Every finding on record at Rutland Nursing Home, Inc

Based on record review, and interviews, conducted during survey, the facility failed to ensure the resident or resident's representative was immediately notified of a significant change in the resident's physical status. This was evident for one of three residents (Resident #1) reviewed for notification. Specifically, on 03/06/2026 at 3:30 PM, License Practical Nurse #1 documented Resident #1 was observed with redness and skin tear to the sacral area and notified the Physician #1. There was no documented evidence that Resident # 1's adult child (the Complainant) was notified of skin changes on 03/06/2026. Findings include:The facility's policy titled Change in Resident Condition last revised on 01/2025, documented the facility will inform the resident /and or the resident's representative when there is a change in condition. The facility's policy titled Pressure Ulcer Prevention and Management last revised on 5/2024, documented when pressure ulcer is identified the registered nurse, nursing supervisor, charge nurse, or licensed practical nurse will notify family members. Circumstances requiring notification include clinical complications such as development of stage two pressure ulcer. Resident #1 was admitted to the facility on [DATE], with diagnosis including encephalopathy (damage to the brain), due to a stroke (blood flow to the brain stopped) and cellulitis (swelling, redness and skin infection) of the right heel. A review of the new admission skin diagram on 02/04/2026 indicated there were two wounds on the right shin and on the right and the left heels. There was no documentation of a sacral wound. The Minimum Data Set (a resident assessment tool) dated 02/11/2026, documented Resident #1 had intact cognitation. Resident #1 required maximum assistance with activity of daily living. A review of the hospital discharge summary, nursing evaluation and admission notes from 02/04/2026 to 03/05/2026 revealed there was no documented evidence that Resident #1 had redness or skin tear to the sacral area. A review of Resident #1's medical record nursing notes from 02/04/2026 to 03/23/2026 revealed on 03/06/2026 at 3:30 PM, Licensed Practical Nurse #1 documented that redness/ skin tear to the sacral area was observed and the medical doctor was notified. The attending physician's orders dated 03/06/2026, revealed daily treatment was ordered to include clean wound with normal saline, pat dry and apply bacitracin until headed. On 03/10/2026, the initial wound care consultation notes documented the sacrum wound size 2 centimeters by 1 centimeters by 1 centimeters due to moisture associated skin damage. During an interstate telephone interview on 07/10/2026 at 12:00 PM, the Complainant stated they were never informed of any issues with the resident's back or left foot while the resident was in the nursing home. During a telephone interview on 07/20/2026 at 12:13 PM, Licensed Practical Nurse #1 stated Resident #1 had an abrasion and that they may have overstated by documenting skin tears and when the skin was observed, the doctor, the wound care nurse, and the Registered Nurse Supervisor #1 were informed. During a telephone interview on 07/20/2026 at 1:26 PM, Register Nurse Manager #1 stated that they were aware Resident #1 had redness of the sacrum in March, 2026 and recalled informing Registered Nurse #2, the wound care nurse, that the family must be informed of any changes. During a telephone interview on 07/22/2026 at 1:00 PM, the Registered Nurse #2 (the wound care nurse) stated they recalled the resident developed a moisture associated decubitus ulcer of the sacrum in March 2026. The wound care nurse does not recall ever seeing or speaking with a family member. During a telephone interview on 08/11/2026 at 3:38 PM, the Administrator acknowledged that there were some issues. The Administrator stated they had just completed a meeting with the wound care nurses. They stated the facility transitioned to electronic medical record in March 2026 and staff in- services are ongoing and future documentation and communication with family will improve. 10 New York Codes, Rules and Regulations 415.3 (f)(2)(ii)(b)

Based on observations, record review, and interviews conducted during survey, the facility failed to ensure that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers. This was evident for one of three residents (Resident #1) reviewed for skin impairment. Specifically, on 03/06/2026, Resident #1 was observed with redness and a skin tear to the sacral area, which was not present during the initial admission. On 03/10/2026, Resident #1's skin was assessed by Registered Nurse #2 (wound care nurse), they documented moisture associated skin damage to the sacral area. Resident #1 was assessed at high risk for pressure ulcer, there were no documented evidence that Resident #1 was turned and positioned every two hours, and scheduled skin checks were done. On 04/07/2026, Resident #1's sacral wound was classified as a stage three pressure ulcer. Findings include:The facility's policy titled Pressure Ulcer Prevention & Management last revised 02/2024, documented when a resident is identified as at risk for development of pressure ulcers, preventive measures may include turning and positioning when in bed, keeping clean and dry, and skin checks every shift. The policy documented that prevention and management include consistent skin assessment, documentation, and progress notes. Resident #1 was admitted from the hospital on [DATE], with diagnosis including encephalopathy (damage to the brain), due to a stroke (blood flow to the brain stopped) and cellulitis (swelling, redness, and skin infection) of the right heel. The Minimum Data Set (a resident assessment tool) dated 02/11/2026, documented Resident #1 had intact cognition. Resident #1 required maximum assistance with activity of daily living. A review of the hospital discharge summary, nursing evaluation and admission notes dated 02/04/2026, revealed Resident #1 had no sacral pressure ulcer on admission to the facility. A review of the Pressure Ulcer Assessment that was completed on admission, dated 02/4/2026, revealed a score of 14 (score of 18 or less means at risk for pressure ulcer). The interventions documented on the care plans included initiating and maintaining pressure ulcer prevention protocol and referring to nutrition. Resident #1 to be turning and positioning every two hours. Moisture barrier to perineal area, and skin checks by Certified Nursing Assistant. A review of the March 2026 Resident Profile/ Certified Nursing Assistant Records documented toileting was missing for total of 41 shifts between 03/01/2026 and 03/31/2026. For mobility documentation was missed for 33 shifts, skin checks were missing for total 45 shifts primarily by the 7:00 AM to 3:00 PM shift. A review of the Resident Profile/ Certified Nursing Assistant Records' from February 2026 to March 2026 revealed instructions included two hourly turning and positioning, two to four hourly checks and change of adult briefs by one person. A review of Nursing Notes for Resident #1 from 02/04/2026 to 03/23/2026, revealed Licensed Practical Nurse #1 documented on 03/06/2026 at 3:30 PM, redness and skin tear to the sacral area was observed and the medical doctor was notified. The Attending Physician's orders dated 03/06/2026, documented cleanse skin tear to gluteal fold, pat dry and apply Bacitracin daily, until healed. A review of the Weekly Wound Rounds on 03/10/2026, revealed the Initial Wound Care Consultation for Resident #1's sacrum wound measured 2 centimeters by 1 centimeters by 1 centimeters, with serous drainage. The wound was described as Moisture Associated Skin Damage. The recommendations included off-loading of the area by repositioning at least every two hours and pressure relieving mattress or cushion. Dressing changes daily and as needed were ordered. On 03/17/2026, the wound size 2 centimeters by 1 centimeters by 0.1 centimeters. There was no change in orders. On 03/24/2026, the sacral wound size was 5 centimeters by 4 centimeters by 0 centimeters. There were no changes with the orders. On 03/31/2026, the sacral wound measured 7 centimeters by 3.5 centimeters by 0.2 centimeters with serous drainage, new treatment was ordered. On 04/07/2026, Resident #1 was transferred to hospital for sepsis and altered mental status and readmitted to the nursing home on [DATE]. During an out-of-state telephone interview on 07/10/2026 at 12:00 PM, the Complainant stated nothing was wrong with Resident #1's left foot, heel or back until Resident #1 was admitted to the nursing home. It was also stated that family members were visiting and informed the complainant that Resident #1was not on an air mattress or was not turned every two hours and that Resident #1 had a sacral ulcer.During an interview on 07/10/2026 at 1:02 PM, Attending Physician #1 stated that the concern was that Resident #1 was not eating and was treated with intravenous antibiotics for a urinary tract infection. Resident #1 was transferred to the hospital for low hemoglobin and that sepsis or pressure ulcer was not the issue.There was zoom meeting with the family to discuss the hospitalization. During a telephone interview on 07/17/2026 at 4:22 PM and on 07/21/2026 at 4:30 PM, the Director of Nursing stated resident's treatment administration record, and certified nursing assistant accountability records were changed from the paper record at the end of March 2026 to facilitate more consistent documentation. The flowsheet history for skin care documentation from 03/06/2026 to 05/15/2026 were reviewed and there were inconsistencies in the documentation. The Director of Nursing stated some document will be in electonic medical record. For residents with a stage two ulcer or above an air mattresses will be required. During a telephone interview on 07/20/2026 at 12:13 PM, Licensed Practical Nurse #1 stated Resident #1 had an abrasion on the sacrum and was unsure whether the wound was an abrasion or a skin tear. During a telephone interview on 07/20/2026 at 1:26 PM, Register Nurse Manager #1 stated they were aware of redness of Resident #1's sacrum in February 2026 and informed the wound care nurse that the family should be informed of any changes. Register Nurse Manager #1 stated that air mattresses are used for stage three pressure ulcers, or for residents with multiple wounds on admission. During a telephone interview on 07/22/2026 at 1:00 PM, the wound care nurse, Registered Nurse #2 stated weekly wound rounds were done with the wound care doctor on Tuesdays when wounds are assessed. The daily wound dressings are done by the unit nurses. Registered Nurse #2 stated that Resident # 1 was assessed in February on admission. The sacral wound appeared in March 2026 and was due to moisture-associated-skin-damage. Registered Nurse #2 stated that occasionally random audits are done to determine whether the recommendations are followed. The sacral ulcer was moisture associated and typically the recommendation is to cleanse, pat dry, and use moisture barrier cream. There are weekly reporting meetings with the nurse managers and sometimes the Director of Nursing to discuss the condition of the residents' wounds. A stage 3 pressure ulcer would need an air mattress.During a telephone interview on 08/11/2026 at 3:38 PM, the facility's Administrator acknowledged there were some issues. The Administrator also stated they have just completed a meeting with the wound care nurses to improve care. The facility transitioned to an electronic medical record in March 2026 and staff in- services and re-education are ongoing. The documentation should get better. 10 New York Codes, Rules, and Regulations 415.12(c)(1)

