swelling. Review of Resident #104's Treatment Administration Record revealed documentation that the compression wrap had been applied daily from 01/06/2025 through 01/10/2025. During observations on 01/06/2025 at 11:05 AM, 01/08/2024 at 10:23 AM, and 01/10/2025 at 12:34 PM, Resident #104 did not have the ACE wrap applied to their left arm. During an interview on 01/08/2025 at 2:50 PM with Certified Nursing Assistant #1 and Certified Nursing Assistant #2, Certified Nursing Assistant #2 stated compression wraps are applied and removed by the nurses. During an interview on 01/10/2025 at 12:37 PM, Licensed Practical Nurse #5 stated they are responsible for completing all treatments, including compression wraps as ordered by the physician. If a treatment was unable to be completed, it should be documented as not done and why, and should not be documented as completed. Resident #104 does not currently have the compression wraps on and they should. During an interview on 1/10/2025 at 12:50 PM, Licensed Practical Nurse Manager #1 stated nurses should not document a treatment as completed if it was not done. The compression wraps are generally ordered for 6:00 AM and the night nurses apply them. If unable to apply, such as when the resident is sleeping, then the nurse should let the oncoming shift know. Resident #104 should get the compression wraps (to their left arm) to treat the swelling and not applying them is not meeting the resident's need. 10 NYCRR 415.11(c)(1)

Based on interviews and record review conducted during the Recertification Survey from 01/06/2025 to 01/14/2025, for four (Residents #31, #47, #80, and #99) of seven residents reviewed, the facility did not ensure the Minimum Data Set Resident Assessment accurately reflected the residents' status. Specifically, the issues involved inaccurate coding for Section I - Active Diagnoses (Resident #47) and Section N - Medications (Residents #31, #80, and #99). This is evidenced by the following: Review of the current Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2024, Section I included the disease conditions in the section required a physician-documented diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure law) in the last 60 days. Section N included medications are to be coded according to the medication's therapeutic category and/or pharmacological classification, not on how they are used. Additionally, antiplatelet medications such as aspirin, should not be coded as an anticoagulant. The facility policy Minimum Data Set (MDS) 3.0, dated August 2019, included the Resident Assessment Instrument (RAI) process had multiple regulatory requirements including, but not limited to, the assessment would accurately reflect the resident's status. 1. Resident #47 had diagnoses including schizoaffective disorder (mental health condition), dementia, and benign prostatic hyperplasia (growth of prostrate size causing difficulty with urination). The Minimum Data Set Resident Assessment, dated 11/27/2024, included Resident #47 had moderate cognitive impairment and Section I (Active Diagnoses) was coded as having a psychotic disorder (other than schizophrenia) within the past seven days (look back period). Review of a medical provider note, dated 11/15/2024, revealed no documented evidence that Resident #47 had psychosis-related behaviors. 2. Resident #99 had diagnoses including stroke, diabetes, and congestive heart failure. The Minimum Data Set Resident Assessment, dated 10/20/2024, included Resident #99 had severe cognitive impairment and Section N (Medications) was coded as receiving an anticoagulant. The Minimum Data Set Resident Assessment, dated 12/18/2024, included Resident #99 received anticoagulant and antiplatelet medications (under Section N). Review of the October 2024 Medication Administration Record revealed Resident #99 was administered Aspirin (an anti-platelet medication) on 10/29/2024 and 10/30/2024. There was no documented evidence that an anticoagulant medication was administered. Review of the December 2024 Medication Administration Record revealed Resident #99 was administered Aspirin and was not administered an anticoagulant medication. 3. Resident #31 had diagnoses including depression, stroke, and hypertension. The Minimum Data Set Resident Assessment, dated 12/10/2024, included the resident was cognitively intact and Section N (Medications) was marked as receiving antidepressant and antianxiety medications. Review of physician's orders revealed escitalopram daily for depression was ordered on 12/03/2024. There were no medications ordered for anxiety. Review of the December 2024 Medication Administration Record revealed escitalopram was administered for depression. There was no documented evidence that an antianxiety medication was administered. During an interview on 01/14/2025 at 9:03 AM with Minimum Data Set Coordinator #1 and Minimum Data Set Coordinator #2, Minimum Data Set Coordinator #1 stated their role consisted of gathering resident information, such as behaviors and medications, to enter and complete sections of the Minimum Data Set Resident Assessment. Minimum Data Set Coordinator #1 stated to complete Section I - Active Diagnoses, they used active diagnoses listed in the resident's electronic Medication and Treatment Administration Records. Minimum Data Set Coordinator #2 stated they determined active diagnoses by reading provider notes during the look back period. Minimum Data Set Coordinator #2 reviewed Resident #47's Minimum Data Set Resident Assessment, dated 11/27/2024, at this time, and stated the resident had the diagnosis of psychotic disorder listed in their health record, but it was not mentioned in a medical provider note (during the look back period) and diagnoses could only be used if the medical provider used (documented) them. Minimum Data Set Coordinator #1 stated when completing Section N- Medications, they reviewed resident Medication Administration Records to determine how medications were classified and had access to a list of medications or would use Google (internet-based search engine) to determine medication classifications. Minimum Data Set Coordinator #1 reviewed Resident #99's Minimum Data Set Resident Assessment, dated 10/30/2024, at this time and stated anticoagulant was selected, but the resident received aspirin and it was not an anticoagulant. Minimum Data Set Coordinator #1 reviewed Resident #31's Minimum Data Set Resident Assessment, dated 12/10/2024, at this time and stated antidepressant and antianxiety medications were selected. Resident #31 received an antidepressant medication, but not an antianxiety medication. During an interview on 01/14/2025 at 12:36 PM, Director of Nursing #1 stated the Minimum Data Set Nurse Coordinators did not report to them, Aspirin was not an anticoagulant, and Minimum Data Set Resident Assessments should include accurate information. During an interview on 01/14/2025 at 1:45 PM, Administrator #1 stated they were not aware of any issues related to Minimum Data Set Resident Assessments not being completed accurately. 10 NYCRR 415.11(b)

Based on observations, interviews, and record reviews conducted during a Recertification Survey from 01/06/2025 to 01/14/2025, the facility did not ensure the daily nurse staffing information was posted on a daily basis. Specifically, the nursing staff information was not posted daily at the beginning of each shift during the survey, the information on the form was not updated to reveal current staffing changes, and the facility did not maintain the daily nursing staffing data for a minimum of 18 months. This is evidenced by the following: During observations on 01/06/2025 at 12:12 PM and 3:03 PM, 01/07/2025 at 11:24 AM and 4:17 PM, and 01/08/2025 at 8:29 AM, the daily nurse staffing information was not posted. During an interview on 01/08/2025 at 11:22 AM, the Director of Human Resources stated they are responsible for completing and posting the daily nurse staffing information. They stated daily nurse staffing information was completed for all shifts in the morning and posted, but was not updated to reflect any changes in staffing at any point during the day. Weekend daily nurse staffing information was printed on Fridays and was supposed to be rotated by the receptionist for Saturday and Sunday and was not updated during the weekend. The Director of Human Resources stated the daily nurse staffing sheets were not saved. They stated the daily nursing staffing information should have been posted for 01/06/2025, 01/07/2005, and 01/08/2025, but was not. The facility was unable to provide any past daily nurse staffing information sheets when requested. During an interview on 01/10/2025 at 9:41 AM, the Director of Nursing stated the daily nurse staffing information should be posted daily in an area readily accessible by residents and visitors, should be updated throughout the day to ensure accuracy, and the information sheets should be retained. They stated the daily nursing staffing information is posted to let residents and visitors know how much staff is currently working. 10 NYCRR 415.13

Based on observations, interviews, and record review conducted during an Abbreviated Survey (complaint #NY00311416), for one (Resident #11) of two residents reviewed, the facility did not ensure parenteral fluids/medications (liquids given via intravenous, also known as IV) were administered and treatments completed were consistent with professional standards of practice and in accordance with the physician's orders, the resident's comprehensive person-centered care plan and the resident's goals and preferences. Specifically, there was inconsistent documented evidence that nursing assessments for proper placement of a catheter, signs and symptoms of infection and dressing changes were completed per physician orders for a peripherally inserted central catheter (a catheter that is inserted through a vein in your arm and ends up in a large vein in the chest, also known as a PIC line). Additionally, antibiotics and flushes (medications used to keep the PIC line patent) were not consistently documented as administered as ordered. This is evidenced by the following: The facility policy, Medication Administration, revised December 2019, documented that medications shall be administered in a safe and timely manner, and as prescribed: only persons licensed or permitted by the State to prepare, administer, and document the administration of medications may do so. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or related functions. Medications must be administered in accordance with the orders, including any required time frame. The individual administering the medication must initial the resident's Medication Administration Record on the appropriate line after giving each medication and before administering the next one. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document as such in designated format space provided for that drug and dose. New personnel authorized to administer medications will not be permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility. The facility policy, Peripheral Catheter Flushing revised January 2022, documented that specific flush orders must be documented, and flushing is performed to ensure and maintain catheter patency. The facility policy, Peripherally Inserted Central Catheter Line Dressing Change revised January 2022, documented a peripherally inserted central catheter insertion site is a potential entry site for bacteria that could produce a catheter-related infection, intravenous sites should be assessed regularly during continuous therapy at least daily during intermittent therapy, and to be performed by a Licensed Nurse. Resident #11 had a diagnosis of osteomyelitis (infection in the bone), amputation (surgical removal) of the fifth right toe, and diabetes. The Minimum Data Set Resident Assessment, dated 3/11/24, revealed the resident was cognitively intact and receiving intravenous medications. The Comprehensive Care Plan initiated on 3/5/24 documented Resident #11 had a peripherally inserted central catheter with goals that included the resident will be free of complications. Interventions included to change the dressing, injection caps, and extension tubing weekly, monitor the catheter every shift and follow pharmacy protocols for flushes with medications. Review of the Physician's orders dated 3/5/24 included the following: a. Vancomycin (antibiotic) intravenous solution, 1.5 gram intravenously every 12 hours. b. Heparin (medication to prevent clotting) solution flush catheter with 5 milliliters (100 units per milliliter) twice daily. c. Normal saline solution flush with five milliliters every 12 hours before and after infusion. d. Measure arm circumference two inches above (catheter) insertion site and measure external catheter length with each dressing change every seven days. e. Observe (catheter) site at least every two hours for signs and symptoms of infection and/or displacement (of catheter) every shift. f. Intravenous dressing kit for central line, apply one application transdermally every seven days and as needed. Review of Resident #11's Medication Administration Records 3/5/24 through 3/31/24 revealed no documented evidence that the vancomycin antibiotic was administered as ordered on 4 occasions, the heparin flush on 5 occasions, the normal saline flushes on 10 occasions, the catheter dressing changed every 7 days on one occasion (going 14 days between dressing changes), that the catheter had been assessed for complications on seven occasions or that proper placement of the catheter was assessed on 8 occasions. Review of Resident #11's Medication Administration Records 4/1/24 through 4/5/24 revealed no documented evidence that the Vancomycin antibiotic and the normal saline flush were administered as ordered on one occasion or that proper placement of the catheter was assessed on one occasion. During observations on 4/4/24 at 9:09 AM Resident #11's peripherally inserted central catheter was covered with a dressing dated 3/25/24 (2 days past due date). Interviews conducted on 4/5/24 included the following: a. At 12:52 PM Licensed Practical Nurse Manager #1stated if there were blank areas on the Medication and Treatment Administration Records then the medication was considered omitted or missed. b. At 1:23 PM Registered Nurse Manager #1stated that when medications or treatments are administrated there is a sign off button in the electronic health record (to record it was completed). In an interview on 4/19/24 at 8:53 AM Registered Nurse #1 stated medication administration and peripherally inserted central catheter care should be completed as ordered. Registered Nurse #1 stated the dressing was not completed as ordered as they were unable to find a dressing kit which was reported to the next shift. Registered Nurse #1 stated documentation for the medications and treatments was done (in the electronic medical record) by clicking off that the task(s) were done and should have been done in real time. Registered Nurse #1 stated they were made aware of the missing documentation for the intravenous vancomycin (after surveyor intervention) on 4/5/24 and went back to sign them off as completed at that time but only for the vancomycin order and not the treatments. Review of the staffing schedule for March and April 2024 provided by the facility revealed that Registered Nurse #1 was not on the schedule on several of the days that were signed off as medication administered by them (after surveyor intervention). In an interview on 4/19/24 at 9:46 AM the Traveling/Floating Director of Nursing (corporate) stated there should be documentation of a dressing when it was changed or if it did not get done. Nursing should document a medication was administered and/or treatment completed right then and there. Missing documentation and back dating medications administered was not consistent with professional standards of practice or in accordance with the physician's orders. 10 NYCRR 415.12(k)(2)