Based on observation, record review, and interviews conducted during survey, the facility failed to ensure a resident receiving enteral feeding received appropriate care and was monitored for complications related to tube feeding. This was evident for one (1) out of five (5) residents reviewed for enteral feeding (Resident #1). Specifically, on 02/20/2026, Resident #1 who received feeding and medications through a nasogastric tube (medical tube inserted through the nose into the stomach) had a change in their breathing pattern and was transferred to the hospital. Resident #1 was diagnosed with respiratory failure due to aspiration pneumonitis (an inflammation of the lung, which may lead to infection often presents rapidly with breathing difficulty, cough, and fever, requiring supportive care like oxygen) caused by a misplaced nasogastric tube in the left lung. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy.The findings include: The facility policy and procedure title Enteral Feeding through Gastrostomy, Mic-key, Nasogastric, Percutaneous Endoscopic Gastrostomy or Percutaneous Endoscopic Jejunostomy Tubes (different types of feeding tubes that deliver food and medication directly into the stomach or small intestine) Adult and Pediatrics, revised on 12/2024 documented always verify tube placement prior to beginning feedings and before administration of medication. Evaluate the resident's abdomen prior to initiating medication to ensure that it is not extended, and there are positive bowel sounds. The preferred method to confirm tube placement and ensure that tube migration has not occurred is to verify the exit length of the tube in centimeters. The procedure includes: the registered nurse will draw back with a 60 ml piston syringe and observe for stomach content. If stomach content is observed, the nurse will record the tube exit depth just above the disc in centimeters in Medical Administration Record or mark the tube placement just above the disc with indelible ink. On the care plan for tube feeding, the nurse will document confirmation of the tube placement in centimeters or indelible marked tube above the disc. Resident #1 was admitted to the facility on [DATE] with diagnosis of prematurity (babies born alive before 37 completed weeks of pregnancy), chronic respiratory failure, ventilator dependent, and nasogastric tube dependent. Minimum Data Set (an assessment tool) dated 02/09/2026, documented Resident #1's cognition was severely impaired. A care plan dated 02/03/2026 documented Resident #1 received fluids via a tube in the gastrointestinal tract evidenced by nasogastric tube present with interventions to check nasogastric tube placement before feeding and medication administration. An Enteral Nutrition Order Form dated 02/02/2026, documented Similac Advance or Similac Alimentum 20 kilocalorie/ounce 1000 milliliters, intermittent feeding of 250 milliliters every six (6) hours, four (4) times a day (at 6:00 AM, 12:00 PM, 6:00 PM and 12:00 AM) at 50 milliliter/hour via a pump. To make 250 milliliters of formula: mix four (4) scoops of powered mix of Similac Advance or Similac Alimentum with 240 milliliters of water.The Physician's Monthly Renewal Orders dated 02/02/2026 documented check nasogastric tube placement before and after giving medication and feeding. A Treatment Administration Record dated from 02/02/2026 to 02/20/2026 documented nursing staff must check the nasogastric tube for the correct placement before feeding and before and after medication administration. There was no documented evidence that the nasogastric tube placement was checked by nursing as per the medical doctor's order. There were no dates, no time, and no nurses' initials confirming that the nasogastric tube was checked. A review of Medication Administration Record dated from 02/02/2026 to 02/20/2026 revealed no documented evidence that the nasogastric tube placement was checked by nursing prior to medication administration.An Enteral Tube Placement Form dated 02/13/2026 documented nasogastric tube was inserted on 02/13/2026. There was no documented evidence that measurement at skin exit of nasogastric tube was documented.A review of facility's surveillance footage from a camera located in Resident #1's room for the date 02/20/2026, starting from 5:45 PM the footage revealed at 6:31 PM, Certified Nursing Assistant #1 came to the room with supplies to provide care and moved the curtain preventing the camera view of Resident #1's crib. At 6:38 PM, Registered Nurse #1 came to the room and attended to Resident #1. At 6:57 PM, Registered Nurse #1 left the room while Certified Nursing Assistant #1 was at bedside. At 6:58 PM, Registered Nurse #1 came back with round tape in their hands. Both Certified Nursing Assistant #1 and Registered Nurse #1 left the room at 7:03 PM. At 7:06 PM, Registered Nurse #1 returned to room and touched feeding pump machine and left. Between 6:51 PM and 7:30 PM, multiple staff including nurses, Respiratory Therapist #2, and Nurse Practitioner #1 entered the room while performing rounds. At 8:16 PM, Registered Nurse #2 came to the room and replaced the feed bottle and the giving set (a set of tubing that is placed into the pump and connects the feed bottle to the nasogastric feeding tube), but since the room curtain was partially drawn, the footage from the camera did not show if Registered Nurse #2 checked the residual (Gastric Residual Volume - the amount of formula, digestive juices, and secretions left in the stomach between feedings and is measured by attaching a syringe to the feeding tube to aspirate the contents, serving as a check for gastric emptying and feeding tolerance) when they replaced the feed bottle and the giving set. At 8:30 PM, the in-view ventilator monitor alarm light (flashing red light) was on and the interdisciplinary team, including four (4) Registered Nurses, Respiratory Therapist #2 and Nurse Practitioner #1, were seen coming into the room and attending to Resident #1. The footage revealed Resident #1 started having respiratory symptoms at 8:30 PM and at 10:55 PM, the emergency medical service team came into Resident #1's room and took charge of the resident's care. A Progress Note dated 02/20/2026 at 7:00 PM written by Nurse Practitioner #1 documented at the beginning of shift from 7:00 PM to 7:00 AM, Resident #1 was resting comfortably. At approximately 8:30 PM, Registered Nurse #2 reported Resident #1 had a low-grade temperature. Tylenol was given and cooling measures with cold pack were initiated. Resident #1 was tachypneic (rapid, shallow breathing) with respiration 45-50 breaths per minute and heart rate of 150-170 beats per minute. Respiratory Therapist #2 was at the bedside, oxygen therapy and frequent suctioning were done. At 10:28 PM, Resident #1 continued to be tachypneic, Heart Rate worsened to 170-210 per minute, persistent fever 101.9. Ibuprofen ordered STAT (immediately). Due to the persistent tachypnea, Resident #1 was transferred to Hospital #1. Resident #1 arrived at the emergency room on [DATE] at 11:24 PM.A Progress Note dated 02/21/2026 at 7:00 AM written by Nurse Practitioner #1 documented Resident #1 was admitted to Hospital #1 with diagnosis of pneumonia and tracheitis (inflammation of the windpipe that connects the voice box to the lungs). Hospital #1's Discharge Summary note dated 02/25/2026 attested by Hospital #1's Medical Doctor documented Resident #1 was admitted for respiratory failure secondary to pneumonia/pneumonitis (inflammation and irritation of the lung tissue) caused by a misplaced nasogastric tube (in left lung) with aspiration (liquid in the airway). Resident #1 was discharged /transferred from Hospital #1 to Hospital #2 on 02/25/2026 at 8:23 PM.Hospital #2's Infectious Diseases Consultation note dated 02/26/2026 at 10:29 AM documented Resident #1 was admitted for respiratory failure caused by aspiration pneumonitis in the setting of nasogastric tube misplacement into the left mainstem bronchus with associated fevers and leukocytosis.A Facility Investigation dated 03/04/2026 written by Director of Nursing documented on 02/20/2026 at approximately 11:00 PM, Resident #1 was transferred to Emergency Department for a sudden onset of tachycardia (resting heart rate over 160-180 beats per minute), respiratory distress, and fever. The facility investigation determined that between 6:45 PM and 7:00 PM on 02/20/2026, Registered Nurse #1 removed and re-secured the tape that was holding Resident #1's nasogastric tube while Resident #1 was receiving enteral feedings. Registered Nurse #1 admitted that after resecuring the tube, the placement of the tube was not verified prior to continuation of the feeding. Resident #1 subsequently experienced an acute change in condition and was transferred to the Emergency Department, where imaging confirmed malposition of the nasogastric tube into the left lung. During an interview on 03/09/2026 at 4:10 PM, the Medical Director stated Nurse Practitioner #1 informed them in the evening of 02/20/2026 that Resident #1 had a high heart rate, high respiratory rate, and despite medical interventions there was no improvement and 911 was called and Resident #1 was transferred to the hospital. Medical Director stated they spoke with Resident #1's parent over the phone on 02/21/2026 who said that they (parent) were told by the hospital that Resident #1's nasogastric tube was in the lung and the parent was upset. The Medical Director stated in their opinion, if the nasogastric tube was in Resident #1's lung while Resident #1 was in the facility receiving food or medication or fluids, Resident #1 would have experienced respiratory symptoms such as coughing, low oxygen, and alarm would alert for suctioning within minutes. The Medical Director stated all symptoms started around 8:30 PM when Nurse Practitioner #1 and Respiratory Therapist #2 were attending Resident #1. The symptoms were managed appropriately and when there was no improvement, 911 was called. Medical Director stated staff actions were appropriate and timely. The Medical Director called the hospital and was told Resident #1's nasogastric tube was in the left lung, and a chest tube was put in place. Medical Director added that the hospital had to perform three (3) X-rays to confirm position of the nasogastric tube. During an interview on 03/09/2026 at 3:36 PM, Certified Nursing Assistant #1 who was assigned to Resident #1 on 02/20/2026 at around 6:30 PM stated they came to provide care and stopped the feeding by pushing the button on the pump machine. Certified Nursing Assistant #1 stated Resident #1 had a lot of secretion from their nose which was common for Resident #1. They further stated the clear film dressing had a lot of secretion on it and all sides of the dressing were lifted, but the middle part was intact. Certified Nursing Assistant #1 stated they called Registered Nurse #1 who came to the room. Certified Nursing Assistant #1 stated Resident #1 was comfortable when Registered Nurse #1 removed the soiled dressing and told them to hold the tube by the nose so they can apply a fresh dressing. Certified Nursing Assistant #1 stated they were holding the tube by the finger on Resident #1's nose and there was no other tape holding the tube. Certified Nursing Assistant #1 stated Registered Nurse #1 could not find dressing tape in the room and left the room to get tape and returned quickly. Certified Nursing Assistant #1 stated they were not supposed to hold nasogastric tube because they are not a nurse. Certified Nursing Assistant #1 stated Registered Nurse #1 came with the tape and replaced the tape while they were holding the nasogastric tube by the nose. Certified Nursing Assistant #1 stated Registered Nurse #1 did not remove or re-insert the nasogastric tube. Certified Nursing Assistant #1 stated Registered Nurse #1 helped them to finish providing care and resumed the feeding. Certified Nursing Assistant #1 stated Registered Nurse #1 did not use a syringe to pull content from stomach before resuming the feeding. During a telephone interview on 03/10/2026 at 12:07 PM, Registered Nurse #1 stated they did not replace the nasogastric tube during their shift, only the soiled dressing tape was removed. Registered Nurse #1 stated they came to Resident #1's room around 6:45 PM - 7:00 PM while Certified Nursing Assistant #1 was providing care. Registered Nurse #1 stated that feeding was paused by Certified Nursing Assistant #1. Registered Nurse #1 stated they observed Resident #1's left cheek dressing that secured the nasogastric tube to left nostril and noted that it was soiled with clear secretion and needed to be changed. Registered Nurse #1 stated the nasogastric tube was in place because they observed a black mark on the tube by the left nostril. Registered Nurse #1 stated they asked Certified Nursing Assistant #1 to hold the nasogastric tube by Resident #1's nose while they were replacing the dressing. Registered Nurse #1 stated they should have called another nurse to assist with the dressing change. Registered Nurse #1 stated they could not find clear tape at Resident #1's nightstand and left the room to get tape while Certified Nursing Assistant #1 was holding the nasogastric tube. Registered Nurse #1 stated that they don't recall if they saw a black mark on the nasogastric tube when they returned to the room and were applying fresh clear tape. Registered Nurse #1 stated they did not disconnect the feeding while changing the dressing and Resident #1 was in no distress. Registered