Based on interviews and record review conducted during the Recertification Survey from [DATE] to [DATE], the facility failed to ensure that all residents had the right to request, refuse, and/or discontinue treatment, and to formulate an advance directive (medical interventions in the event of a life-threatening episode) that would be honored for 5 (Residents #57, #76, #104, #364, and #508) of 35 residents reviewed. Specifically, the facility failed to ensure residents' advance directive (code status) identifiers were consistently documented for Resident #57, #104, #364 and #508, whose Medical Orders for Life-Sustaining Treatment (MOLST) identified their code status as Do Not Resuscitate (DNR -meaning to allow natural death and not initiate Cardiopulmonary Resuscitation (CPR) in the absence of pulse and respiration) while their physician orders documented orders for Full Code (to initiate CPR). Additionally, MOLST forms for Residents #57, #364, and #508 identified them as cognitively intact, with the ability to sign the MOLST form in the presence of witnesses (verifying understanding and accuracy) but had the verbal consent box checked and were not signed by the residents. The MOLST forms for Residents #76 and #104 who were identified by the facility as cognitively impaired also had the verbal consent box checked without evidence that the residents' representatives had been consulted to verify the resident's wishes. Of the 35 resident MOLST forms reviewed, 22 had the verbal consent box checked instead of resident and/or representatives' signatures. The facility's policy and procedure (P&P) did not direct staff where to locate the residents' code status, and multiple staff members interviewed identified different sources to locate a resident's code status. This resulted in the likelihood for serious injury, harm, and death for all the residents in the facility (census of 121) that was Immediate Jeopardy (IJ). The Findings are: The facility P&P Advance Directives, dated February 2019, documented Advance Directives indicate preferences regarding treatment options and include, but are not limited to a living will, durable power of attorney for health care, Do Not Resuscitate, Do Not Hospitalize, Do Not Intubate, Life-Sustaining Treatment, Feeding Restrictions, Medication Restrictions, and Other Treatment Restrictions. The resident (and/or resident representative, as appropriate) will be educated by the Social Worker (SW) or designee concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. The nurse or designee will notify the Attending Physician of the resident's code status and/or any advance directive so that the appropriate orders can be documented in the resident's medical record and plan of care. 1. Resident #508 had diagnoses including end stage renal (kidney) disease requiring dialysis (treatment for people with kidney failure), pulmonary embolism (blood clot in the lungs), and diabetes. The Minimum Data Set (MDS - resident assessment tool), dated [DATE], documented the resident was cognitively intact. Physician orders, dated [DATE], documented Resident #508's code status was to attempt CPR (in the event their heart or breathing stopped). When reviewed on [DATE] at 1:23 PM, the physician order had been changed to DNR. The resident's MOLST form, dated [DATE], documented their wishes for DNR and that Resident #508 had given verbal consent. The signature line was blank. Resident #508's Comprehensive Care Plan (CCP), dated [DATE], documented Resident #508 had a MOLST and the resident was to receive CPR if needed. In a progress note, dated [DATE] SW #1, documented Resident #508 was cognitively intact, wished to receive CPR should they need it, and that their wishes would be regarded and respected throughout their stay. During an interview on [DATE] at 11:24 AM, Resident #508 stated they recalled speaking to a facility staff member about their advance directive wishes on the day they were admitted : If they were found unresponsive, they would want the staff to attempt CPR. Resident #508 did not remember signing a pink form (the paper MOLST form) related to their advance directive status. When interviewed again on [DATE] at 2:29 PM, Resident #508 stated no staff member had spoken to them on that day ([DATE]) regarding their advance directive status or any changes to it and reiterated that their wishes were for CPR. During an interview on [DATE] at 12:20 PM, the Director of Nursing (DON) stated they would expect staff to find the resident's code status on the MOLST form and that all staff had been informed to look at the pink paper (MOLST form) to find the code status. During an interview on [DATE] at 3:02 PM, the Medical Director (MD) stated there had been discrepancies identified with the MOLST orders and the facility was working to correct the issues. The MD stated they would expect the MOLST order and physician orders to match. If the information was different in one place there was the potential for something to be done that went against the resident's wishes. During an interview on [DATE] at 4:00 PM, Registered Nurse (RN) #1 (Admisssion's Nurse) stated SW #1 had come to them that day regarding MOLST discrepancies for two residents. They were unable to recall which residents, but that they had updated the code status orders for both residents in the Electronic Medical Record (EMR). RN #1 stated that they had not confirmed the code status with either resident prior to changing the orders. During an interview on [DATE] at 4:14 PM, SW #1 stated RN #1 meets with the resident, if cognitively intact, at the time of admission to discuss their code status then enters the order for code status in the EMR and in the resident's CCP. SW #1 stated they had identified two discrepancies with code status orders that day (after surveyor intervention) and brought the concerns to RN #1 so the orders could be updated. SW #1 stated they had not confirmed the code status with either resident prior to bringing the discrepancies to RN #1. During an interview on [DATE] at 11:47 AM, RN #1 stated they were not sure why verbal consent was checked on the MOLST forms for residents who were cognitively intact, but that those residents should be allowed to sign their MOLST form if they are able. RN #1 stated the MOLST is not always signed in front of the resident. 2. Resident #364 had diagnoses that included pulmonary fibrosis (disease in which the lungs become scarred and damaged causing difficulty in breathing) and emphysema (lung disease which results in shortness of breath). A progress note dated [DATE] and authored by RN #1 documented that Resident #364 was oriented to person, place, time, and situation. Review of physician orders dated [DATE] revealed orders for code status were to attempt CPR. Resident #364's MOLST form dated [DATE] and signed by the physician documented the resident's code status as DNR. Additionally, the MOLST form included that verbal consent was obtained from Resident #364 and the signature line was blank. During an interview on [DATE] at 10:42 AM, LPN #1 stated to identify a resident's code status, they would check the 'pink sheet' (MOLST form) in the chart. LPN #1 stated there are also code status orders in the EMR. During an interview on [DATE] at 10:54 AM, Registered Nurse Manager (RNM) #1 stated staff should check the resident's MOLST to identify their code status. RNM #1 stated that on admission, if a resident had a MOLST, they verify the MOLST/code status wishes with the resident, explain (to residents or their representative) what the MOLST is, what CPR is, and go over each section of the MOLST. RNM #1 said that after discussing it with the resident they would then fill out the MOLST form and place the code status order in the EMR and that the MOLST form and code status order in the EMR should absolutely match. At 11:30 AM RNM #1 reviewed Resident #364's MOLST for DNR and the physician orders for CPR with the surveyor and stated they would address the discrepancies. 3. Resident #57 had diagnoses including hypertension, depression, and diabetes. The MDS assessment dated [DATE] documented the resident was cognitively intact and did not have any advance directives. Resident #57's MOLST form dated [DATE] documented DNR wishes. The verbal consent box was checked, and the signature line was blank. Resident #57's physician orders, dated [DATE] for advanced directives included Full Code. 4. Resident #104 had diagnoses that included a stroke, aphasia (difficulty speaking) and encephalopathy (a brain disease that affects brain function). The MDS assessment dated [DATE] documented the resident had moderately impaired cognition. Physician orders, dated [DATE], documented the resident's advanced directives were for Full Code. Resident #104's MOLST, dated [DATE], documented DNR wishes. The verbal consent box was checked, and the signature line was blank. There was no evidence of Resident #104's representative's input. During an interview on [DATE] at 10:20 AM, Resident #104, was unable to verbalize their advance directive wishes. During an interview on [DATE] at 11:48 AM, RN #1 stated that when they had explained advanced directives with Resident #104 the resident seemed confused, but that they thought the resident had understood. RN #1 said that when a resident was cognitively impaired, they should speak with the residents' responsible party to determine advance directives and maybe this was something that needed to be reviewed. 5. Resident #76 had diagnoses including dementia, anxiety, and depression. The MDS assessment dated [DATE] documented the resident had severe impairment of cognitive function. The current physician orders dated [DATE] documented advanced directives were for Full Code. The resident's MOLST form, dated [DATE] and last reviewed on [DATE], documented wishes for CPR and that verbal consent had been obtained (from a severely impaired cognitively resident) and the signature line was blank. During an interview on [DATE] at 11:16 AM, SW #1 stated Resident #76 had severe impairment of cognitive function and was unable to make decisions regarding advance directive status. Additionally, if a resident had cognitive impairment, the responsible party should be consulted regarding the resident's advance directive wishes. During an interview on [DATE], at 10:23 AM, LPN #6 stated they would check the EMR for a resident's code status as it would be quicker than checking the MOLST form. During an interview on [DATE], at 10:28 AM, LPN #7 stated they would check the EMR and the MOLST form for a resident's code status. Additionally, LPN #7 stated there have been discrepancies in resident's code status between the EMR and MOLST form. During an interview on [DATE] at 11:13 AM RN #1 stated when admitting a new resident, they would discuss advanced directives with the resident or representative and if no family members were present and the resident was unable to answer, they would reach out to the resident's family. RN #1 said staff are trained to go directly to the MOLST to determine a resident's code status during a code situation, and the EMR should not used as the primary location for determining code status. During an interview on [DATE] at 2:32 PM, the Director of Nursing (DON) stated on admission, the admission's nurse should discuss the resident's code status with the resident (or representative). The admission's nurse should then take the MOLST form to the medical provider for them to review and sign and then it should then go in the resident's chart and the code status order placed in the EMR. During off shifts, the nurse admitting the resident is responsible for determining the resident's code status and follow the same process. The DON said Social Work used to lead the process regarding advanced directives, but there was a process change (not sure when) and now Nursing does. The DON said that Social Work was conducting MOLST audits, which consisted of checking if the MOLST was in the chart and if the MOLST matched the physician's order. The DON said that they had reviewed with nursing staff how to determine a resident's code status on admission, how to document the orders in the EMR and where to look to determine a resident's code status (if needed). During an interview on [DATE] at 11:30 AM, The Administrator stated that advanced directives were discussed during Quality Assurance Performance Improvement (QAPI) meetings due to the importance of the topic and that concerns were discussed at the [DATE] meeting due to results of a recent advanced directive audit. The Administrator stated that a possible root cause of the audit results was that the admission's nurse had been out for two weeks, and the plan was to continue monitoring the audits to see if the audit results were a one-time thing. During an interview on [DATE] at 12:14 PM with the Administrator and DON, the Administrator stated that in [DATE] Nursing (versus Social Work) took more of a lead regarding advanced directive discussions with residents or their representatives due to the clinical complexities of the MOLST forms. The Administrator stated that the [DATE] audits identified missing signatures, so they changed their process to the admission's nurse discussing the issue with the residents and representatives. The DON stated that the MOLST forms had changed and were more detailed, resulting in nurses being more involved in explaining the details to the resident or representatives. During an interview on [DATE] at 11:04 AM, the Administrator stated that the audits had been done quarterly and were changed to monthly, and that the Director of Social Work conducted the audits. The Regional Social Work team provided education and training on completing the audits. The Administrator stated they believed the training included the verbal consent process. The Administrator stated that the QAPI Committee was not aware that the verbal consent box was being checked on multiple MOLST forms. The Administrator stated that initially, it was identified that the code status orders did not match the MOLST forms and believed that the issue had been fixed. IJ was identified and declared on [DATE] and the facility Administrator was notified at 6:06 PM. On [DATE] the survey team declared that the IJ was removed, effective [DATE], based on the following corrective actions taken by the facility: -A facility-wide code status audit for clarification of all resident's advanced directive wishes was conducted to ensure all physician orders and MOLST forms were accurate. The audit included whether residents were cognitively able to make decisions regarding their MOLST wishes and had been given the opportunity to sign the MOLST form indicating it was understood and accurate. If the resident was cognitively impaired, the resident's representatives were contacted. - The facility completed immediate re-education/training for all nursing staff regarding advance directives, MOLST completion (including use of verbal consent), Basic Life Support, and the location of resident's advance directives. Nursing staff not scheduled to work or out on leave would be educated prior to working their next shift. -The facility policy was revised (awaiting corporate approval) to include where staff should locate all residents' advanced directives. 10 NYCRR 415.3(f)(1)(ii)