Nurse #1 stated they helped to wash Resident #1 without disconnecting the feeding from the nasogastric tube. Registered Nurse #1 stated they did not see Resident #1's nasogastric tube coming out and did not re-insert it on 02/20/2026. Registered Nurse #1 also stated they start the feeding at 6:00 PM and checked residual prior to initiating the feeding. Registered Nurse #1 stated that it is right practice to document in the resident's chart the date, time, amount of residual checked and sign in the Treatment Administration Record, but sometimes they omitted to document in the notes and Treatment Administration Record. During an interview on 03/10/2026 at 1:48 PM, Clinical Manager Registered Nurse #1 stated nurses should check placement of nasogastric tube by checking a mark on nasogastric tube by the nose and using syringe to pull back and see stomach content before and after medication and feeding administration. Clinical Manager Nurse #1 stated the nurses should have documented in Resident #1's progress notes and Treatment Administration Record. Clinical Manager Nurse #1 stated it was not practice in the facility to document in Treatment Administration Record that verification of nasogastric tube placement was done. Clinical Manager Registered Nurse #1 stated the nurse should always check a mark on nasogastric tube by the nose and stomach residual when resuming the feeding. Clinical Manager Registered Nurse #1 stated if resident was getting a bed bath or care that requires several maneuvers of the body, the nurse should disconnect the feeding completely and re-connect after checking the nasogastric tube placement with residual content of the stomach. During an interview on 03/10/2026 at 3:07 PM, Attending Physician #1 stated they became aware on 02/23/2026 that Resident #1 went to the hospital due to respiratory distress. Nurse Practitioner #1 was onsite and attended to Resident #1 during the transfer. Resident #1 had nasogastric tube for nutrition and medication, nurses were required to confirm placement by aspiration gastric content from the stomach before medication or feeding. Attending Physician #1 also stated the measurement at skin exit of nasogastric tube should have being documented on the Enteral Tube Placement Form. During an interview on 03/11/2026 at 3:18 PM, Registered Nurse # 2 stated they worked on 02/20/2026 7:00PM - 7:00 AM shift and just before 8:00 PM Resident #1's feeding machine was showing error (the feeding not going). Registered Nurse # 2 stated they were not assigned to Resident #1, but the feeding machine was showing an error, and they changed the feeding bottle. Registered Nurse # 2 stated they verified the nasogastric placement by pulling the residual content of stomach to the syringe before connecting to the feeding machine but did not look for the mark on the tube. Registered Nurse # 2 stated Resident #1 was calm, sleeping with no distress at that time. Registered Nurse # 2 stated they did not document verification of the nasogastric placement in Resident #1's progress note and Treatment Administration Record because they were not assigned to Resident #1. Registered Nurse # 2 further stated it should be documented. During an interview on 03/11/2026 at 4:30 PM, Senior Director of Pediatrics stated they were informed on 02/24/2026 at 2:00 PM that Resident #1's x-ray result from the hospital showed the resident's nasogastric tube was in the left lung. Senior Director of Pediatrics stated they immediately started an investigation and reviewed the camera footage and concluded that the nasogastric tube terminated in Resident #1's left lung could have had happened between 6:45 PM and 8:20 PM. Senior Director of Pediatrics stated after nasogastric tube dressing that holds the tube in place was removed, Registered Nurse #1 let Certified Nurse Assistant #1 hold the tube by Resident #1's nose and they went out of the room to look for clean dressing tape. Senior Director of Pediatrics stated Registered Nurse #1 should have sent Certified Nurse Assistant #1 to get the dressing tape or call another nurse for assistance with the dressing change. Senior Director of Pediatrics also stated Registered Nurse #1 did not verify nasogastric tube placement before resuming the feeding. Senior Director of Pediatrics stated based on their investigation, the dressing change was the only major manipulation that could cause the nasogastric tube to be dislodged. Senior Director of Pediatrics stated registered nurses must verify nasogastric tube placement before medication administration, before feeding, and document same in progress note and in Treatment Administration Record as ordered by Medical Doctor. During an interview on 03/12/2026 at 3:52 PM, Director of Nursing stated they became aware on 02/25/2026 that Resident #1's nasogastric tube terminated in the left lung on 02/20/2026 and their investigation revealed that Registered Nurse #1 may have dislodged the nasogastric tube during the dressing change. Director of Nursing stated Registered Nurse #1 should have called another nurse to assist with doing the dressing change. They stated that Registered Nurse #1 should not have had Certified Nursing Assistant #1 hold the nasogastric tube while Registered Nurse #1 left the room to look for dressing tape. Director of Nursing stated Registered Nurse #1 should have checked the nasogastric tube placement after dressing change and documented in the Treatment Administration Record verification of nasogastric tube placement. During an interview on 03/19/2026 at 10:18 AM, the Administrator stated that on 02/25/2026, the Director of Nursing made them aware of the incident with Resident #1 that occurred on 02/20/2026. The Administrator stated they learned that when Resident #1 went to the hospital it was found that Resident #1's nasogastric tube was in the left lung instead of in the stomach. 10 New York Codes, Rules, and Regulations 415.12(g)(2)

Based on observation, record review, and interviews conducted during the onsite visit for Complaint NY00384371, it was determined that the facility failed to maintain safe and comfortable temperature levels. This was evident on six (6) of the seven (7) resident floors, where 22 out of 34 rooms sampled had temperatures above the Federal and State requirements in accordance with 42 CFR Part 483 and 10 NYCRR: 415.29 range of 71 degrees Fahrenheit to 81 degrees Fahrenheit. Specifically, on 06/23/2025, Resident #1 submitted a complaint to the New York State Department of Health that there was loss of air conditioning on the sixth floor. The temperature on the sixth floor was 86.9 degrees Fahrenheit. From 06/24/2025 through 06/25/2025, two (2) additional complaints were submitted to the New York State Department of Health regarding high temperatures throughout the facility, stating all residents were affected. The facility documented Resident #1's room and other residents' room temperatures had exceeded safe and comfortable ranges.The findings are:The facility's policy and procedure on Extreme Heat Emergency dated 03/2025, documented all departments at the facility are responsible to be prepared to respond to periods of high temperature and humidity with appropriate, well, coordinated resident care. The policy further documented the plan will be activated whenever the inside temperature reached 78 degrees Fahrenheit on any unit.Observations during the initial tour of the facility on 06/24/2025 from 9:50 AM to 12:00 PM, recorded temperatures in resident rooms and corridors measured above Federal and State required ranges of 71 degrees Fahrenheit to 81degrees Fahrenheit. Temperatures were observed between 61.7 degrees Fahrenheit and 86.9 degrees Fahrenheit. On 06/25/2025 between 10:00 AM and 12:00 PM, the temperature in resident rooms and in the corridors measured in the range of 79.1 degrees Fahrenheit to 87.6 degrees Fahrenheit.A review of the facility's temperature logs for 06/23/2025 at 8:00 AM, documented temperatures from 78.0 degrees Fahrenheit to 82.5 degrees Fahrenheit. The facility temperature logs for resident rooms for 06/25/2025, included temperatures ranging between 78.7 degrees Fahrenheit to 85.3 degrees Fahrenheit. During an interview on 06/25/2025 at 1:30 PM, the Director of Maintenance stated the equipment was old, and although the chiller was providing chilled water, the units in resident rooms were blowing weak, and the air was not circulating well. The Director of Maintenance further stated that portable units were being ordered and would be delivered that evening or in the morning. In addition, the facility would also be ordering a portable unit to supplement the air handler.During an interview on 06/25/2025 at 9:46 AM, the Director of Nursing stated the energy company (ConEdison) had reduced the power voltage to the facility, but no residents were affected. Residents' medical conditions were being monitored.During an interview on 06/27/2025 at 9:59 AM, Resident #10 stated on 06/24/2025 and 06/25/2025 the facility was hot and uncomfortable. They stated the fan was blowing warm air. During an interview on 06/25/2025 at 11:27 AM, Certified Nursing Assistant #1 stated the facility was hot during the last few days and residents and staff were complaining. They stated portable air conditioning units were installed that morning on 06/25/2025. They stated residents were taken to the dayroom and given water to keep them cool. During an interview on 06/25/2025 at 12:23 PM, the Medical Director stated there were no residents impacted by the heat wave and no residents were sent to the hospital. They stated the facility has implemented the emergency preparedness plan which includes monitoring residents' vital signs (pulse, temperature, blood pressure) every shift, ensuring residents are hydrated, applying ice packs to keep them cool, and providing ice chips. They stated an order for extra hydration administration was placed for all residents with a percutaneous endoscopic gastrostomy tube (feeding tube). During an interview on 06/27/2025 at 2:48 PM, the Administrator stated on 06/23/2025 they received a complaint from a resident on the sixth floor about the unit being warm. They stated there was a spike in the temperature and the air conditioning system was functioning, however, it was difficult for the rooms to remain cool. They stated after the Department of Health was onsite and spoke with them on 06/24/2025, they ordered forty portable air conditioning units and an additional twenty portable air conditioning units on 06/25/2025. 10 NYCRR: 415.5(h)(4)

Based on observation, record review, and interviews conducted during an Abbreviated Survey and Partial Extended Survey (NY00384371), the facility failed to ensure it was administered in a manner that enables 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, on 06/23/2025 to 06/25/2025, complaints were submitted to the New York State Department of Health regarding high temperatures throughout the facility. The Administrator failed to provide effective leadership and oversight to ensure that comfortable and safe temperature levels were maintained in residents' rooms and common areas in the facility.The findings are:The facility's policy and procedure on Extreme Heat Emergency dated 03/2025, documented all departments at the facility are responsible to be prepared to respond to periods of high temperature and humidity with appropriate, well, coordinated resident care. The policy further documented the plan will be activated whenever the inside temperature reached 78 degrees Fahrenheit on any unit.During an observation on the units on 06/24/2025 and 06/25/2025 the temperature ranged between 82.2-degree Fahrenheit and 87.6-degree Fahrenheit.During an interview on 06/25/2025 at 9:46 AM, the Director of Nursing stated the energy company (ConEdison) had reduced the power voltage to the facility. Residents' medical conditions were being monitored.During an interview on 06/27/2025 at 9:59 AM, Resident # 10 stated on 06/24/2025 and 06/25/2025 the facility was hot and uncomfortable. They stated the fan was blowing warm air.During an interview on 06/25/2025 at 11:27 AM, Certified Nursing Assistant #1 stated the facility was hot and residents, and staff are complaining. They stated the portable air conditioning units were installed on 06/25/2025.During an interview on 06/27/2025 at 2:48 PM, the Administrator stated on 06/23/2025 they received a complaint from a resident on the sixth floor about the unit being warm. They stated there was a spike in the temperature and the air conditioning system was functioning, however, it was difficult for the rooms to remain cool. They stated after the Department of Health was onsite and spoke with them on 06/24/2025, they ordered forty portable air conditioning units and an additional twenty portable air conditioning units on 06/25/2025.10 NYCRR 415.26