Based on observations, interviews, and record reviews conducted during the COVID-19 Infection Control Focus Survey, complaint #NY 352, it was determined that for three of three residential units, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of COVID-19. The facility staff failed to consistently follow infection control precautions for residents on standard and droplet precautions potentially resulting in cross contamination for 89 residents not identified as having COVID-19. Specifically, two staff members were observed exiting the rooms of two residents (Residents #3 and #4) that had COVID-19 without removing (doffing) Personal Protective Equipment. The staff members either entered the room of a resident that did not have COVID-19 or continued to deliver meal trays without putting on (donning) new Personal Protective Equipment. Additionally, the facility did not protect three residents (Residents #6, #7, and #9) that were asymptomatic and did not have COVID-19. All three residents were residing in rooms with residents that had COVID-19. This resulted in Immediate Jeopardy to resident health and safety that is widespread. This is evidenced by the following: The facility COVID-19 Personal Protective Equipment (PPE) Use policy, revised 4/15/20, included to wear the same gown when interacting with more that one resident known to be infected with the same infectious disease and are housed in the same location (i.e. COVID-19 residents residing in an isolation cohort). The facility Outbreak Management policy, created 3/24/20, revealed that current recommendations are to isolate in place when a private room is not available. Roommates of isolated residents might already be exposed, it is generally not recommended to separate them in this scenario. (Center Disease Control, March 2020) Review of the Center for Medicare and Medicaid Services (CMS) COVID-19 Long-Term Care Facility Guidelines, dated 4/2/20, included full PPE should be worn per Centers of Disease Control (CDC) guidelines for the care of any resident with known or suspected COVID-19 per CDC guidance on conservation of PPE. Long-Term Care facilities should separate residents who have COVID-19 from residents who do not or have unknown status. 1. a. Resident #4 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 3/24/20, revealed the resident had moderately impaired cognition. Review of Resident #4's medical record revealed the resident was positive for COVID-19 on 4/9/20. During a continuous observation conducted on 4/21/20 at 5:50 p.m., Certified Nursing Assistant (CNA) #1 was observed providing hands-on feeding assistance to Resident #4. CNA #1 was wearing the following PPE: a one-piece yellow protective suit, a surgical mask, a face shield, and two pairs of gloves. There was a sign on Resident #4's door that directed to see the nurse. During the observation, CNA #1 touched the outer surface of the face shield with her gloved hand. After providing feeding assistance, CNA #1 exited Resident #4's room with the meal tray in her gloved hands. CNA #1 emptied the meal tray into a large, red trash bin outside of Resident #4's room. CNA #1 then removed her first pair of gloves, picked up the empty meal tray, walked down the hall, and returned the empty tray to the meal transport cart that was holding other resident meal trays that had not been passed yet. CNA #1 then returned to the red trash bin, removed and discarded her second pair of gloves. CNA #1 proceeded down the hall across from the resident's room, accessed the keypad lock to enter the clean utility room, and washed her hands. At 5:57 p.m., CNA #1 collected another meal tray from the cart and proceeded to the room of Resident #5. CNA #1 was observed in Resident #5's room for ten minutes providing hands on feeding assistance. CNA #1 did not cleanse, disinfect, or doff her yellow protective suit during the observation. Review of Resident #5's medical record revealed the resident was not tested for COVID-19 and was asymptomatic (showing no symptoms). When interviewed on 4/21/20 at 6:10 p.m., CNA #1 stated that staff wear the same yellow protective suit to care for all residents. CNA #1 said she should have wiped her suit down when leaving Resident #4's room but had not done so. b. Resident #3 has [DIAGNOSES REDACTED]. The MDS Assessment, dated 4/2/20, revealed the resident had moderately impaired cognition. Review of Resident #3's medical record revealed that the resident was positive for COVID-19 on 4/15/20. In an observation on 4/21/20 at 5:20 p.m., Resident #3 was in their room. There was a sign on the door that directed to see the nurse and an isolation set up on the door which contained gloves. CNA #2 entered the resident's room wearing a yellow one-piece protective suit and a mask with no gloves to deliver the resident's dinner tray. CNA #2 washed her hands with soap and water prior to leaving the room, and then went to the food cart and picked up another resident's tray and proceeded to pass trays on the unit. When interviewed at that time, CNA #2 said that Resident #3 has COVID-19. She said that staff wear the same yellow protective suits when caring for all residents and staff do not need to change the suits. She said the isolation set-up was for the last resident that was in the A bed. When asked about wearing gloves, she said that she washed her hands with soap and water. CNA #2 did not cleanse, disinfect, or doff her yellow protective suit during the observation. 2. a. Resident #1 has [DIAGNOSES REDACTED]. The MDS Assessment, dated 3/20/20, revealed that the resident was cognitively intact. Review of Resident #1's medical record revealed that the resident was positive for COVID-19 on 4/18/20. In an observation on 4/21/20 at 4:15 p.m., Resident #1 was observed in a semi-private room with the door open. Resident #1 was in bed with their mouth wide open, snoring, and was not wearing a mask. The resident's roommate (Resident #7) was in their bed with no mask. The curtain between the beds was pulled partially covering about 3/4 of the length of the beds. The sign on the door directed to see the nurse. Review of Resident #7's medical record revealed that the resident was not tested for COVID-19 and was asymptomatic. When interviewed by telephone on 4/22/20 at 12:20 p.m., the Registered Nurse (RN) Regional Director of Clinical Services said that the facility was moving Resident #1 to another room on the second floor that day. In an observation on 4/23/20 at 11:27 a.m., Resident #1 and Resident #7 remained in the same room together. b. Review of the facility's Infection Surveillance Sheet revealed that Resident #8 tested positive for COVID-19 on 4/13/20. In an observation on 4/23/20 at 12:09 p.m., the door to Residents #8 and #9's room had a droplet precaution sign. Both Resident #8 and Resident #9 were in their beds, and neither resident was wearing a mask. Review of the medical record for Resident #9 revealed that the resident was not tested for COVID-19 and was asymptomatic. 3. Resident #2 has [DIAGNOSES REDACTED]. The MDS Assessment, dated 4/1/20, revealed the resident had moderately impaired cognition. Review of Resident #2's medical record revealed that the resident was positive for COVID-19 on 4/20/20. In an observation on 4/23/20 at 12:27 p.m., the door to Resident #2's room had a droplet precaution sign. Both Resident #2 and Resident #6 were in their beds, and neither resident was wearing a mask. Review of Resident #6's medical record revealed that the resident was not tested for COVID-19 and was asymptomatic. When interviewed on 4/21/20 at 5:50 p.m., Licensed Practical Nurse (LPN) #1 said that resident's that are positive for COVID-19 have signs on their door that directs to see the nurse. She said that staff should put a blue gown over the yellow one-piece protective suits before entering resident's rooms that are COVID-19 positive. She said the blue gown should be removed before leaving the resident's room. In an interview on 4/24/20 at 9:23 a.m., the RN Regional Director of Clinical Services said that Residents #6, #7, and #9 had not been tested for COVID-19 and were asymptomatic and presumed negative. She said the facility was following CDC guidelines which recommended no movement of residents who had likely had an exposure to COVID-19. She said the privacy curtain should be pulled when a resident that is positive for COVID-19 rooms with a resident that is negative for COVID-19. She said the rooms allow for a 6-foot distance between the residents. She said both residents should wear masks, and the entire room should be placed on droplet precautions. She said she was not aware if the guidance for cohorting residents had changed. The facility's allegation of compliance to remove the Immediate Jeopardy, dated 4/24/20, included the following: a. Staff would be educated on infection control practices including, but not limited to, preventing cross contamination with an emphasis on factors that can lead to cross contamination, infection control practices, importance of appropriate PPE, implementing proper PPE with return demonstrations, and policies related to COVID-19. Proper signage on COVID-19 rooms doors that direct staff on the type of PPE needed and procedure for donning and doffing. b. Move residents that are not positive for COVID-19 so that they are no longer residing with residents that are positive for COVID-19. The Immediate Jeopardy was removed on 4/25/20 based upon surveyor observations and verifications which included the following: a. Observations revealed that Residents #6, #7, and #9 no longer reside in rooms with COVID-19 residents. b. Observations revealed that all COVID-19 residents had an isolation set up hanging on the door that was stocked with PPE and appropriate signage that directed staff on type of PPE needed and procedure for donning and doffing. Staff were removing all PPE prior to exiting a COVID-19 room (exception cleaning face shield with Clorox wipes) and performing hand hygiene. c. Staff were educated on infection control policies and procedures related to COVID-19 including PPE requirements, preventing cross contamination, donning and doffing PPE, and hand hygiene. The facility provided a copy of the power point used for education and signature sheets for those that completed the education. As of 4/25/20, 60 percent of the staff had been educated with a plan to educate all staff prior to working their next scheduled shift. On 4/27/20, greater than 90 percent of the staff had been educated with a plan to continue to educate all staff and new hires. (10 NYCRR 415.19)

Based on interviews and record reviews conducted during the Abbreviated Survey (complaint #NY 158), the facility did not provide necessary care and services to attain and maintain the resident's highest practicable well-being for one (Resident #1)of three residents reviewed. Specifically, staff did not complete skin checks including monitoring Resident #1's recently healed diabetic wounds as ordered by the physician, and the staff did not notify the Registered Nurse or physician regarding a change in the calloused area. Subsequently, the resident developed a severe wound infection and was admitted to the hospital, with an expected 40 to 60 days of treatment with intravenous antibiotics via a PICC (Peripherally Inserted Central Catheter, line inserted for access to the large central veins near the heart) line. This resulted in actual harm for Resident #1, which is not immediate jeopardy, and is evidenced by the following: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 12/27/19, revealed that the resident was cognitively intact and had a [MEDICAL CONDITION] with the application of dressings to the feet. Review of the facility policy, Risk and Skin Assessments, last revised November 2019, included that a skin assessment will be done by a licensed nurse weekly. The Comprehensive Care Plan, dated 12/23/19, included that the resident was at risk for impaired skin integrity related to diabetes and a history of ulceration. The goal was that the resident would not develop additional sites of impaired skin integrity. The interventions included to apply moisturizer as needed to the skin, do not massage over bony prominences and use mild cleansers for peri care/washing, give medications as ordered for pain, and report to physician any signs of deterioration or significant change to area of impairment. The current Certified Nursing Assistant (CNA) Care Kardex included under skin inspection to monitor for redness, open areas, scratches, cuts, bruises, and report changes to the nurse. Physician orders, dated 12/26/19, included a weekly skin assessment every Thursday evening with shower. The Wound Evaluation and Management Summary, dated 12/31/19 and signed by the wound care specialty physician, revealed that the diabetic wound on the left plantar foot was resolved, and to follow up as needed. The January 2020 Treatment Administration Records (TARs) included an entry for weekly skin assessment every Thursday evening. The entries for 1/2/20, 1/9/20, and 1/16/20 were signed off as completed. There was also an entry for skin prep and a dressing to the left plantar foot that was signed off daily as completed except for three days (1/4/20, 1/10/20, and 1/13/20). Review of the nursing progress notes, Nurse Practitioner, and physician notes revealed no documentation of skin assessments after 12/31/19. The Hospital Admission Emergency Department Notes revealed that on admission to the emergency department on 1/19/20 the resident's left foot had three areas of concern. The trans-metatarsal amputation incision had two blackened areas and the plantar aspect area was open with foul smelling drainage. When the areas were probed, they extended to the bone. Results of the culture and sensitivity of the wounds were Group B streptococcus, Staphylococcus aureus, staphylococcus lugdunensis, and Corynebacterium (bacterias that can cause infection). The facility's Incident and Accident Report and Investigation, dated 1/21/20, revealed the facility was notified the resident was admitted to the hospital with [REDACTED]. The investigation revealed that weekly skin checks were not completed on 1/2/20, 1/9/20, and 1/16/20. The nurses had initialed the TAR but did not complete a weekly skin note with the results of the head to toe check and admitted that they did not complete the skin checks. When interviewed on 1/23/20 at 11:00 a.m., CNA #1 stated that she never saw the resident's bare feet. She said when she provided cares, the resident had socks on, and she did not remove them. During an interview on 1/23/20 at 12:33 p.m., Licensed Practical Nurse (LPN) #1 said she signed the TAR that she completed skin checks, however, did not complete the checks. She said she completed daily wound care to a callous on the bottom of the left foot. LPN #1 said that on 1/17/20, she noticed that the callous had more drainage than ususal and was dark brown. She said she noticed the callous seemed to be mushier then previously. She said she did not report that to anyone. When interviewed on 1/22/20 at 12:51 p.m., the ADON/Wound Care Nurse said that the resident had some wounds on their feet that were seen by the skin team (Wound Care Physician and herself). She stated that those wounds (right plantar medial and the left plantar foot) were resolved on 12/31/19. She said after the resident's family reported to the facility that the resident was admitted to the hospital with [REDACTED]. She said she found that after the initial skin assessment, the nurses did not do another skin assessment and were not looking at the resident's skin. She said, That was on us. She said she expects the nurses to look at the resident's skin every week on shower day even if the resident does not take a shower. In an interview on 1/29/20 at 12:50 p.m., the Director of Nursing stated that she never looked at the resident's skin. She said that the LPNs should have been doing weekly skin monitoring and writing a note. She said that after the resident went to the hospital the family told her the resident had infections in their left foot and when it was investigated, it was found that there were no skin checks documented for the resident. In an interview on 1/23/20 at 11:22 a.m., the Nurse Practitioner said that she assessed the resident's feet on 12/31/19 when she completed the admission assessment. She said the resident's feet were dry and scaly and that she does not remember seeing a left trans-metatarsal amputation or anything significant like an infection. She said she expects the nurses to do weekly skin checks and report changes to the ADON. She said no one told her that skin checks were not being done. When interviewed by telephone on 1/24/20 at 12:35 p.m., the facility Skin Care Physician said he only looks at the wounds that the nurses tell him about, he does not look at the whole body. He said that the wounds on the resident's feet were healed on 12/31/19 and he was not asked to see the resident again. The Skin Care Physician stated that he expects the nurses to observe the skin and report to him when they find issues. He said that callouses and eschar areas need to be watched carefully and kept dry. He said that if a nurse found an area under the callous to be mushy, he would have expected that to be reported immediately. He said that could be a sign that the wound was deterioriating. (10 NYCRR 415.12)

Based on interviews and record reviews conducted during the Abbreviated Survey (complaint #NY 245) completed on 6/5/19, it was determined that for one (Resident #13) of six residents reviewed, the facility did not ensure that each resident received the necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being. Specifically, the facility did not ensure that the resident received ongoing monitoring of behavioral conditions, an individualized behavioral care plan, and/or implementation of psychiatric services recommendations. This led to increased behaviors, including physically attacking another resident causing an injury that resulted in actual harm. This is evidenced by the following: Resident #13 was admitted to the facility on [DATE] and was recently readmitted on [DATE] with a long history of psychiatric care and current [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 4/7/19, revealed that the resident had severely impaired cognition, inattention and disorganized thinking, had no behavioral or mood symptoms, and received antipsychotic medication. The undated facility policy, [MEDICAL CONDITION] Medications/Behavior Monitoring included that during the interdisciplinary report staff would discuss any behavioral changes in residents. The Social Worker will initiate a behavior tracking form, behavior care plan, and a behavior care card related to the behavior problem. The use of the tracking form will continue for one week after behavior is noted and then reviewed to ensure appropriate interventions are in place. The hospital discharge paperwork, dated 3/18/19, included that the resident needed 1:1 supervision for impulsivity, decreased safety awareness, and to ensure he did not color on the walls while at the hospital. The nursing home administration agreed to being able to meet the residents and his return to the facility. The resident was discharged on [MEDICATION NAME] 300 milligrams (mg) twice a day (mood stabilizer) and [MEDICATION NAME] 20 mg daily (antipsychotic). Readmission medical orders, dated 3/19/19, included [MEDICATION NAME] 300 mg twice a day and [MEDICATION NAME] 20 mg at bedtime. A Nurse Practitioner (NP) note, dated 3/21/19, included that the resident was recently readmitted following hospitalization for a urinary tract infection and mental status changes and his [MEDICATION NAME] was decreased and he has returned to his baseline. A previous Activities of Daily Living Certified Nursing Assistant (CNA) Care Plan, dated 3/9/18, included that the resident will urinate and smear feces on furniture and walls, to discourage pens and pencils in room (resident will write on walls and tables), sink water to be shut off except when supervised, prompt resident to go for a walk every two to three hours with cues for safety, and that the resident was at risk for physically/sexually/verbally aggressive behavior. The current undated CNA Care Card included no behavioral or mood interventions. The Comprehensive Care Plan, dated 4/14/19 and revised 5/7/19, included general behavioral interventions but did not include any resident specific behavioral interventions. Review of Psychiatric Consults, dated from 5/9/18 to 4/28/19, revealed that the resident had severely impaired cognitive function, no insight, and poor judgement. He was unable to engage or comprehend non-pharmacological interventions and was unable to use or learn safety measures. The resident had shown ongoing aggression, agitation, impulsivity, wandering/explorative behaviors, and an increased risk of altercation/violence. The 4/28/19 psychiatrist consult revealed that he saw the resident following a recent hospitalization for reports of increased behaviors including damage and destruction of property, removal of Wanderguard and leaving the secured unit, and difficulty redirecting. The resident was generally fixated on pencils/writing/scribbling/drawing. He had episodes of aggression/violence in the past because his medications were adjusted down or discontinued while in the hospital. The resident did relatively well before his recent hospitalization for a urinary tract infection and change in [MEDICATION NAME] levels. The psychiatrist recommended an increase in [MEDICATION NAME] to 300 mg and 600 mg daily for three days, then increase to 600 mg twice a day (checking [MEDICATION NAME] levels once a week), then target dose up to 1,500 mg daily. The resident may also need an increase in [MEDICATION NAME]. The facility was unable to provide medical orders for, or documentation as to why the psychiatric medication changes were not implemented. Additionally, there was a lack of documentation of behavioral monitoring and interventions. A NP note, dated 5/2/19, included that the resident was back to his baseline, his behavior was stable with current treatment of [REDACTED]. Review of the Nursing Progress Notes, dated 5/6/19, revealed that the resident had an increase in his behavioral outbursts over the last few weeks and was struggling to maintain his composure on the unit, he was intimidating to other residents, and was often intrusive and unable to maintain boundaries. On 5/6/19 the resident broke a beside table, struck another resident in the torso and face injuring the other resident, and sat himself on the floor. A NP note, dated 5/6/19, included that she was asked to see the resident for increased aggressive behavior including hitting, yelling, and cursing at another resident and breaking an overbed table. The resident was a danger to himself and others and was sent to the hospital for further evaluation. The facility investigation form, dated 5/7/19 at 4:30p.m., revealed the resident had increased aggressive behavior including ripping a toilet off the wall two weeks prior. On 5/6/19, the resident wandered into the dining area and unprovoked walked up to another resident, punched him several times in the torso and slapped him in the left side of his face causing a small hematoma, and broke an over bed table. The resident was sent to the emergency roiagnom on [DATE] for evaluation and has remained in the hospital psychiatric unit while awaiting more appropriate placement. Interviews conducted on 5/21/19 included the following: a. At 10:27 a.m. and again on 5/31/19 at 12:29 p.m., the NP said that the resident wanders and can normally be redirected; however, when the resident is aggressive staff do not know what he will do, he tends to hit things like the sink or walls but not people. She said there was a lot of new staff on the unit who may not know how to care for residents like him. She said residents like him also do not adjust well to staff changes. She said that the facility installed chalk boards for the resident to write on but was not aware of other nonpharmacological interventions attempted or currently in place. The NP said that the resident's behaviors should have been documented by nursing and she should have been notified when his behaviors increased. The NP said that she was not made aware of the 4/28/19 psych consult recommendations until after surveyor intervention. The NP said she would have wanted to see the consult and would have implemented the recommendations and watched the resident more closely. b. At 11:42 a.m., CNA #1 said that the resident normally does not bother anyone, and if he is wandering or having behaviors she will direct him to chalk on the walls and redirect him away from other residents. She said that she never directly looked at his care plan to determine behavioral interventions. c. At 12:06 p.m., LPN #2 said that the resident had been getting more agitated over the last two to three weeks and redirecting was not easy. She said he would try to get in her medication cart, and when she tried to redirect him he would stand up tall (he was a tall and large man) and try to bully her. She said the resident also broke the toilet in the shower room and punched a hole in the wall. She said that the medication nurse should have documented and reported the behaviors. LPN #1 said she had never heard of the resident having any physical contact with another resident prior to 5/6/19. Interviews conducted on 5/22/19 included the following: a. At 9:19 a.m., 1:06 p.m., and 4:26 p.m., the Corporate Director of Nursing (DON) said that the resident has behaviors but they were never directed towards other residents prior to 5/6/19. She said that his behaviors should have been documented by nursing but she could not find any additional information. She said the increased aggressive behaviors might have been different if the facility had regular staff instead of agency staff. She also said that the facility was not helping the resident reach his maximum capabilities, were not specially trained for his needs, and were no longer able to meet his needs and therefore he was not able to return to the facility after the 5/6/19 incident. b. At 3:46 p.m., the ADON said that the resident was a threat to residents and staff and the facility was unable to meet his psychiatric needs and he belonged somewhere that could. She said staff should be documenting the resident's behaviors even if routine, however the staff were not aware they needed to do that. When interviewed on 6/5/19 at 8:44 a.m., the SW said that she had limited interaction with the resident. The SW said that the resident fluctuated between calmer days and increased agitation where he would strike out at the physical surroundings. The SW said she never initiated a behavior log as nursing staff were supposed to document behaviors in the computerized medical record, however they have been very inconsistent in doing so. The SW said that the resident's behavioral care plan did not include resident specific interventions and she was not aware of any besides providing him with chalk. She said that she gives the psychiatric recommendations to the NP or Corporate DON and did not know why the recommendations were not put into place. (10 NYCRR 415.12(f)(1))