Based on observation, record review, and interviews conducted during an abbreviated survey (NY00371268), the facility failed to ensure that a resident was free from resident-to-resident abuse. This was evident for one (1) out of five (5) residents (Resident #1) sampled. Specifically, on 01/31/2025 at 2:50 PM, Licensed Practical Nurse #1 witnessed an altercation between Resident #1 and Resident #2 in the elevator at the lobby level . Licensed Practical Nurse #1 separated the residents. Resident #1 and Resident #2 were assessed by Registered Nurse Supervisor #1 and there were no injuries. The facility failed to ensure timely safety measures to prevent further abuse. On 01/31/2025 at 5:25 PM, Resident #1 complained of left side chest pain and stated that Resident #2 entered their room and hit them. Resident #1 was transferred to the emergency room for evaluation and returned to the facility on [DATE] at 7:00 AM with diagnoses of an acute fracture (break) to the left fourth rib. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy. The findings are: The facility's policy and procedure on Abuse, Mistreatment, Neglect, Exploitation, Misappropriation and Reporting dated 11/2024, documented the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The objective of the policy is to comply with the seven-step approach which includes protection. Residents must be protected from offenders. Resident #1 was admitted to the facility with diagnoses including a stroke with left sided weakness, depression and adjustment disorder with mixed emotional features. The Minimum Data Set (an assessment tool) dated 12/27/2024, documented Resident #1's cognition was intact, and they were able to self-propel their wheelchair. A care plan titled: Risk for Abuse dated 06/18/2024, documented Resident #1 was at high risk for abuse due to previous history of altercations and abuse to others. Resident #1 was impulsive and displayed aggressive threatening behavior to peers. Resident #1 argued with peers frequently and had been abused by others. The interventions included: verbal counseling, emotional support, and referrals to the psychiatrist as needed. The Risk for Abuse care plan was updated on 01/31/2025 with interventions for 1:1 monitoring for safety after the second incident occurred. Resident #2 was admitted to the facility with diagnoses that included neuralgia/neuropathy (nerve pain/nerve damage), depression, and adjustment disorder. The Minimum Data Set, dated [DATE], documented Resident #2 was cognitively intact, and required one (1) person supervision with activities of daily living. Resident #2 was wheelchair bound and was able to self-propel their wheelchair. The facility's Incident Overview and Occurrence Report dated 01/31/2025 at 2:50 PM, documented the first incident occurred in the elevator at the lobby level and was witnessed by Licensed Practical Nurse #1. Resident #1 was the initial aggressor who hit Resident #2 in the torso. Resident #2 then hit Resident #1 in the chest area as Resident #1 was being removed from the elevator by Licensed Practical Nurse #1. Residents #1 and #2 were separated and both residents were assessed by Registered Nurse Supervisor #1 and the Medical Doctor between 3:30 PM and 4:00 PM. The families were notified, social work, and psychiatric consultations were placed, and emotional support provided. There were no injuries. On 01/31/2025 at 4:10 PM, Law enforcement was called, responded, and both residents refused to press charges. On 01/31/2025 at 5:25 PM, Resident #1 complained of pain to the left side of their chest, and stated they were hit by Resident #2 in their room. Resident #1 was transferred to the hospital emergency department for further evaluation. On 02/01/2025 at 7:00 AM, Resident #1 returned to the facility with diagnosis of an acute left rib fracture. Resident #2 was moved to another unit in the facility. On 02/03/2025 at 7:00 AM, while Resident #1 was being assessed by Medical Doctor #1 they decided to press charges against Resident #2 and Law Enforcement was called. Resident #2 was arrested and removed from the facility. Resident #2 returned to the facility on [DATE] with an Order of Protection to stay away from Resident #1. In a Nursing Note dated 01/31/2025 at 4:00 PM, Registered Nurse Supervisor #1 documented an altercation occurred in the elevator. Resident #1 reported being punched in torso by Resident #2. Medical Doctor #1, and Social Worker #1 were informed. The Residents were separated, physical assessment was done, and emotional support was provided. There was no sign of injuries and close visual monitoring was arranged to be started. There was no documented evidence that close visual monitoring was implemented to protect the residents. In a Nursing Progress Note dated 01/31/2025 at 5:25 PM, Registered Nurse Supervisor #1 documented there was an unwitnessed altercation in Resident #1's room. Resident #1 was complaining of pain to the left side of the chest. Medical Doctor #2 was informed, and Resident #1 was transferred via ambulance to the hospital emergency department for further evaluation. The Emergency Department Summary documented on 01/31/2025 6:50 PM, Resident #1 arrived in the emergency room, complaining of chest pains. A chest x-ray and a cat scan of the chest was done on 02/01/2025 at 12:37 AM. Resident #1 was diagnosed with a Closed Fracture of the fourth (4th) left side rib. On 02/01/2025 at 7:11 AM, Resident #1 was discharged back to the facility. In a Social Worker Incident Report dated 02/03/2025, Social Worker #1 documented Resident #1 stated they first hit Resident #2 in the elevator on 01/31/2025, and that Resident #2 hit them in return and staff separated them. Resident #1 stated they went directly to their room after the elevator incident; while eating their meal a few hours later, Resident #2 entered their room, and they had another altercation. The [NAME] County Criminal Court Order of Protection dated 02/04/2025 documented that Resident #2 must stay away from Resident #1. During an interview on 05/14/2025 at 3:12 PM, Licensed Practical Nurse #1 stated Residents #1 and #2 were in the elevator in their wheelchairs next to each other facing the back of the elevator. Licensed Practical Nurse #1 stated they heard Resident #1 was talking to themself, then Resident #1 asked Resident #2 What are you are looking at? and hit Resident # 2 in the torso. Licensed Practical Nurse #1 stated they immediately intervened by removing Resident #1 from the elevator at which time Resident #2 hit Resident #1 in their chest area. Licensed Practical Nurse #1 stated two Certified Nursing Assistants in the lobby assisted with removing Resident #1 from the elevator. Licensed Practical Nurse #1 stated Resident #2 remained in the elevator. Licensed Practical Nurse #1 informed Registered Nurse Supervisor #1 and Licensed Practical Nurse #1 stated they were interviewed by police officers on 01/31/2025 about the incident in the elevator. During an interview on 05/14/2025 at 2:06 PM, Licensed Practical Nurse # 2 stated that Resident #1 and Resident #2, always go on and off the unit independently. The staff on the unit were unaware of the altercation in the elevator until they were informed by Registered Nurse Supervisor #1. Licensed Practical Nurse #2 stated on 01/31/2025 about 4:00 PM, Resident #1 came to the unit and was assessed by the Registered Nurse Supervisor #1. Licensed Practical Nurse # 2 stated they then went to take Resident # 2's vital signs after 5:00 PM and Registered Nurse Supervisor #1 called to inform them that Resident #1 would be put on 1:1 supervision. They were then informed that Resident #1 would be transferred to the emergency room after another altercation occurred with Resident #2. During interviews on 05/14/2025 between 2:51 PM and 3:00 PM, Certified Nursing Assistants #3, #4 and #5 (who were present on the unit on 01/31/2025 with Licensed Practical Nurse # 2), stated at about 5:25 PM, they heard a commotion coming from Resident #1's room and they all responded. Those interviewed stated Resident #2 was in Resident #1's room and said nothing. Those interviewed stated Resident #1 stated that Resident #2 hit them on their left side of the chest which was very painful. Those interviewed stated Resident #2 was removed from the room and Registered Nurse Supervisor #1 was called. Those interviewed stated Resident # 1 was transferred to the hospital emergency room for further evaluation as requested by the on-call Medical Doctor #2. During a telephone interview on 05/19/2025 at 1:40 PM, Registered Nurse Supervisor #1 provided the following details regarding the incidents involving Resident #1 and Resident #2: they were informed about the elevator altercation on 01/31/2025 at 3:30 PM by the Assistant Director of Nursing #1 and Licensed Practical Nurse #1. Social Worker #1 spoke to both residents who refused to be moved off their unit. The Senior Director of Nursing was informed of the resident's refusal to move and instructed that Resident #1 should be placed on 1:1 monitoring. Licensed Practical Nurse #1 was informed to assign a Certified Nursing Assistant but then later called Registered Nurse Supervisor #1 and told them that another altercation occurred in Resident #1's room. Registered Nurse Supervisor #1 returned immediately to the unit where Resident #2 was in the hallway agitated and yelling. Resident #2 was removed as far away as possible from Resident #1 and went off the floor. Resident #1 was visibly in pain and bracing their left side. The Director of Nursing and the medical doctor on call were informed and ordered Resident #1 be transferred to the emergency room for evaluation. Resident #1's family was informed, and a message was left for Resident #2's family. Resident #1 returned to the facility on [DATE] at 7:00 AM from the emergency room. The imaging reports in the electronic medical record revealed there was an acute fracture of the fourth (4th) rib that was not identified on previous reports. The Director of Nursing was informed. During an interview on 05/15/2025 at 5:15 PM, the Director of Nursing stated they were not in the facility on the evening of 01/31/2025 but were called immediately after the elevator altercation. Registered Nurse Supervisor #1 was told to move Resident #2 to a separate floor, call law enforcement, and put Resident # 1 on 1:1 supervision. The Director of Nursing stated they were informed that the 71st precinct officers responded, and Resident #1 did not want to speak to them. After the elevator altercation Resident #1 remained in the lobby for 45 minutes to one (1) hour and was calmed down by staff in the lobby. Resident #2 went to the cafeteria and then to their floor. Registered Nurse Supervisor #1 assessed both residents asked them about moving to another unit, and they both refused. While Licensed Practical Nurse #1 was determining which Certified Nursing Assistant would be assigned to 1:1 monitoring for the evening shift, the second incident occurred in Resident #1's room. The Director of Nursing stated that after the first incident, time elapsed before Resident #1 was placed on 1:1 supervision. The Director of Nursing stated video surveillance cameras are not in the elevator but are in the main lobby only and the video surveillance showed Resident #1 was being removed from the elevator by staff. The video surveillance was given to the Attorney General's office. During a telephone interview on 06/12/2025 at 3:50 PM, the Administrator stated they received a call from the Nursing Director about the elevator incident before it was reported to the Department of Health and were told that the staff separated Resident #1 and Resident #2 and there were no injuries. The Administrator stated law enforcement was called and came to the facility. The Administrator stated they were informed of the second incident by the Director of Nursing but did not recall the time they were informed, and they were also told and made aware that Resident #1 sustained a fracture. During a telephone interview on 06/12/2025 at 2:00 PM, Medical Doctor #1 stated they saw Resident #1 after they returned from the hospital. Medical Doctor #1 stated Resident #1 was seen by on-call Medical Doctor #2 who gave the orders on the weekend to have Resident #1 transferred to the emergency department. Medical Doctor #1 stated Resident #1 and Resident #2 were assessed on 02/03/2025 and the imaging results for Resident #1 were reviewed. Medical Doctor #1 stated Resident #2 was complaining of pain to the face, there was no swelling, the police took Resident #2 to the Emergency Department before taking Resident #2 to central booking where Resident #2 was charged, and the order of protection was issued before Resident #2 was allowed to be returned to the facility. 10 NYCRR 415.4(b)(1)(i)

Based on record review and interview conducted during the Recertification and Complaint Survey (NY00369624 and NY00354365) conducted from 03/24/2025 to 03/31/2025, the facility did not ensure residents received adequate supervision and assistance devices consistent with resident's needs, goals, and care plan to prevent accidents. This was evident for 2 (Residents #108 and #260) of 2 residents investigated for Accidents out of 39 total sampled residents. Specifically, (1) Resident #108 fell and hit the back of head causing injury to left eye orbital while being transferred to bed by 2 Certified Nursing Assistants, and 2. (2) Resident #260 who required a harness while out of the crib and in a wheelchair was removed from wheelchair with harness and placed in a Gerichair without any harness causing Resident #260 to move and fall to the floor. The findings include: 1. Resident #108 has diagnoses that included Cerebrovascular Disease (medical term for stroke, interruption in the flow of blood to cells in the brain), Non-Alzheimer's Dementia (memory impairment in the elderly), and Hemiplegia (one sided weakness of the face, arm, and leg). The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #108 had severely impaired cognitive skills for daily decision making and was totally dependent on staff for all Activities of Daily Living. The Comprehensive Care Plan for Fall dated 04/2023 documented that Resident #108 had a history of falls, or at risk for fall or injury. Goals included that Resident will be free of falls/injury, minimize risks of falls/injury (personal-environmental). Interventions included provide on-going assessment of risk factors, orient frequently; refer to Rehab for Occupational/Physical Therapies, and teach transfer techniques. The Nursing Progress note dated 1/20/25 documented that Resident #108 fell and hit the back of their head on the floor while being transferred to bed by 2 Certified Nursing Assistants. The Physician's order dated 01/02/2025 documented transfer resident to hospital status post fall. The document titled Investigative Incident Report dated 01/21/2025 documented that on 1/20/25 during the evening shift (5:15pm), two Certified Nursing Assistants were transferring Resident #108 from the chair to bed using Hoyer lift when resident fell . Resident #108 was transferred to hospital Emergency Department for further evaluation. On 1/21/25 at approximately 2:00 pm, Director of Nursing was notified that resident sustained an acute fracture of the left orbit. The Resident Incident/Accident - Supervisor's Investigation Report dated 1/26/2025 documented that the contributing Factor to Resident #108's fall and injury was poor transferring technique and use of equipment. The Axial Computed Tomography (CT) images (X-Ray photograph) results dated 01/21/2025 documented that Resident #108 had Periorbital soft tissue (tissue surrounding left eye) swelling and laceration on the left side; intra-orbital emphysema (fluid) on the left side; Acute comminuted fractures of the lateral wall of the left orbit; Fracture extends into the frontal skull on the left side. On 03/27/2025 at 03:31 PM, Certified Nursing Assistant #3 was interviewed and stated that they were assisting the Certified Nursing Assistant assigned to Resident #108 with transferring Resident #108 with the Hoyer lift on the day of incident. Resident #108 was in a Geri-chair and the Hoyer lift canvas sling had already been placed underneath Resident #108 by the previous shift. Certified Nursing Assistant #3 also stated the sling was checked by the two Certified Nursing Assistants transferring the resident, and hooked up to the Hoyer lift, and Resident #108 was moved up in the chair and chair placed close to the bed. Resident #108 slid down to the floor while being transferred, and their head was hanging off of the sling and resting on the floor while their body was on the bed. Certified Nursing Assistant #3 stated that Resident #108 was not fidgeting during the transfer and the sliding movement to the floor happened very fast. Certified Nursing Assistant #3 was unable to explain or demonstrate how the Hoyer lift canvas sling was placed under Resident #108 when the fall occurred. Certified Nursing Assistant #3 stated that they had in-service on the use of the Hoyer lift before the accident and after the accident occurred but could not explain the instruction given on placement of Hoyer Lift canvas sling. On 03/27/2025 at 03:36 PM, Certified Nursing Assistant #4 was interviewed and stated that they were on one-to-one observation with another resident on the unit when Resident #108 was reportedly fell off from Hoyer. Certified Nursing Assistant #4 stated that they were told that Resident #108 fell from the Hoyer lift during transfer but was not present in the room when the incident occurred. Certified Nursing Assistant further stated that they were given training on the use of the Hoyer lift before the accident and shortly after the incident but could not remember the instruction given on the placement of the Hoyer lift pad. On 03/28/2025 at 09:42 AM, Certified Nursing Assistant #5 was interviewed and stated that the representative of the company that supplied the Hoyer lift came to give in-service, but no demonstration was given, they just talked them through it and gave them a website to watch the video. Certified Nursing Assistant #5 stated that no specific instruction was given on whether to cross the strap, but they will normally cross it to ensure resident is properly fixed. On 03/28/202525 at 10:07 AM, Certified Nursing Assistant #6 was interviewed and stated that they have been given in-service on the use of Hoyer lift but cannot remember if they were specifically educated how to place the sling, they know if the resident is small the sling's straps should be crossed to prevent resident coming off. Certified Nursing Assistant #6 stated that they were educated that the Hoyer lift should always be used with two staff assist. On 03/27/2025at 03:45 PM, Licensed Practical Nurse #3 was interviewed and stated that they were on the floor on the day of the accident but did not witness Resident #108's fall. Licensed Practical Nurse #3 also stated that when they were called to the room, Resident #108 was observed hanging on the Hoyer lift canvas sling with their head on the floor. Licensed Practical Nurse #3 stated that they thought the strap was not crossed when Resident #108 was hooked to the Hoyer lift, but the pad should have been crossed. Licensed Practical Nurse #3 also stated that they have since been instructed that the strap should be crossed when transferring resident. On 03/27/2025 at 03:58 PM, Licensed Practical Nurse #4 was interviewed and stated that two Certified Nursing Assistants were in the room transferring the resident when one of them came to notify them that Resident #108 was hanging from the Hoyer Lift. Licensed Practical Nurse #4 also stated that when they entered Resident #108's room, they observed that one of their feet was in the canvas, and the rest of Resident #108's body was on the floor. Licensed Practical Nurse #4 further stated that Certified Nursing Assistant #3 reported that Resident #108 slipped off the canvas. Licensed Practical Nurse #4 stated that the Hoyer lift canvas sling was not crossed under the legs of Resident #108 which could have caused Resident #108 to slip off the sling easily. Licensed Practical Nurse #4 also stated that when the staff was initially given training on the use of the sling, they were told not to cross the straps under the resident's leg, but after the incident they were told to cross it to prevent residents from sliding off. The Certified Nursing Assistant assigned to Resident #108 is no longer employed at the facility and attempts to contact them on 03/27/2025 at 04:10 PM and on 03/28/25 at 08:58 AM were unsuccessful. On 03/28/2025 at 09:00 AM, Registered Nurse #3 was interviewed and stated that they got the call that Resident #108 fell , went in to check and observed Resident #108 lying on their back on the floor. Registered Nurse #3 also stated that the Certified Nursing Assistants reported that Resident #108 slipped out of Hoyer lift canvas sling and fell on the floor. Registered Nurse #3 further stated that they did not know what instructional training was given to the Certified Nursing Assistants regarding placement of Hoyer lift canvas slings during transfer of residents. On 03/28/2025 at 09:13 AM, the Staff Development Coordinator was interviewed and stated that when the facility got the new Hoyer lift, the company that supplied the equipment came in to educate the staff. The Staff Development Coordinator also stated they educated the staff before they started using the equipment and they continue to educate staff thereafter, and on an annual basis and periodically check for competency and staff are re-inserviced when there is an incident. The Staff Development Coordinator further stated that from the report given and return demonstration by the assigned staff, Resident #108 was not placed properly on the Hoyer lift canvas sling, which caused Resident #108 to fall off the sling during transfer. The Staff Development Coordinator stated that staff were adequately educated on proper placement of canvas sling and use of Hoyer lift before and after the accident. On 03/28/2025 at 11:56 AM, the Senior Associate Director of Nursing was interviewed and stated that they have an educator doing periodic in-service to staff on the use of equipment, Managers are on the floor to monitor that staff are competent, and if any staff is noted not to be competent they are given re- inservice. The Senior Associate Director of Nursing also stated that some staff are not comfortable even with the in-service, and they try to re-educate the staff several times. The Senior Associate Director further stated that based on return demonstration by the involved Certified Nursing Assistants during the investigation, Resident #108 fell backward indicating the resident was not properly placed on the sling and staff did not securely control the resident's body on the sling, using poor transfer technique. On 03/31/2025 at 11:29 AM, the Director of Nursing was interviewed and stated it is users' error that caused Resident #108 to fall off the Hoyer lift, and they think that the Certified Nursing Assistants did not properly support the top half of Resident #108's body during the transfer. The Director of Nursing also stated that all Certified Nursing Assistants were given training by the equipment vendor and the facility educator as part of their orientation, and the incident could have been avoided if the Certified Nursing Assistants used appropriate technique to support the resident during the transfer. The Director of Nursing further stated that based on the report that Resident #108 fell from the top of the canvas sling, the lack of support caused the fall. On 03/31/2025 at 12:09 PM, the Administrator was interviewed and stated upon review of the investigation with the clinical team, they found out that the Hoyer lift was not malfunctioning, and it was the one of the Certified Nursing Assistants that did not properly support Resident #108 during transfer that caused the fall. The Administrator stated that the Certified Nursing Assistants should have followed the training received and as a result one of the Certified Nursing Assistants was terminated, and the other one was suspended. 