Based on interviews and record reviews conducted during an Abbreviated Survey (complaints #NY 477, #NY 153, #NY 271, and #NY 117) completed on 6/5/19, it was determined that for 1 (Resident #3) of 24 residents reviewed, the facility did not ensure that each resident received the necessary care and services to attain and maintain the resident's highest practical well-being. Specifically, Resident #3 did not have insulin ordered upon admisson and his blood glucose levels were not consistently monitored per the medical provider. The resident became hyperglycemic (elevated blood sugar) and was hospitalized resulting in actual harm for the resident. This is evidenced by the following: Resident #3 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 12/28/18, revealed that the resident had moderately impaired cognition and was not receiving insulin injections. The Hospital Discharge Medication list, dated 10/29/18, revealed that the resident was to continue to receive the following insulin orders: a. Humalog (fast acting insulin) 100 units per milliliter (ml) injection at bedtime based on the resident's blood glucose (BG) results. If BG is 141 to 200, no units; 201 to 250, 1 unit; 251 to 300, 2 units; 301 to 350, 3 units; and greater than 351, 4 units. b. Humalog 100 units/ml three times daily before meals, give 2 units for every 50 points the BG is above 100. The hospital bloodwork, dated 10/30/18, revealed a hemoglobin A1C (HbA1c - test result reflects your average blood sugar level for several months) of 6.5 percent (reference range of 4.0 to 6.0 percent). Medical admission orders [REDACTED]. The order was transcribed onto the Medication Administration Record (MAR) and documented as completed daily except on 10/30/18 (nothing documented) and ranged from 147 to 227. There were no orders for insulin and no explanation as to why the hospital recommendations were not followed. Review of the medical record from 10/29/18 to 1/24/19, revealed diabetes listed as a problem in the medical progress notes but no plan to manage or monitor the diabetes until 1/25/19. Additionally, there were no documented BG checks between 11/7/18 and 1/24/19 found in the medical record. Medical orders, dated 1/25/19, included to administer Humalog 100 units/ml, inject 10 units x 1 now for [MEDICAL CONDITION] and start sliding scale based on BG levels. If BG is between 0 to 200, no units; 201 to 250, 2 units; 251 to 300, 4 units, 301 to 350, 6 units; 351 to 400, 8 units; 401 to 450, 10 units and inform medical if BG is less than 60 or greater than 450. The orders did not include how often to check the BGs and administer the sliding scale. Also ordered was to check a fasting BG and HbA1c on 1/26/19 but no results were found in the medical record for this bloodwork. Review of the (MONTH) 2019 MAR revealed that on 1/25/19 the resident had a BG of 600 and was given a one time dose of Humalog 10 units. The MARs included the sliding scale coverage in addition to 8 units of baseline (despite no orders for baseline insulin), and BG checks were done three times a day before meals from 1/25/19 through 1/30/19 and ranged from 136 to 441. Physician orders, dated 1/28/19, included [MEDICATION NAME] (long acting insulin used to control BG over 24 hours) 10 units every evening at 5:00 p.m., to check the BG prior to the insulin administration, and to include a snack at bedtime. Review of the (MONTH) 2019 MAR revealed that the [MEDICATION NAME] was administered at 9:00 p.m. as opposed to 5:00 p.m., and no BG check was done prior to administration of the [MEDICATION NAME]. A physician order, dated 1/30/19 at 11:00 a.m., included to administer a baseline Humalog 8 units in addition to the sliding scale as ordered on [DATE] (for a BG of 441) and recheck the BG one hour after coverage. The (MONTH) 2019 MAR revealed that 10 units of Humalog was administered on 1/30/19 at 11:30 a.m., for the 441 BG per the sliding scale, however, there was no documentation that the 8 units of baseline Humalog insulin was also administered or that the BG was rechecked one hour after coverage. A physician order, dated 1/30/19, revealed that the resident was transferred to the hospital at 3:00 p.m., due to an uncontrolled BG reading of 570. The resident did not return to the facility. Review of the hospital medical records, dated 2/6/19, included that the resident was admitted with [MEDICAL CONDITION], questionable pneumonia, and a urinary tract infection. The medical records included that the resident's HbA1c on 1/26/19 (while in the facility) was 10.1 percent and on 1/31/19, it was 10.4 percent. The report included that the resident had elevated/increasing blood glucose levels over the last several weeks and poor intake and adjustments were made to the resident's insulin medications. In an interview on 5/20/19 at 10:52 a.m., a family member said that the resident managed to keep his BGs between approximately 90 to 100 on oral agents when home but was changed to insulin coverage at the hospital prior to being admitted to the facility. The family member said they were told by facility staff that the resident's BGs were stable and that he did not need his diabetic medications, but on 1/25/19 the resident's BG was 600 and they did not send him to the hospital. The family member said it was not until 1/30/19 that the resident was hospitalized for [REDACTED]. When interviewed on 5/21/19 at 10:27 a.m. and on 6/3/19 at 12:13 p.m., the Nurse Practitioner (NP), who gave the verbal orders on admission, said that the resident came from the hospital to the facility on insulin and should have been receiving it and having his BGs checked regularly. She said she did not know why that was not done. The NP said she normally addressed diabetes control in her notes but could not state why she did not for this resident. She said that she ordered Humalog on 1/25/19 because it came to her attention that the resident's BG checks were not being done and insulin was not being given. The NP said she did not review the MAR and relied on the nurses to tell her how the resident was doing. She said the nurse told her the resident's BGs were good even though they were not being done. She said that she ordered [MEDICATION NAME] at 5:00 p.m. since it peaks in three to four hours and staff could better monitor if the resident's BG dropped and she did not know that it was transcribed and given at 9:00 p.m. The NP said on 1/30/19 she added Humalog 8 units as a baseline along with the sliding scale, but after review of the MARS she could see it was transcribed incorrectly. She said the resident should have received 18 units on 1/30/19 at 11:30 a.m. (versus the 10 units documented) when his BG was 441. The NP said that prior to 1/25/19, the resident was lethargic and she thought it was [DIAGNOSES REDACTED] (chronic sleep disorder that causes overwhelming daytime drowsiness) but never checked his BGs to see if that might have been the cause. She said the resident also had increased skin breakdown which could possibly be due to higher BGs. When interviewed on 6/4/19 at 8:57 a.m., the primary Licensed Practical Nurse (LPN) said she was not routinely checking the resident's BG because he had no symptoms and it was not ordered. The LPN said she could not remember the exact day, but the resident was cold, clammy, sweating, and mentally out of it, so she contacted the NP and she was told to check the resident's BG. The LPN said the resident's BG was greater than 600, and the NP ordered a one time dose of insulin and to recheck the BG in one hour. She said she thought the second BG was still high, but she could not remember what it was. In conclusion, the facility did not assess or develop a plan for the management and monitoring of the resident's diabetes. Insulin was not ordered timely upon admission and the resident's BG were not monitored for several weeks. When insulin was ordered there was no frequency for administration provided for the Humalog sliding scale. The Humalog insulin was not consistently administered in the correct dosage (baseline plus the sliding scale units), and the order for [MEDICATION NAME]was not transcribed and scheduled on the MAR as ordered. As a result, the resident was sent to the hospital with [MEDICAL CONDITION] significant elevated HbA1c and medication adjustments were made. (10 NYCRR 415.12)

Based on interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 839) completed on [DATE], it was determined that for one (Resident #1) of three residents reviewed for quality of care, the facility did not provide the necessary care and services to attain and maintain the resident's highest practicable well-being. The issues involved the lack of a timely Registered Nurse (RN) assessment for complaints of abdominal pain and low-grade temperature, the lack of timely contact with the on-call medical provider for abdominal pain, low grade temperature, and high blood glucose readings, and bowel medications were administered incorrectly which resulted in delay of treatment and the resident expired. This is evidenced by the following: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated [DATE], revealed the resident had severely impaired cognition, diabetes, and received insulin. The untitled facility policy, effective [DATE], included if no parameters are set in the physician's orders [REDACTED]. The Assure Platinum Blood Glucose Monitoring System User Instruction Manual provided by the facility, revealed that if your blood glucose is above 600 you will receive a high reading. Repeat the test with a new test strip. If the message shows again, contact your healthcare professional immediately. The facility policy, Bowel Regimen/Documentation, dated 2017, included a bowel movement (BM) protocol that directed if no BM in three full days (nine shifts), give [MEDICATION NAME] (laxative) 30 cubic centimeter (cc) once at 8:00 p.m. On-call medical provider message: On [DATE] at 3:40 p.m., the Assistant Director of Nursing (ADON) dialed the on-call medical provider's telephone number and placed the call on speaker phone. The voice message directed to dial #1 for emergency message, #2 for routine message, and #3 for notification message. The physician orders, dated [DATE], included [MEDICATION NAME] 30 cc if no BM in three days. The BM record revealed that the resident had two large BMs on [DATE]. The [DATE] Medication Administration Record [REDACTED]. The Medical Orders for Life Sustaining Treatment (MOLST), dated [DATE], included Do Not Resuscitate, do not send to hospital unless pain or severe symptoms cannot be otherwise controlled. The MOLST was reviewed and updated on [DATE] by the medical provider with no changes. The evening shift 24-hour report, dated [DATE], included painful firm abdomen, more pain in the left lower abdomen, blood pressure was ,[DATE], heart rate 110, respirations 18, oxygen saturation level 94 percent, temperature 100.2 degrees Fahrenheit, and [MEDICATION NAME] was given at 9:30 p.m. with results pending. The progress note, dated [DATE] at 10:33 p.m., revealed that Licensed Practical Nurse (LPN) #1 was called to the unit as the resident had complaints of right lower quadrant pain and a low-grade temperature. The resident's abdomen was firm, distended, bowel sounds positive in all four quadrants, and the resident had two large BMs on [DATE]. Vital signs included blood pressure ,[DATE], heart rate 110, temperature 100.2 degrees Fahrenheit, and the oxygen saturation level was 94 percent. The resident was given as needed [MEDICATION NAME] at 9:30 p.m. with results pending. LPN #1 documented that medical was notified and pending further order. The addendum progress note, dated [DATE], completed by LPN #2 at 10:34 p.m., included painful right lower abdominal area. The progress note, dated [DATE] at 7:06 a.m., revealed that the RN Supervisor was notified by LPN #3 that the resident was not feeling well and seemed to have labored breathing. LPN #3 checked the resident's vital signs and BG and documented the following results: blood pressure was ,[DATE], temperature was 100.2 degrees Fahrenheit, heart rate was 126 and BG read HIGH. The RN Supervisor directed LPN #3 to notify on-call medical of the resident's new vital signs and changes in comparison to vitals taken on the evening shift. LPN #3 called the on-call medical provider at approximately 3:40 a.m. and left a detailed message and asked for a return call. LPN #3 rechecked the resident's BG at 4:37 a.m. and the BG read 514. The RN Supervisor instructed LPN #3 to call medical again and press #1 for an immediate call back due to the resident's BG being high. LPN #3 called the RN Supervisor back at 5:45 a.m. to notify her that on-call medical had not called back. The RN Supervisor came to the floor to check the chart for other measures to be taken to help lower the resident's BG. At that time, LPN #3 reported that the resident was no longer breathing. The RN Supervisor assessed with [REDACTED]. The on-call medical provider called back at 8:00 a.m. and gave an order to release the body to the funeral home. The progress note, dated [DATE] at 8:48 a.m., revealed that LPN #3 noted that the resident was not feeling well and seemed to have labored breathing. The RN Supervisor was notified and a message was left for medical on-call regarding the resident's condition and BG. The RN Supervisor gave directions to notify on-call medical with the new set of vital signs and changes in comparison to vital signs taken on the evening shift. LPN #3 called on-call a second time at approximately 3:40 a.m. and left a detailed message and asked for a return call. LPN #3 rechecked the resident's BG at 4:37 a.m. and BG read 514. The RN Supervisor came to the floor and checked the chart for other measures to help lower BG. The BG had decreased from last check and the resident's temperature was 98.9 degrees Fahrenheit. The resident was offered fluids and declined. LPN #3 went to the resident's room at 5:45 a.m. and the resident was unresponsive. The RN Supervisor assessed the resident and there were no signs of breathing or pulses noted. A message was left for the on-call medical provider that the resident expired. The medical provider called back at 8:00 a.m. and gave an order to release the body to the funeral home. When interviewed on [DATE] at 12:30 p.m., the ADON stated that the resident's MOLST included may send to the hospital if cannot control pain. She said on [DATE], the on-call medical provider was notified of the resident's low-grade temp and complaints of abdominal pain but did not call back. The ADON stated that the Nurse Practitioner (NP) on-call stated she tried to call back but no one answered the telephone. The ADON said that she was in the facility on the evening of [DATE], and LPN #1 reported to her at 10:55 p.m. that the resident had complaints of abdominal pain and had a low-grade temperature. The ADON said she did not assess the resident because she was on her way out the door. The ADON stated that LPN #1 put a call out to medical because the resident did not have an order for [REDACTED]. When interviewed on [DATE] at 2:20 p.m., the RN Supervisor stated that LPN #1 reported that the on-call medical provider was called at 9:30 p.m. for the resident, however, when the NP called back at 12:30 a.m. she provided orders for another resident. The RN Supervisor stated that LPN #3 did not follow-up with the NP regarding the resident's complaints of abdominal pain and his temperature when speaking to the on-call NP at 12:30 a.m. because LPN #3 did not think about the resident at that time. The RN Supervisor stated that she assessed the resident at 3:40 a.m., and the resident's abdomen was firm and distended, he was breathing easy and did not appear to be in pain. The RN Supervisor stated that at 4:30 a.m. LPN #3 notified her that the on-call NP did not call back. The RN Supervisor said she told LPN #3 to hit #1 when calling on-call for an immediate call back. The RN