41709 Resident #260 has diagnoses that include Down Syndrome, Failure To Thrive, and Pulmonary Hypertension. The Annual Minimum Data Set assessment dated [DATE] documented that Resident #260 was severely cognitively impaired and required dependent care for all Activities of Daily Living. The Minimum Data set further documented Resident #260 have no fall history. During multiple observations from 03/26/2025 at 09:03 AM to 03/31/2025 at 09:00 AM, Resident #260 was observed in constant motion, moving arm and legs, and always making sounds. Resident #260 observed seated in multiple locations such as wheelchair, in crib, in a wheelchair in the hallways, receiving feeding and was never at rest. The Comprehensive Care Plan titled Falls/Injury Actual dated initiated 3/12/2024 and last reviewed 9/09/2024 had interventions that included provide ongoing assessment of risk factors, investigate falls, assess judgement/mental status and provide supervision in accordance with needs. Refer to Physical therapy/Occupational Therapy. Resident in crib. The Nursing progress notes dated 9/12/2024 documented Resident #260 is alert and responsive to tactile stimuli. Received out of bed to wheelchair at 7:00am, sleeping on and off with no signs of acute distress. The schoolteacher later reported that the resident accidentally fell off the recliner chair in the playroom while they were doing an activity with Resident #260 and another resident. Resident #260 was assessed with no visible injury, and the doctor and the unit manager notified. Resident was assessed and recommended transfer to the hospital Brookdale for Computed Tomography scan of the head, the resident fell on the right side of head in addition to history of intracranial pressure and shunt. Resident had no loss of consciousness, and the resident remained playful with the staff. Monitoring continued until resident was transferred to Brookdale at 1:40 PM for Computed Tomography scan. The Nursing progress note dated 9/12/2024 at 10:30 PM documented Resident #260 was awake and responsive returned from the Emergency Department via ambulance accompanied by two Emergency Medical Attendant and Certified Nursing Assistant. Body check done, seen and evaluated by Medical Doctor, orders in place. Status post fall evaluation, resume diet, medications and feeding as per Medical Doctor's order. The Computer Tomography Scan of head results dated 9/12/2024 documented scan of the head without contrast, no evidence of fracture or occlusion, no evidence of mass, midline shift or intracranial hemorrhage, or large territory infarction. Result unremarkable. The Nursing progress note dated 09/13/2024 at 4:30 am documented Resident #260 was lethargic, difficulty to arouse, placed on oxygen via Nasal canula Oxygen. Doctor called and made aware continue to monitor closely. Resident #260 resting calmly. The Resident Profile/Certified Nursing Assistant Accountability instructions dated 9/2024 documented Resident #260 required total dependent assistance for dressing, elimination, personal hygiene, eating, transfers, oral care, and out of bed in chair with seatbelt. The Resident Profile/Certified Nursing Assistant Accountability Record dated 8/2024 documented Resident #260 always required wheelchair seat belt and harness. The Nursing Fall Risk evaluations dated 9/16/2024 and 10/25/2024 documented Resident #260 was high risk with a score of 15. The Facility Incident Report Summary dated 9/12/2024 documented that on 9/12/2024, Resident #260 was in class when the teacher reported to nursing that Resident #260 fell from armchair to right side, and Resident #260 was examined by medical doctor and was unremarkable. Resident #260 was transferred to hospital for evaluation where a Computer Tomography scan was done and found the shunt was in place with no hydrocephalus. Medical progress notes dated 8/9/2024 documented that Resident #260 experienced an episode of altered mental status and sudden respiratory distress suspicious of shunt malfunction. Medical admission note dated 1/20/2025 documented resident had Ventricular Peritoneal Shunt revision on 8/29/2024 and latest revision on 9/13/2024. A statement dated 9/12/2024 written by the Teacher documented that student Resident #260 was sitting on an armchair with another student while learning math numbers. The Teacher documented that they often serve Residents in small group of two to incorporate some social skills. Resident #260 was in the wheelchair and teacher took Resident #260 out of wheelchair and placed Resident #260 in the armchair at about 10:00 am in the playroom. Resident #260 was sitting on an armchair with another student while learning math numbers, which teacher often do to serve residents in small group of two to incorporate some social skills. As they worked with the residents, they noticed another resident was very active and needed to be moved. They picked up that resident to shift onto another chair, and as soon as they did this, Resident #260 moved in the armchair and fell out of the chair to the floor. They immediately picked up Resident #260 and comforted Resident #260. At that point another staff walked by and the nurse came. The Teacher involved in the incident was not currently working at the facility and was not available for interview. On 03/27/2025 at 09:24 AM, the Speech Therapist was interviewed and stated that they were walking by the playroom when they heard a loud thud and saw Resident #260 on the floor. The Speech Therapist also stated that they saw the teacher pick Resident #260 up from the floor and place Resident #260 back in the chair. The Speech Therapist further stated that Resident #260 was in the Geri chair and was not secured in the chair. The Speech Therapist stated they immediately reported the incident to the nurse on the unit. On 03/27/2025 at 09:33 AM, Registered Nurse #6 was interviewed and stated that on the day of the incident was passing by the playroom, going to the back of the school area and noticed that the Teacher was in the playroom with two residents, including Resident #260. Registered Nurse #6 also stated they saw the Teacher standing next to the Ger-chair trying to pick up Resident #260 and told the Teacher to be careful because the Resident #260 was not in wheelchair and is very active. Registered Nurse #6 further stated that approximately two minutes later the Speech Therapist reported that Resident #260 fell to the floor. Registered Nurse #6 stated that when they went into the playroom Resident #260 was in the Teacher's arms, and the Teacher was cradling and soothing Resident #260 who was not crying. Nurse #6 stated that Resident #260 was not crying, and the Teacher stated that Resident #260 fell out of the chair. Registered Nurse #6 stated that they immediately assessed Resident #260. On 03/27/2025 at 09:40 AM, Registered Nurse #7 was interviewed and stated that they were informed about the incident regarding Resident #260 and immediately assessed them and found no injury, crying and or other signs of distress at the time. Registered Nurse #7 also stated that they immediately reported to the Medical Doctor, Nurse Manager and Director of Nursing. Registered Nurse #7 further stated that Resident #260 was closely monitored and later that day started crying and had changes in their vital signs. Registered Nurse #7 stated that Resident #260 was sent out to the hospital and return to the unit in no distress, was monitored by staff. Later at night Resident #260 was lethargic, and eventually had respiratory distress, and was taken to the hospital where their Ventricular Peritoneal Shunt was revised due to increased intracranial pressure. Registered Nurse #7 also stated that Resident #260 is super active, full of energy and when taken out of the crib they must be placed in a wheelchair with harness restraints because of their constant movement. On 03/27/2025 at 09:44 AM, the Pediatric Medical Doctor was interviewed and stated that they examined Resident #260 at the time of the fall and Resident #260 had no visible injury, their vital signs were stable at the time, and they ordered that Resident #260 be transferred to the hospital secondary to a history of Ventricular Peritoneal Shunt. The Pediatric Medical Doctor also stated the Ventricular Peritoneal Shunt is used to treat hydrocephalus, a condition where excessive fluid builds up in the brain, and the shunt is used to drain the excess fluid in the abdomen of resident #260. The Pediatric Medical Doctor further stated they did document all that occurred in the chart including involving the medical examiner to look at the case and they all concluded the fall did not contribute to the later increase in intracranial pressure, leading to replacing the Ventricular Peritoneal Shunt on 9/13/2024 a day after the fall. The Pediatric Medical Doctor stated this was concluded because in the past Resident #260 had the same condition without falls and without trauma. On 03/28/2025 at 03:45 PM, the Director of Nursing was interviewed and stated that it was not appropriate for the teacher to transfer Resident #260 from the specialized wheelchair to the armchair that Resident #260 was placed in because Resident #260 is a very active resident and moves constantly. The Director of Nursing also stated that the teachers are trained in working with residents and the Teacher should have known that Resident #260 needed to be placed in the wheelchair with the seatbelt or they needed to stay close to Resident #260. The Director of Nursing further stated that this fall could have been prevented if Resident #260 was not removed from their wheelchair. The Director of Nursing stated that the teacher is not available as they are on Medical Leave. On 03/31/2025 at 09:02 AM, the Senior Director of Nursing for Pediatrics and Young Adults was interviewed and stated that Resident #260 is very active and depends on staff to meet all their needs. The Senior Director of Nursing for Pediatrics and Young Adults stated that prior to this incident, the Teacher was allowed to take residents from the bedroom to classroom or playroom, and the Teacher usually works one to one or in groups with the residents. The Senior Director of Nursing for Pediatrics and Young Adults stated that Resident #260 would have been safe with the teacher if on one to one supervision, and the accident could probably have been avoided if the teacher did not take the Resident #260 out of the wheelchair. 10 NYCRR 415.12(h)(2)

Based on observations, record review, and interviews conducted during the onsite survey for the recertification survey from 03/24/2025 to 03/31/2025, the facility did not ensure that food was handled in accordance with professional standards for food service safety and staff did not ensure that infection control practices were maintained in the kitchen. This was evident during the Kitchen task. Specifically, dietary staff with visible facial hair and no beard restraints were observed assisting with food tray preparation on the tray line and removing cleaned items from the dish machine. The findings are: The facility policy titled Uniform Policy revised June 2024 stated that hair nets, beard restraints and department approved caps are required throughout all areas of the Department of Food and Nutrition. The facility policy titled Food Safety revised August 2024 stated that staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. Dietary staff must wear hair restraints (hairnet, hat and or/beard restraint to prevent hair from contaminating food. During observation of the tray line temperatures on 03/26/2025 at 11:32 AM, Dietary Technician #1 was observed on the tray line placing items on resident trays for the lunch meal. Dietary Technician #1 had visible facial hair and was not wearing a beard restraint On 3/26/2025 at 11:41 AM, Dietary Aide #4 was observed walking through the kitchen toward the trayline. Dietary Aide #4 had a full beard and was wearing a surgical mask only. On 03/26/2025 at 11:43 AM, Dietary Aide #2 was observed opening the refrigerator and removing sandwiches. At 11:48 AM, Dietary Aide #2 was observed removing plastic lids, handling dishware in the refrigerator, and placing clean dishes on the meal cart. Dietary Aide #2 had a visible beard and was not wearing a beard restraint. On 03/26/2025 at 11:45 AM, Dietary Aide #1 was observed at the hand washing sink washing their hands. Dietary Aide #1 had a visible beard and was wearing a yellow surgical mask only. On 03/27/2025 at 09:59 AM, Dietary Aide #3 was observed removing dishes from the dietary carts. Dietary Aide #3 had visible facial hair and was wearing a surgical mask only and their hair not fully restrained under the hair net that they were wearing. On 03/31/2025 at 09:12 AM, Dietary Aide #5 was observed on the tray line placing food items on the tray. Dietary Aide #5 had a visible mustache and goatee was not wearing a beard restraint. In addition, their hair was not fully restrained under the hair net. There were no beard nets observed in the kitchen. During an interview on 3/26/2025 at 11:45 AM, Dietary Aide #1 stated that they should be wearing a beard net because they do not want any hair to fall into the food. Dietary Aide #1 also stated that they wear a surgical mask all the time, and their beard does not grow very much so they do not always wear a beard net. During an interview on 03/26/2025 at 11:52 AM, Dietary Aide #2 stated when they are around food, they should wear a beard net to protect hair from flying