Supervisor stated that the resident's BG was 514, and she told LPN #3 they needed an order for [REDACTED]. The RN Supervisor stated that the on-call NP was again called after 5:00 a.m., and LPN #3 reported at 5:45 a.m. that the on-call NP still had not returned the call. The RN Supervisor stated that when calling the on-call medical provider, choice #1 should be pressed for emergencies. She said that she has had previous occasions when calling the on-call NP when the NP has said not to press #1 and say emergency. The RN Supervisor stated that the ADON advised her that she should have sent the resident to the hospital without a physician's orders [REDACTED]. The RN Supervisor asked for a policy and the ADON said, No, it is upfront. When interviewed on [DATE] at 3:45 p.m., LPN #1 stated that on [DATE], LPN #2 called her to the unit around 9:30p.m. to 10:00 p.m., due to the resident's distended abdomen, low grade temperature and complaints of abdominal pain. LPN #1 stated that when asked if he was in pain, the resident had facial grimacing during abdominal palpation that told her he had pain. LPN #1 stated that she called the on-call medical provider and pressed #3 for notification because she felt the resident was stable at that time, and she expected the on-call medical provider would call back in an hour or two. LPN #1 said that she did not hear from on-call before she left at 11:00 p.m., and she reported her observations to the RN Supervisor and suggested maybe she should call the on-call medical provider again. LPN #1 stated that LPN #2 administered [MEDICATION NAME] for distended abdomen, but the resident had two large BMs the day before and the resident should not have received [MEDICATION NAME] unless there were no BMs in three days. LPN #1 stated that if a RN is not in the building, she is expected to call the on- call RN for an assessment. LPN #1 stated she did not request a RN assessment because medical was notified, and she assumed the RN Supervisor would do her rounds and follow-up with the resident. LPN #1 stated that she did not understand that a resident could be sent to the hospital without a medical provider order. When interviewed on [DATE] at 5:30 p.m., LPN #2 stated that the resident complained of left lower abdomen pain around 9:00 p.m., and his abdomen was firm, so she administered [MEDICATION NAME] to rule out constipation. LPN #2 stated that she checked the resident's BM record and saw he had one the day before, but the Certified Nursing Assistant (CNA) said the resident did not have a BM on [DATE] during the evening shift. LPN #2 stated that she did not talk to the CNAs who recorded the two large BMs on [DATE]. LPN #2 stated that she documented left abdominal pain, but the pain was on the right side. LPN #2 stated that the on-call medical provider usually returns calls to the Supervisor. LPN #2 said if it was her, she would have called the on-call medical provider back before she left. LPN #2 stated that if there is no RN in the building, the Director of Nursing (DON) needs to be called if the nurses are having trouble getting in touch with the on-call medical provider. LPN #2 said that the nurses need a physician order [REDACTED]. When interviewed on [DATE] at 11:20 a.m., the NP stated that she received an emergency call from the facility between 12:15 a.m. and 12:30 a.m. on [DATE], and could not get through as no one answered. The NP stated that she received a routine call from LPN #1 advising her the resident had a low-grade fever, abdominal distention and was administered [MEDICATION NAME]. The NP stated she called back to give an order for [REDACTED].#3 did not mention the resident's low grade fever or anything about abdominal pain. The NP stated that she received another call at 3:00 a.m. about the resident, but it was not an emergency. The NP stated that she tried to call back, but no one answered. The NP said she received a routine call at 5:00 a.m. from the RN Supervisor who advised her that the resident had passed away. The NP said that LPN #3 never said that the call was urgent and reported the resident's BG was elevated, but not how elevated. The NP stated that if the nurses are having difficulties getting in touch with on-call, they are expected to call the DON and the DON will text the NP. The NP stated that if the nurses reported the observations on the first call as an emergency instead of notification, she would have asked questions and handled the call differently. The NP said that the on-call medical provider was not required to call back for notifications. When interviewed on [DATE] at 12:40 p.m., LPN #3 stated that on [DATE] at 11:00 p.m. or so, she received report that the resident was having abdominal pain and had a temperature. She said they were waiting for the NP to call back. LPN #3 stated that when she first called the on-call NP, she pressed #2 for routine because the NP gets upset when you push #1 if it is not an emergency. LPN #3 stated that the RN Supervisor told her to call back and press #1 and she did, and the NP called back around 12:30 p.m. concerning another resident. LPN #3 stated that the first BG reading she took read high, and she took the BG because the CNA said the resident had labored breathing and it looked like the shakes which is huge for diabetics. LPN #3 stated that she called on-call and pressed #2 and left a message that the BG was high. LPN #3 stated that high could be as high as 2,000, you do not know. LPN #3 stated that after she called the on-call NP, she sat by the telephone with two CNAs but the NP never called back. LPN #3 stated that she took another BG around 4:45 a.m., and the results were 514, and at that time, she called the on- call medical provider and pressed #1 for an emergency. LPN #3 said that the resident's abdomen was really distended and it looked like there was a baby in there. LPN #3 said that the resident had not been right since the beginning of the night shift, and should have been assessed by a RN at 9:30 p.m., and the situation handled then. LPN #3 stated that after the incident, the ADON said that she could have called 911. LPN #3 said she never was told or saw that in writing, and LPNs cannot assess. When interviewed on [DATE] at 1:30 p.m., the evening CNA stated that on [DATE], the resident was moaning when he tried to wake him up. He said the resident was difficult to wake up. The evening CNA stated that he reported to LPN #2 that this was not normal for the resident. When interviewed on [DATE] at 12:25 p.m., the first floor Nurse Manager (NM) stated that when calling the on-call medical provider, if it is an emergency, push #1 for emergency, and if there is no return call in 20 minutes, call again and, if the on-call medical provider does not call back, send the resident to the hospital. When interviewed on [DATE] at 12:38 p.m., the LPN/NM stated that when calling the on-call medical provider, hit #1 for emergency and call the DON; wait 10 to 15 minutes depending on the emergency, then call the on-call medical provider again. She said if there was no response, call the DON, ADON or Supervisor. (10 NYCRR 415.12)

Based on observations, resident and staff interviews, and record reviews, it was determined during an Extended Survey and complaint investigation(#NY 873) that the facility failed to maintain a Quality Assessment and Assurance (QAA) Committee that readily and consistently identified and corrected quality deficiencies. THIS IS A REPEAT DEFICIENCY FROM THE RECERTIFICATION SURVEY OF 4/25/12. This resulted in no actual harm with potential for serious harm that is IMMEDIATE JEOPARDY TO RESIDENT HEALTH AND SAFETY. Facility staff lack knowledge of the QAA process. This is demonstrated by citations at F323, Accidents/Supervision (L); F314, Pressure Ulcers (G); F253, Housekeeping/Maintenance (F); and multiple repeated deficiencies for up to five Recertification Survey cycles (F225, F246, F282, F253, F314, F315, F323, F333, F431, F441, and F520. The findings are: 1. F 323 - Repeated from Recertification Surveys of 4/25/12 and 6/17/11 and an Abbreviated Survey of 4/26/13. The facility failed to maintain an environment free of accident hazards as evidenced by the presence of a damaged extension cord, with exposed metal [MEDICATION NAME], that was plugged into a live electrical outlet in Resident room [ROOM NUMBER]. In an interview on 6/25/13 at 12:30 p.m., the Maintenance Director stated that the facility did not have a policy/procedure in place that addressed safe use of electrical outlets. In an interview on 6/27/13 at 9:56 a.m., the Director of Central Supply stated that he had observed this damaged extension cord, had logged the issue in the maintenance log book, but had not removed this extension cord from the room immediately. 2. F253 - Repeated from the Recertification Surveys of 4/25/12, 6/17/11, 6/10/10, and 8/27/09, and from the Abbreviated Surveys of 2/8/13 and 1/24/13. Housekeeping and maintenance services do not provide a sanitary, orderly, and comfortable interior. The facility continues to have faulty ceiling leaks, plumbing leaks, and subsequent pools of stagnating water, and faulty or nonfunctioning ventilation systems, in addition to other identified concerns. 3. F314 - Repeated from the Abbreviated Surveys of 4/26/13 and 8/3/12. Residents are not receiving timely and consistent treatment and services to heal existing pressure sores and to prevent new pressure sores from developing. 4. F225 - Repeated from the Recertification Surveys of 4/25/12 and 6/17/11, and Abbreviated Surveys of 2/28/13 and 4/26/13. The facility did not complete thorough investigations of incidents to rule out abuse, neglect or mistreatment. 5. F246 - Repeated from the Recertification Survey of 4/25/12. The facility did not ensure that resident call bells are kept within a resident's reach. 6. F282 - Repeated from the Recertification Surveys of 4/25/12 and 6/17/11. Residents are not being provided services by qualified staff according to comprehensive assessments. 7. F315 - Repeated from the Abbreviated Survey of 8/3/12. Lack of consistent urinary catheter care, including, but not limited to, urinary catheters that were not secured to prevent discomfort and unplanned removal. 8. F333 - Repeated from the Recertification Survey of 4/25/12. The facility failed to maintain a Quality Assurance and Assessment Committee. 9. F431 - Repeated from Recertification Surveys of 4/25/12, 6/17/11, 6/10/10, and 8/2/09. The facility does not ensure that controlled substances are stored in a safe and secure environment. 10. F441 - Repeated from the Recertification Surveys of 4/25/12, 6/17/11, and 6/10/10. The facility does not consistently manage systems to ensure that infection control policies and procedures are enforced. 11. F520 - Repeated from the Recertification Survey of 4/25/12. The facility failed to maintain a Quality Assessment and Assurance (QAA) Committee that readily and consistently identifies and corrects quality deficiencies. When interviewed on 6/28/13 at 10:10 a.m., the Administrator said she started an audit tool for previous surveys but never completed the paperwork. She said she takes notes when she does rounds, but they were not part of quality assurance and did not keep them. (10 NYCRR 415.27(a-c))

Based on observations, resident and staff interviews, and record reviews, it was determined that for Resident #20 and the 72 other residents residing in the facility, facility staff failed to ensure that the resident environment remained as free of accident hazards as possible. Specifically, a 12-foot long extension cord that was missing the plastic plug housing, which exposed wires and metal electrodes, was found in an alert, nonambulatory, and legally blind resident's room. The cord was plugged into an electrically energized outlet behind the resident's bed. The exposed end of the cord was underneath the metal bedside stand intertwined with the telephone cord. The condition and location of this extension cord placed Resident #20 at risk for electrical shock and all facility residents at risk for a potential fire. This resulted in no actual harm with potential for serious harm that is IMMEDIATE JEOPARDY AND SUBSTANDARD QUALITY OF CARE. In addition, based on observations, staff interviews, and record reviews, it was determined that for two of two residents observed for lack of adequate supervision/accidents, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents. THIS IS A REPEAT DEFICIENCY FROM THE ABBREVIATED SURVEY OF 4/26/13. Specifically, Resident #11, who has prescribed aspiration precautions, was not supervised at all times when eating/drinking, and Resident #60's right foot was dragged across the floor during multiple observed wheelchair transports. This resulted in a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following: 1. Resident #20 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Assessment, dated 5/18/13, revealed that the resident's cognitive skills for daily decision making are intact. Observations made during the Life Safety Code tour on 6/25/13 from 8:23 a.m. to 10:30 a.m. revealed the presence of damaged or broken electrical outlets in Resident Rooms #102, #117, #220, and #222. During an interview that day at 12:30 p.m., the Maintenance Director stated that there were no preventative maintenance plans in place specific to assessment of electrical outlet safety. Also, staff are expected to report all maintenance issues in the maintenance requisition log books. Observations, interviews and record review completed on 6/27/13 were as follows: a. At 9:28 a.m., the first floor maintenance log book located at the nurses' station was reviewed by the surveyor. This log included a requisition, dated 6/20/13 for Resident Room #110B, for a resident reported issue related to the end of a brown extension cord. The requisition was written by the Director of Central Supply (DCS), who wrote, "likely to be replaced." b. At 9:30 a.m., a brown extension cord was plugged into the duplex electrical receptacle on the wall behind the bed closest to the window. The extension cord was not equipped with a grounding prong, nor did it have surge protection. The receiving end of the extension cord furthest from the wall outlet was broken, exposing two metal electrodes. Copper wiring was lying on the floor beneath the metal nightstand approximately 2 feet from the bed. Two brown broken plastic pieces of the covering for the receiving end were sitting on the nightstand. The surveyor immediately unplugged the extension cord and gave it to the Maintenance Director, who was shown the work order. c. At 9:50 a.m., the breaker at the electrical panel designated for the electrical plugs in Room #110 was in the ON position. d. At 9:56 a.m., the DCS stated that he had seen the brown extension cord in the same condition that the surveyor had found it in and just figured it needed to be replaced. Also, he entered the repair request in the maintenance log book and thought he told maintenance about the issue. e. From 10:15 a.m. to 12:14 p.m., multi-plug electrical adaptors and extension cords that lacked surge protection were found in Resident Rooms #101, #107, #109, #114, and #216. Additionally, the third prong grounding portion of the duplex outlet in Resident Room #107 had an approximately 1/4-inch broken and missing section of the receptacle, and the duplex outlet in Resident Room #217 (A-bed) was cracked. f. At 12:30 p.m. and 12:40 p.m, the maintenance staff worker stated he did not know about the damaged extension cord until that day. The DCS did not tell him about this issue and has been asked to report issues like this immediately. Also, the DCS checks the maintenance log books about every three days. The maintenance staff worker checks the log books multiple times daily. Observations, resident and staff interviews, and record review, completed on 6/28/13, included the following: a. At 9:00 a.m., a Certified Nursing Assistant (CNA) said that she recalled the extension cord in Resident Room #110 looked like there were two gold pieces on the end. The CNA stated that she reported this to a nurse. She usually reports this to a nurse or makes an entry into the maintenance log book. b. At 9:00 a.m., Resident # 20 explained that the extension cord in her room (that she had brought from home) was frayed and sparked when she tried to plug it in. She did report this to the DCS, who also saw that it sparked. The DCS did not take the extension cord at that time. Resident #20 reported that she uses the extension cord for her tape recorder and usually plugs this in herself. After it sparked, she unplugged the cord and put it behind her bed so that no one would get hurt. c. At 10:00 a.m., the Director of Social Work (DSW) stated that on 6/26/13 she called the maintenance worker to report that five maintenance requests had not been signed. She did not review the content of the requests. d. At 3:08 p.m. the Administrator provided documentation of audits conducted of the maintenance repair requisition log books. The audits were directed as part of a Plan of Correction from a previous deficiency and were to be conducted weekly. The Administrator stated that she has not been doing the audits weekly. A review of the audit records revealed that the last audit performed by the Administrator was conducted on 6/14/13. From 3/1/13 to 6/14/13 audits were performed weekly at intervals of 10 to 17 days apart. Interventions taken to remove the Immediate Jeopardy included the following: a. The surveyor unplugged the damaged extension cord on 6/27/13 at 9:30 a.m. and gave the cord directly to the Maintenance Director. b. The Administrator presented a memo on 6/27/13 that included a plan for maintenance staff to search each room in the facility for frayed extension cords and to remove them immediately. Eight undamaged extension cords were found and removed by early afternoon on 6/27/13. Also, the Administrator met with the leadership team and formulated a plan to distribute and review the Fire Prevention plan to all staff. Staff education for identification of fire hazards was developed. Surveyors verified that the immediacy had been removed on 6/28/13 prior to survey exit based upon the following: a. At 10:10 a.m., the Administrator was interviewed. She reported that once she learned about the damaged extension cord, she reeducated the leadership team regarding fire safety measures. Evening and night staff were inserviced on 6/27/13, and the day shift was inserviced on 6/28/13. Any others not working those shifts would be inserviced when they arrived for the next shift. Additionally, maintenance had completed approximately 50 percent review of the entire building for fire safety and electrical issues. b. At 12:45 p.m., the 12-foot long brown extension cord found in Resident #20's room was in the custody of the Maintenance Director. 2. Resident #11 has [DIAGNOSES REDACTED]. Review of the Speech Language Pathologist's discharge summary, dated 3/18/13, revealed that due to intermittent pocketing of food over the last week, a history of CVA and tracheotomy, observed impulsivity during meals, and an abnormal breathing pattern, the resident continues to need aspiration precautions (100 percent supervision while eating/drinking). The nursing recommendations were to elevate head of bed 90 degrees or out of bed for feeding, check oral cavity for pocketing, no free water without supervision, small bits/sips, and alternate food with fluids. A nursing progress note, dated 3/18/13 and written by the former Director of Nursing (DON), revealed that she spoke to the resident regarding an order for [REDACTED]. She noted the resident has the capacity to make his own decisions and that he is fully aware of the risks of choking. The resident wishes to eat in his room unsupervised and that the Physician Assistant (PA) and therapy were notified. On the Personal Care Profile, dated 4/11/12, under the eating section, aspiration precaution is not checked, and there are no feeding guidelines. The June 2013 physician orders [REDACTED]. Review of the MDS Assessment, dated 6/15/13, revealed that the resident's cognitive skills for daily decision making are intact. In an observation on 6/24/13 at 7:45 a.m., the resident was in bed, eating breakfast (waffles, sausages and beverages) unsupervised. There was a red dot on his name plate outside the door and a sign above the head of the bed that reads, "Please see nurse before giving food and drink." At 8:00 a.m., the resident was still eating in his room, and there was a Baby Ruth candy bar sitting on the tray table. At 10:30 a.m., the tray was removed from the room, and there was a Baby Ruth candy bar wrapper on the tray table. Observations, staff interviews, and record reviews, completed on 6/25/13 were as follows: a. At 8:00 a.m., the resident was in his room eating unsupervised (waffles, sausage and beverages). The resident's meal ticket included to provide supervision for aspiration precautions. b. At 8:10 a.m., the CNA said that the red dot on the name plate means the resident is on aspiration precautions and needs to be watched when eating. She said that "supervise" means to remain in the room with the resident. c. At 8:15 a.m., the Licensed Practical Nurse (LPN) said that a red dot on the name plate means that the resident is on aspiration precautions and chokes easily. She said that she goes up and down the halls and monitors the residents eating in their rooms. She said this resident is pretty independent and does well. d. At 2:15 p.m., there were a bag of pecan chocolate chip cookies, a can of orange soda, a water pitcher, and a cup of water on the resident's tray table next to his bed and within the resident's reach. e. At 2:25 p.m., the Registered Nurse Manager said that a red dot on the door means that a resident is on aspiration precautions. She said that the resident is able to feed himself and that he needs monitoring while eating. She said that the nurses walk back and forth in the hallways during meals and check on him approximately every five minutes. f. At 2:40 p.m., the LPN and staff educator said that special instructions from Speech Language Pathology and aspiration precautions should be noted on the Personal Care Profile. She said that the medical staff and Speech Language Pathology are the only ones that can discontinue aspiration precautions. g. At 3:00 p.m., the Speech Language Pathologist said that 100 percent supervision means that the resident cannot eat or drink alone. The Speech Language Pathologist said the previous DON reported that the resident was able to make his own quality of life decisions, and he rejected supervision and aspiration precautions. Also, the resident continues to be at risk and should be on aspiration precautions. The Speech Language Pathologist was not included in a team meeting. h. At 3:10 p.m., the acting DON said that the red dot on the name plate means the resident is on aspiration precautions. Supervision is ideally continuous, but this resident does not allow us to do that, so we do intermittent supervision, which was a compromise to keep him safe. She said that this plan should be written on the CCP and that the resident should not have food or drink left in his room between meals. The acting DON said that aspiration precautions should be checked on the Personal Care Profile, and any specific nursing recommendations from Speech Language Pathology should be added. She stated that the Speech Language Pathology nursing recommendations cannot be followed unless staff remains with the resident at all times. i. At 3:40 p.m., the PA said it is his expectation that nursing supervise the resident 100 percent of the time per Speech Language Pathology recommendations. He said the resident could choke and aspirate. He said that nursing may have mentioned to him that the resident refused supervision at meals, however, there was no formal meeting or plan. j. At 3:55 p.m., the Diet Technician said that if a resident is on aspiration precautions, they are supervised at all times. She said that the team decided to monitor this resident when he was eating in his room by having the nurses walk up and down the hall and checking in on him while he was eating instead of sitting with the resident because he did not like to be "babied." She said that nursing normally would write the CCP for this type of plan, since they are monitoring the resident. k. At 4:05 p.m., the evening CNA said that a red dot on a nameplate means the resident is on aspiration precautions. He said if the resident is eating in his room, he needs to be supervised. l. At 4:05 p.m., the Administrator said that there is a new policy for aspiration precautions. She said this resident has capacity and does not want to be supervised in his room. She said we now have one nurse in the dining room and the other nurse monitoring the hallways. When asked how she ensures that Speech Language Pathology/nursing recommendations are followed, she said that they are not done for this resident. She said that the team meeting and those in attendance should be documented, as well as the plan to keep the resident as safe as possible. When interviewed on 6/26/13 at 2:00 p.m., the resident said the staff probably told him the risks of eating alone in his room. Also, someone sat in the room while he had dinner on 6/25/13, and he did not mind that they were in the room. The facility's undated policy, "Aspiration Precautions," revealed that if a resident has capacity and can clearly verbalize the potential negative outcomes of not following aspiration precaution procedures or the recommended dietary alterations as presented by Speech Language Pathology, the Speech Language Pathologist will document this. The clinical team, including the attending physician, will discuss the safest way to provide food and fluids to this resident. 3. Resident #60 has [DIAGNOSES REDACTED]. Review of the CCP, dated 11/1/12, revealed that the resident is nonambulatory and is able to maneuver her wheelchair. During an observation on 6/24/13 at 8:20 a.m., the resident was being transported in a wheelchair from her room to the dining room (approximately 30 feet). During this transport, the resident's right foot was dragged under the wheelchair. The toe of the resident's right shoe repeatedly caught on the linoleum floor. After surveyor intervention, the CNA asked the resident to raise her feet, and the resident complied for the remainder of the transport of approximately 2 feet. In an interview that day at 11:00 a.m., the CNA stated the resident drags her feet and will not keep them up. The CNA said that the resident does not have foot pedals for her wheelchair and does not self propel in the wheelchair anymore. In a subsequent observation on 6/27/13 at 9:38 a.m., the resident was being transported in a wheelchair by a LPN from the dining room to the hallway approximately 20 feet. The resident's right foot was dragged on the floor under the wheelchair during the entire transport. At 9:50 a.m., the resident was transported by an activities staff member from the second floor hallway into the elevator. The resident's right foot was bent backwards under the wheelchair and caught on the elevator threshold. When interviewed at that time, the activities staff member stated that the resident can no longer hold her feet up during transport, and her foot does catch on the floor. The activities staff member said the resident needs foot pedals for her wheelchair. In an interview on 6/27/13 at 1:50 p.m., the Physical Therapist stated that the resident's foot should not be dragging. She added the resident has decreased function in that foot due to a past fracture, and if she is unable to hold her foot up when pushed, she needs foot pedals. Review of a Physical Therapy Assessment, dated 6/27/13, revealed that the resident is unable to self propel and unable to adequately lift her leg for transport, therefore, pedals are recommended for transport. (10 NYCRR 415.12(h)(1)(2))