from their face into the food. During an interview on 03/26/2025 at 11:50 AM, Dietary Technician #1 was interviewed and stated they are not usually on the tray line, and should be wearing a beard net, so hair does not get into the food. During an interview on 03/27/2025 at 10:00 AM, Dietary Aide #3 stated they forgot to get a beard net, and they should wear one when they serve food, so food does not fall in the food. During an interview on 03/27/2025 at 10:04 AM, Dietary Aide #4 stated they should have put on a hair net before they entered the kitchen to go on the tray line and should wear a hair net to prevent contamination. Dietary Aide #4 also stated they should be wearing a face mask in the kitchen, and they need to have a beard net on also to stop hair from getting in food. During an interview on 03/27/2025 at 10:14 AM, the Food Service Supervisor #2 stated that staff are required to wear a surgical mask if they did not receive a flu shot, and beard guards should be worn at all times when they enter the kitchen, so hair does not get into the food. The Food Service Supervisor #2 also stated that staff need to wear a beard restraint when they have a mustache or visible beard. Food Service Supervisor #2 further stated that they look at the staff daily to make sure they are wearing the correct uniform items, including hair and beard nets. During an interview on 03/27/2025 at 10:19 AM, the Production Manager who is Food Service Supervisor #1 stated that staff should be wearing their uniform and appropriate personal protective equipment to include hair net, beard guard, washer smock and gloves while in the kitchen doing their assigned job duties. Food Service Supervisor #1 also stated that beard guards should be worn whenever staff are in the kitchen with their beard and mustache covered, and if they have long hair, it should be covered to prevent the hair from getting in the residents food. Food Service Supervisor #1 further stated that they try do rounds every day to check if staff need to wear personal protective equipment, and they are currently out of beard guards right now. During an interview on 03/27/2025 at 10:25 AM, the Food Service Director stated staff should use a hair net, beard guard if necessary and bouffant caps. [NAME] guards should be used with any facial hair if they are in any place where food is being served or prepared. The Food Service Director also stated that staff in the dish room should be wearing beard guards because there is a potential that they can contaminate food, contaminating plate or container due to uncovered facial hair. During an interview on 03/31/2025 at 09:14 AM, Dietary Aide #5 stated they get a beard net when they come into the kitchen but today there were only hair nets and no beard nets were available for use. Dietary Aide #5 stated they should wear a hair net and beard net to prevent hair from falling into the food on the tray line. 10 NYCRR 415.14(h)

Based on observation, record review, and interviews conducted during the recertification survey from 03/24/2025 to 03/31/2025 the facility did not ensure residents who are unable to carry out activities of daily living received the necessary services to maintain mobility and function. This was evident for 1 (Resident #120) of 2 residents reviewed for Rehab and Restorative out of a total sample of 39 residents. Specifically, Resident #120 did not receive the Nursing Rehabilitation Standing and Balance Program in March 2025 as recommended by the Rehabilitation Department. The finding is: The facility policy titled Restorative Nursing Programs implemented 01/2000 and last revised 01/2025 states it is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Residents, as identified during the comprehensive assessment process will receive services from restorative aides when they are assessed to have a need for such services. Resident #120 had active diagnoses which included Hemiplegia, Traumatic Brain Injury and Seizure Disorder. The Annual Minimum Data Set assessment dated [DATE] documented that Resident #120 was cognitively intact, required dependent assistance with toileting, showering self, lower body dressing, putting on/taking off footwear and toilet transfer, substantial assistance with chair to bed to chair transfer and moderate assistance for sit to stand. On 03/25/2025 at 10:41 AM, Resident #120 was interviewed and stated that they are supposed to be getting therapy in the morning at the bedside, however, it has been two weeks since someone came. The Comprehensive Care Plan titled Self Care Deficit-total implemented on 02/13/2025 documented problem as resident's inability to provide for all of one's own Activities of Daily Living needs. The Comprehensive Care Plan documented that this was evidenced by total assistance needed in bed mobility, transfer, locomotion, dressing, toilet use, personal hygiene and bathing related to incomplete performance secondary to medical diagnosis. Interventions included provide 1-person total assistance during transfer, provide total assistance with bed mobility, and use mechanical lift to transfer. The Endorsement Form dated 11/29/2024 documented Resident #120 referred to a standing program for the frequency of twice daily 2-3 times for a duration as tolerated, using rolling walker or wall banister. The Physical Therapy Screening Form dated 02/04/2025 documented Resident #120 as not steady and only able to stabilize with staff assistance when moving from seated to standing position. Physical therapy recommendation documented that skilled physical therapy program is not indicated at this time, due to no changes in functional status. Resident #120 was recommended to continue with current plan of care. On 03/27/2025 at 12:05 PM the Nursing Rehabilitation Program Sheet dated March 2025 was reviewed and did not contain any evidence that Resident #120 received the Standing Balance Program as the sheet was not signed off on any dates. On 03/28/2025 at 12:05 PM, the Rehabilitation Aide #1 provided the State Surveyor a Nursing Rehabilitation Program Sheet dated March 2025 which was signed off on all dates and did not explain why the previous form provided was incomplete. There was no documented evidence that Resident #120 had been provided with or received the recommended Nursing Rehabilitation and Standing Program during the month of March 2025. On 03/28/2025 at 11:08 AM, the Director of Rehabilitation was interviewed and stated that Resident #120 was not picked up by physical therapy on 02/04/2025 as Resident #120 functional level was the same as on previous screenings. The Director of Rehabilitation #1 also stated that the recommendation of the physical therapist was to continue with the current plan of care which was the nursing rehabilitation standing and balance program which Resident #120 was currently on. The Director of Rehabilitation further stated that it is a standing order and Resident #120 is supposed to be receiving nursing rehab for the standing and balance program. The Director of Rehabilitation stated that if a resident does not receive recommended services, they can experience a decline in function. On 03/28/2025 at 12:05 PM, Rehabilitation Aide #1 was interviewed and stated they are not the regular rehabilitation aide for Resident #120 and have been providing care for Resident #120 since March 13th, 2025. Rehabilitation Aide #1 further stated that Resident #120 is supposed to be on the standing program daily as tolerated, however, Resident #120 has a history of refusals and when Resident #120 refuses, it is documented as 0 on the Nursing Rehabilitation Program Sheet and signed off. On 03/31/2025 at 10:37 AM, the Director of Nursing Services was interviewed and stated they are responsible for overseeing the nursing rehabilitation. After a resident is discharged from a therapy program, a team that consists of the Director of Nursing Services and the Unit Nurse Manager will meet with the nursing rehab team. The nursing rehab team is in serviced on what recommendations the residents are discharged with and are responsible to carry it over. The Residents Doctor is also made aware regarding the recommendations the resident is discharged with. The Director of Nursing Services further stated that they are responsible for doing occasional audits of resident's charts to ensure the resident is receiving nursing rehabilitation. The Director of Nursing Services stated that Resident #120 has a history of refusals, but it should have been documented timely and appropriately by Rehabilitation Aide #1. The Director of Nursing also stated that it was not acceptable that the Nursing Program Rehabilitation Sheet dated March 2025 was filled in and signed off on various dates after the State Surveyor requested the document. 10 NYCRR 415.12(a)(3)

Based on record review and interview during the Recertification Survey conducted from 03/24/2025 to 03/31/2025, the facility did not ensure that Minimum Data Set assessments accurately reflected a resident's status. This was evident for 1 (Resident #743) of 1 resident reviewed for accuracy of assessment out of 39 total sampled residents. Specifically, Resident #743's Minimum Data Set assessments did not accurately reflect the Resident's gender. The findings are: The facility policy titled Completion of Minimum Data Set 3.0 last revised 2025 stated that the Minimum Data Set will be completed by the interdisciplinary team and the Minimum Data Set Coordinator will transcribe assessment data completed by concerned disciplines into the Minimum Data Set book. Review for accuracy prior to submission by Minimum Data Set Assessors and clinical disciplines is necessary. Resident #743 was admitted to the facility with diagnoses that included Respiratory Failure and Tracheostomy. The Admission Minimum Data Set assessment dated [DATE], the Quarterly Minimum Data Set assessment dated [DATE] and the Discharge Minimum Data Set assessment dated [DATE] documented the gender of Resident #743 as female. The undated Resident's Profile documented that the legal sex of Resident #743 was male. The Admission Face Sheet dated 06/24/2024 also documented sex as male for Resident #743. On 03/27/2025 at 04:26 PM, Resident #743's parent was interviewed and stated that Resident #743 was a male. On 03/28/2025 at 11:26 AM, the Director of Clinical Reimbursement who oversees the Minimum Data Set Department was interviewed and stated that the gender that entered on the Minimum Data Set assessment is prepopulated based on the gender entered on the face sheet. The Director of Clinical Reimbursement also stated that the Admissions Department is responsible for inputting the gender and ensuring that it is accurate. The Director of Admissions further stated that they did not believe any of the Minimum Data Set assessors could edit that field after it was set by the Admissions team. On 03/28/2025 at 12:01 PM, the Director of Admissions was interviewed and stated that when a resident is admitted to the facility, the Admissions Department creates a face sheet for the resident in the electronic medical record. The face sheet includes the resident's demographic information, including their gender. This information then automatically populates into the Minimum Data Set assessments. The Director of Admissions also stated that they began working for the facility in November 2024, after Resident #743 was initially admitted , but that they believed that Resident #743's gender being coded as female instead of male was an error by someone on the Admissions team. 10 NYCRR 415.11(b)