Based on observations, resident and staff interviews, and record reviews, it was determined that during an Extended Survey, which included a complaint investigation (#NY 873), the Administrator failed to ensure that the facility was administered in an effective and efficient manner that would enable each resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being as evidenced by failure to ensure that the resident environment remained as free of accident hazards as possible and failure to show evidence that appropriate plans of correction were developed and implemented to correct identified repeated deficiencies. This resulted in no actual harm with potential for serious harm that is IMMEDIATE JEOPARDY TO RESIDENT HEALTH AND SAFETY. The Immediate Jeopardy was removed on 6/28/13 prior to exit. This is evidenced by the following: 1. During an interview made during the Life Safety Code tour on 6/25/13 at 12:30 p.m., the Maintenance Director stated that there were no preventative maintenance plans in place specific to assessment of electrical outlet safety, including the necessity for grounded electrical plugs. F323 Accidents and Supervision, S/S = L The administration failed to ensure that the resident environment remained as free of accident hazards as possible. Issues involved a 12-foot long extension cord that was missing the plastic housing, which exposed wires and metal [MEDICATION NAME], that was found in an alert, nonambulatory, and legally blind resident's room. This extension cord was plugged into an electrically energized outlet behind the resident's bed. The exposed end of the extension cord was found lying underneath the metal bedside stand intertwined with the telephone cord. During interviews on 6/28/13 at 10:10 a.m., the Administrator said that she was not aware of the issue with the damaged extension cord and should have been. In another interview at 3:08 p.m., the Administrator provided documentation of audits that were directed as part of a Plan of Correction from a previous deficiency and were to be conducted weekly. The Administrator stated that she had not been doing the audits weekly. A review of the audit records provided revealed that the last audit performed by the Administrator was conducted on 6/14/13. From 3/1/13 through 6/14/13 audits were performed at intervals of 10 to 17 days. There was a lack of comprehensive facility policies and procedures that included preventative maintenance plans specific to electrical outlet safety, including the necessity for use of grounded plugs. 2. F253 - Repeated from the Recertification Surveys of 4/25/12, 6/17/11, 6/10/10, and 8/27/09, and from the Abbreviated Surveys of 2/8/13 and 1/24/13. Housekeeping and maintenance services do not provide a sanitary, orderly, and comfortable interior. The facility continues to have faulty ceiling leaks, plumbing leaks, and subsequent pools of stagnating water, and faulty or nonfunctioning ventilation systems, in addition to other identified concerns. 3. F314 - Repeated from the Abbreviated Surveys of 4/26/13 and 8/3/12. Residents are not receiving timely and consistent treatment and services to heal existing pressure sores and to prevent new pressure sores from developing. 4. F225 - Repeated from the Recertification Surveys of 4/25/12 and 6/17/11, and Abbreviated Surveys of 2/28/13 and 4/26/13. The facility did not complete thorough investigations of incidents to rule out abuse, neglect or mistreatment. 5. F246 - Repeated from the Recertification Survey of 4/25/12. The facility did not ensure that resident call bells are kept within a resident's reach. 6. F282 - Repeated from the Recertification Surveys of 4/25/12 and 6/17/11. Residents are not being provided services by qualified staff according to comprehensive assessments. 7. F315 - Repeated from the Abbreviated Survey of 8/3/12. Lack of consistent urinary catheter care, including, but not limited to, urinary catheters that were not secured to prevent discomfort and unplanned removal. 8. F333 - Repeated from the Recertification Survey of 4/25/12. The facility failed to maintain a Quality Assurance and Assessment Committee. 9. F431 - Repeated from Recertification Surveys of 4/25/12, 6/17/11, 6/10/10, and 8/2/09. The facility does not ensure that controlled substances are stored in a safe and secure environment. 10. F441 - Repeated from the Recertification Surveys of 4/25/12, 6/17/11, and 6/10/10. The facility does not consistently manage systems to ensure that infection control policies and procedures are enforced. 11. F520 - Repeated from the Recertification Survey of 4/25/12. The facility failed to maintain a Quality Assessment and Assurance (QAA) Committee that readily and consistently identifies and corrects quality deficiencies. When interviewed on 6/28/13 at 10:10 a.m., the Administrator said she started an audit tool for previous surveys but never completed the paperwork. She said she takes notes when she does rounds, but they were not part of Quality Assurance and did not keep them. (10 NYCRR 415.26)

Based on observations, resident and staff interviews, and record reviews, it was determined that for one (Resident #6) of three residents reviewed for pressure sores, the facility failed to ensure that a resident having a pressure sore received the necessary treatment and services to promote healing and to prevent new sores from developing. THIS IS A REPEAT DEFICIENCY FROM THE ABBREVIATED SURVEYS OF 4/26/13 AND 8/3/12. Specifically, Resident #6, who has a chronic Stage III sacral pressure sore that failed to progress toward healing, did not have a care planned pressure relieving device in a wheelchair, and was not repositioned according to the care plan for an extended time period. This resulted in actual harm that is not immediate jeopardy, and is evidenced by the following: Resident #6 has [DIAGNOSES REDACTED]. Review of the Strong Wound Clinic note, dated 9/26/12, revealed that the Stage III sacral pressure sore measured 1.8 centimeters (cm) long x .7 cm wide and .6 cm deep and that 75 percent of the wound bed had granulating tissue. There were no dressing changes recommended from this visit. Review of the Strong Wound Clinic note, dated 1/28/13, revealed that the resident had a Stage III sacral pressure sore that was healing. Treatment recommendations were to wash the wound, pack with [MEDICATION NAME] (packing), and to cover the wound with foam dressing daily. In addition, the resident was to have a specialty bed, wheelchair cushion, and was not to be out of bed sitting for more than two hours at a time. Follow-up at the wound clinic was to be as needed. Review of the facility's Wound Care Flow Sheet, dated January 2013, revealed that the sacral wound measured 2.2 cm long x 1 cm wide x .4 cm deep. Also noted was that this wound originated on 12/7/11. The original measurements were not included. Review of the facility's Wound Care Flow Sheets, dated from January 2013 through June 2013, revealed that the status of the wound did not change. Documentation on the nursing care plan, dated March 2013, shows that the resident had sacral pressure sores, a history of healed heel pressure sores, required assistance with turning and repositioning, needed pressure relieving devices for the bed and chair, heel protectors on at all times, and would be seen for wound clinic consults. In a physician progress notes [REDACTED]. Review of the Certified Nursing Assistant (CNA) Personal Care Profile, dated 4/15/13, revealed that the resident should have an air mattress on the bed and heel and elbow protectors. The Personal Care Profile did not include a plan for a pressure relieving device in the wheelchair and is checked "No" for turning and positioning. Physician orders, dated 5/8/13, include treatment to the sacral pressure ulcer for wound cleansing, to pack the wound with [MEDICATION NAME], and cover with a foam dressing. There were no treatment changes over a six month period. Review of the Minimum Data Set (MDS) Assessment, dated 5/25/13, revealed that the resident has clear speech, makes herself understood and usually understands, and is described by staff to be with severe cognitive impairment. In addition, it revealed that she had a Stage IV pressure ulcer on her sacrum and a pressure relieving device for her bed and chair. Intermittent observations made on 6/24/13 from 8:00 a.m. to 2:00 p.m. revealed that the resident was in bed, lying on her back and buttocks. An air mattress was in place. The heels were resting directly on the mattress. The resident's heel booties were in the room but were not on the resident's feet during these observations. During intermittent observations made on 6/25/13 from 11:00 a.m. to 4:00 p.m. and in a continuous observation on 6/26/13 from 10:30 a.m. to 1:30 p.m., the resident was sitting in her wheelchair. There was no pressure relieving devices in the chair during these observations. In an interview on 6/26/13 at 1:30 p.m., the resident stated that her bottom hurt. During an observation of wound care in the presence of the Nurse Manager (NM) on 6/26/13 at 8:20 a.m., the resident was in bed and was not wearing heel booties. The sacral pressure sore measured at 2.1cm long x .9 cm wide x 1 cm deep. There was some mild undermining. At that time, the NM described the resident's heels as red in color and very dry. Interviews on 6/26/13 were as follows: a. At 8:20 a.m., the Physician Assistant (PA) described the resident's sacral pressure sore as a Stage III with some undermining. The PA stated that wound has been stable and had not changed in size. b. At 11:40 a.m., the physician stated that she thought the resident was still being followed by the wound clinic. The physician described the sacral pressure sore as a chronic wound and said that while six months is a long time without improvement, chronic wounds take months to heal. The physician said that the resident should be re-evaluated at the wound clinic for possible treatment changes. c. At 1:35 p.m., the Certified Nursing Assistant (CNA) stated that the resident has not had a chair cushion for awhile, and she was not aware that the resident needed heel booties. This was the first time the CNA saw the booties sitting in the resident's room. She went on to say that she usually gets the resident up in the chair between 9:00 a.m. and 10:00 a.m, and the resident goes back to bed after lunch, but on 6/25/13, the resident was up longer for an activity. The CNA also said that on 6/24/13 the resident did not get out of bed by choice. After surveyor intervention, the PA's progress note, dated 6/27/13, showed that the sacral wound was dry, that the dressing would be changed to [MEDICATION NAME] packing with [MEDICATION NAME] cover, and a wound clinic evaluation would be ordered. Review of the undated facility policy, "Skin Care Team/Weekly Quality Assurance," revealed that during weekly skin rounds the team will discuss appropriateness of current treatment and/or recommendations for change. If skin area shows no improvement after two weeks from the same treatment, the current treatment may be considered ineffective, and a treatment change recommendation will be at the discretion of the skin team. This policy also includes that the CNA will ensure consistency in complying with current positioning methods. (10 NYCRR 415.12(c)(2))

Based on observations, resident and staff interviews, and record reviews conducted during an Abbreviated Survey (complaint #NY 377) completed on 8/3/12, it was determined that for one of two residents reviewed for urinary catheters, the facility failed to provide appropriate treatment and services to prevent catheter related complications. The issue involved the lack of consistent and appropriate Foley care for Resident #1; subsequently, the resident sustained [REDACTED]. Resident #1 was readmitted to the facility 3/4/12 following a fall with [DIAGNOSES REDACTED]. An undated hospital discharge instruction sheet included instructions to keep the urine drainage bag below the level of the bladder to prevent infections. Physician orders [REDACTED]. Personal Care Profiles, from 2/17/12 through 7/27/12, include to provide care for a Foley catheter. The Comprehensive Care Plan, dated 3/5/12, includes Foley care per facility policy and use of a leg drainage bag when out of bed. Review of the Minimum Data Set Assessment, dated 5/23/12, included that the resident was cognitively impaired and required assistance with all personal care. Physician orders, dated 6/11/12 through 7/30/12, include Foley care per protocol. Review of the July 2012 treatment sheets revealed that there were 33 of 93 opportunities to complete urinary catheter care that were not signed off as done. Review of a urology consult, dated 7/11/12, revealed that the urologist changed the resident's catheter because of "crustation" (dried drainage). The urologist noted that the resident had sustained erosion of the urethra caused by too much tension on the catheter as a result of improper placement of the catheter. He suggested that the resident may need a supra-pubic tube (catheter directly into the bladder via the abdomen bypassing the penis). In an acute note, dated 7/19/12, the Physician's Assistant (PA) assessed the presence of frank blood in the catheter. The PA documented that a urinalysis would be ordered,and the urologist would be contacted to schedule the soonest available appointment to place a suprapubic catheter. On a medical request form, dated 7/24/12 at 11:30 a.m., the PA wrote an order for [REDACTED]. Labs done STAT (immediately) that day showed an electrolyte imbalance and possible UTI. Review of the hospital discharge summary, dated 7/27/12, revealed that the resident's discharge [DIAGNOSES REDACTED]. Review of the July 2012 CNA signature sheet used to document that care was completed, revealed lack of documentation that care was completed for 31 of 93 opportunities. During an observation made on 8/2/12 at 7:45 a.m., the resident was laying in bed with his lower extremities elevated. A urinary catheter leg collection bag was attached to his left calf. This bag was filled to maximum capacity and elevated above bladder level. The catheter was pulled tight to reach the leg bag creating tension on the urethral meatus (opening in the penis through which the catheter is inserted) and urine was flowing back into the bladder. The meatus was red, swollen, and was leaking red and brown drainage. The resident stated at that time that the area was numb. The Nurse Manager was immediately notified. The leg bag was emptied of 750 cubic centimeters (cc) of urine, and when emptied, immediately refilled with another 300 cc of urine. When interviewed at that time, the Certified Nursing Assistant stated that the leg bag should not be left on all night because it cannot drain properly. Also, this could cause an infection and that the brown drainage was not good. In interviews on 8/2/12 at 8:30 a.m., the Licensed Practical Nurse/Nurse Manager (LPN/NM) stated that the leg bag should be switched to a drainage bag at night to drain properly and prevent infection and tension. At 9:30 a.m., the LPN/NM stated that CNAs are expected to sign that care was provided on the CNA signature sheet. Signatures on these sheets should not be missing. In a progress note, dated 8/2/12 at 11:45 a.m, the PA note documented the presence of drainage from the catheter site and a plan to request the placement of a suprapubic catheter. The PA noted that he reemphasized with the nursing staff the need to provide appropriate urinary catheter care; specifically, have urine drain to gravity and have proper slack in the tubing to avoid tension. In an interview on 8/2/12 at 12:00 p.m., the PA reported that the skin around the resident's meatus was slightly swollen and red. The PA did not think it was infected and also did not think that further erosion had occurred since the resident's urologist visit. He added that the drainage bag should never be above the level of the bladder and that it could cause an infection. He stated that the resident was not symptomatic at that time and was already on antibiotics for a UTI. Review of the undated facility's policy, "Foley Catheter and Related Care," revealed that Foley catheter care is provided to maintain personal hygiene and prevent urinary tract infections. Part of the procedure requires the caregiver to wash the urethral area with soap and water, and to wash a male's penis from the penis to the scrotum. The catheter should be checked for position and leakage, and connecter ends of the Foley catheter to the urine collection bag be wiped with an alcohol swab before connecting to a new bag. There are no further instructions to explain the proper positioning of the catheter when a leg urine collection bag is being used. (10 NYCRR 415.12)