Based on observation, record review and staff interviews conducted during the Recertification survey from 03/24/2025 to 03/31/2025, the facility did not ensure that a person-centered comprehensive care plan was developed and implemented to address the resident's medical, physical, mental, and psychosocial needs. This was evident for 1 (Resident #102) of 2 residents reviewed for Edema out of a sample of 39 residents. Specifically, a person-centered care plan was not developed and implemented for Resident #102 who had edema. The findings are: The facility policy titled Comprehensive Care Planning initiated 08/2020 and revised 01/2025 stated that an individualized, interdisciplinary Comprehensive Care Plan is developed by an interdisciplinary team representing all appropriate health care professionals as soon as possible after admission and no later than 1 week after comprehensive assessment are competed. The policy also stated that the resident's comprehensive care plan must be individualized, reflect an interdisciplinary approach to each problem, strength need and severity of condition, impairment, or disease. The policy further stated that the comprehensive care plan must be resident centered and the care and treatment goals realistic and measurable. Resident #102 was admitted to the facility with diagnoses that included Lymphedema of bilateral lower extremities and Type 2 Diabetes Mellitus. The Admission Minimum Data Set 3.0 assessment dated [DATE] documented Resident #102 had intact cognition and required set up assistance, partial to moderate assistance of 1 - 2 staff with Activities of Daily Living. During an interview on 03/25/2025 at 10:29 AM, Resident #102 stated that they have edema, use compression stockings, and they need to have their legs measured, so the compression stockings fit. Resident #102 also stated that a Certified Nursing Assistant assisted them with the compression stockings which did not fit them, and they have not worn them since last month. During observation on 03/25/2025 at 10:29 AM Resident #102 bilateral legs were observed to be edematous. The Physician's order dated 02/07/2025 and 03/10/2025 documented extra-large compression stockings. The Nursing Admission Evaluation dated 11/6/24 documented that Resident #102 has a history of diabetes mellitus, lower extremity lymphedema. The Medical provider progress notes dated 11/15/2024, 11/19/2024, 11/20/2024 documented lymphedema. The Nursing Monthly Progress notes dated November 2024, December 2024, January 2025, February 2025 and March 2025 did not document the status of the resident's lymphedema. During an interview on 03/31/2025 at 01:24 PM, Registered Nurse #10, who was the Nurse Manager, stated that they review care plans daily and they address any concerns related to care plans. Registered Nurse #10 also stated that they looked at Resident's #102 care plans this week, and they do not recall seeing a care plan for edema for Resident #102. During an interview on 03/31/2025 at 11:48 AM, Registered Nurse #8 stated Resident #102 has issues with their legs being weak, they are able to transfer, use the bathroom, and walk a little bit. Registered Nurse #8 also stated that they could not recall if they had observed Resident #102 with lymphedema, however Resident #102 has a diagnosis of lymphedema and venous insufficiency, and they would need care plan for the diagnosis. Registered Nurse #8 further stated that each nurse is assigned care plans due for residents and if a nurse is out then the care plan is done by another nurse when it is due. 10 NYCRR 415.11(c)(1)

Based on record review and interview conducted during the Recertification survey between 03/24/2025 and 03/31/2025, the facility did not ensure that resident's comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the episodic, comprehensive, and quarterly review assessments. This was evident for 2 (Resident #376 and Resident #194) of 5 residents reviewed for Unnecessary Medications out of an investigative sample of 39 residents. Specifically, 1). The Comprehensive Care Plan for Infection/Antibiotic Use for Resident #376 was last reviewed on 02/25/2025 and was not updated to reflect use of a Peripheral Intravenous Catheter line to give intravenous antibiotics or after Resident #376 completed a course of intravenous antibiotics, and 2). The Major Depressive Disorder and the Psychotropic Drug Use Comprehensive Care Plan for Resident #194 was not reviewed or revised after each assessment. The findings are: The facility policy and procedure titled Comprehensive Care Planning last reviewed 01/2025 stated that the resident's Comprehensive Care Plan must be individualized, reflect an interdisciplinary approach to each problem, strength, need, and severity of condition, impairment, or disease, and must be reviewed within the time frame noted for each specific goal (at least quarterly). 1. Resident #376 was readmitted to the facility with diagnoses that included Deep Vein Thrombosis, Hypertension, and Diabetes Mellitus. The Admission Minimum Data Set, dated dated dated [DATE] documented that Resident #376 had moderate impairment in cognition and required total dependence of staff for most Activities of Daily Living. The Comprehensive Care Plan for Infection dated 4/20/24 last updated 2/25/25 documented that Resident #376 has infection secondary to Cerebral abscess. Goals included that resident will be free of infection and will have no signs or symptoms of infection. Interventions included provide ongoing assessment of infectious process. The last update on 02/25/2025 documented Penicillin G Potassium in Dextrose 5W 20,000 units/milliliters for 30 days due to Cerebral Abscess. The Physician's order dated 02/25/2025 documented Penicillin G Potassium in Dextrose 5W 20,000 units/milliliters-infuse 4,000,000 units via Intravenous every 4 hours for 30 days Cerebral Abscess. The Nursing Progress note dated 02/26/2025 documented that Resident #376 was started on Penicillin Potassium every 4 hours via intravenous line on right upper arm. The Nursing Progress note dated 3/21/2025 documented that Resident #376 completed antibiotic therapy with no adverse reaction. There was no documented evidence that the Comprehensive Care Plan for Infection/Antibiotic Use was updated to reflect Resident #376's use of a Peripheral Intravenous Catheter line for the antibiotics, and there were no interventions regarding monitoring and evaluation of Resident #376's intravenous line access. There was also no documented evidence that the Comprehensive Care Plan for Infection/Antibiotic Use was updated after Resident #376 completed a course of intravenous antibiotics. On 03/31/2025 at 10:08 AM, Licensed Practical Nurse #5 was interviewed and stated that the Registered Nurse initiates the care plan, and Licensed Practical Nurse may update the care plan every 3 months. Licensed Practical Nurse #5 also stated that Registered Nurse updates the episodic care plans. Licensed Practical Nurse #5 further stated that they did not know why Resident #376's care plan was not updated after the completion of antibiotics because they thought the Registered Nurse administering the medication should update the care plan when the medication was completed. On 03/31/2025 at 10:24 AM, the Unit Clinical Nurse Manager, Registered Nurse #5 was interviewed and stated the Registered Nurse assesses, flushes the Peripheral Intravenous Catheter line and connected the Antibiotics therapy, the Licensed Practical Nurse monitors for running until it is completed and call Registered Nurse to disconnect, flush, and remove the line when the medication infusion is completed. Registered Nurse #5 further stated that the Licensed Practical Nurse is expected to notify the Nurse Manger Resident #376 completed the total 30-day-dose of antibiotics for the care plan to be updated. Registered Nurse #5 stated that there are over 78 residents that they are responsible for on the units, and they may not be aware that Resident #376 has completed the antibiotics if they are not notified by the nurse giving the medication. On 03/28/2025 at 11:47 AM, the Senior Associate Director of Nursing was interviewed and stated the Registered Nurse/Unit Manager are supposed to be evaluating and documenting resident's care plan and updating the care plan on completion of the antibiotic treatment. The Senior Associate Director also stated that they were not aware that the care plan had not been updated and was unable to explain why this had not been done for Resident #376 after use of antibiotics. On 03/31/2025 at 11:43 AM, the Director of Nursing was interviewed and stated that the Nursing Supervisors, Nurse Managers and the Registered Nurses along with themselves are responsible for ensuring that all care plans are up to date. The Director of Nursing also stated that the Licensed Practical Nurses and Registered Nurses document daily administration of the medication, and the Registered Nurse Unit Manager should have ensured that the care plan for Resident #376 was updated after the assessment and evaluation of the resident's completion of the medication. The Director of Nursing further stated that they were not aware that the care plan had not been updated. 50894 2. Resident #194 was admitted to the facility with diagnoses including Spinal Cord Compression and Major Depressive Disorder. An Annual Minimum Data Set Assessment was completed on 08/02/2024, and Quarterly Minimum Data Set Assessments were completed on 10/26/2024 and 01/19/2025. All Minimum Data Set assessments documented that Resident #194 was cognitively intact, and was taking an antidepressant medication. The Current Inpatient Medication Orders documented that Resident #194 had an order dated 01/29/2025 for Trazodone 50 mg at bedtime to treat depression. The Comprehensive Care Plan titled Major Depressive Disorder implemented 08/18/2023 documented expected outcomes including that Resident #194 resident would not harm self or others, would accept medication as ordered, would participate in recreational activities as needed, and would verbalize concerns with staff. The outcome evaluation for these goals was last dated 10/17/2024. There was no documented evidence that the Major Depressive Disorder Care Plan was evaluated after 10/17/2024. The Comprehensive Care Plan titled Psychotropic Drug Use implemented 08/18/2023 documented expected outcomes including that Resident #194 would maximize functional potential and well-being while minimizing use of medication, be free of accidents, maintain current level of functioning, and have reduced drug induced side effects. The outcome evaluation for these goals was last dated 07/16/2024. There was no documented evidence that the Psychotropic Drug Use Care Plan was evaluated after 07/16/2024. On 03/27/2025 at 11:17 AM, Registered Nurse #1, who is a Registered Nurse Manager, was interviewed and stated that Resident #194's Comprehensive Care Plans for Major Depressive Disorder and Psychotropic Drug Use were not up to date. Registered Nurse #1 also stated that the nurse manager who attends the comprehensive care plan quarterly meeting for the resident is responsible for updating the care plans. Registered Nurse #1 was unable to provide an explanation for why Resident #194's care plans were not updated on a quarterly basis. On 03/28/2025 at 11:20 AM, the Director of Nursing was interviewed and stated that Comprehensive Care Plans should be updated on a quarterly basis. The Director of Nursing also stated that the nurse manager who attends the comprehensive care plan meeting for the resident would be responsible for updating care plans for Major Depressive Disorder and Psychotropic Drug Use. The care plan would be updated based on the resident's status, their most recent Minimum Data Set assessment, and any changes in status discussed during the care plan meeting. The Director of Nursing was unable to provide an explanation for why Resident #194's care plans were not updated on a quarterly basis. 10 NYCRR 415.11(c)(2)(i-iii)

Based on observation, interview, and record review conducted during the Recertification survey from 03/24/2025 to 03/31/2025, the facility did not ensure a resident was given psychotropic medication to treat a specific condition as diagnosed and documented in the clinical record. This was evident for 1 (Resident #12U) of 5 residents reviewed for Unnecessary Medication out of 39 total sampled residents. Specifically,1. Resident #125 was not provided with nonpharmacological interventions to address behavior before an antipsychotic medication was restarted, and 2. Resident #125 was prescribed a psychotropic medication without an appropriate diagnosis. The findings are: The facility policy titled Free From Unnecessary Antipsychotic Drugs effective 11/28/2017 and revised 11/2/2024 stated residents are given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as documented by monitoring and documentation of the resident's response to the medication 1.Resident #125 had diagnoses that included Non-Alzheimer's Dementia, Anxiety Disorder, and Psychotic Disorder. On 03/26/25 at 09:55 AM, Resident #125 was observed seated in a wheelchair at their bedside with the privacy curtain drawn. Resident #125 was alert and oriented and verbally responsive when greeted. Tremors of right upper extremity were observed. Resident #125 was calm and verbalized that they had no concerns at present. The Annual Minimum Data Set assessment dated [DATE] documented that Resident #125 had intact cognition, no mood symptoms, no behaviors, no rejection of care and no wandering. The Annual Minimum Data Set assessment also documented that Resident #125 had no falls, and was Antipsychotic, Antianxiety, and Antidepressant. The Annual Minimum Data Set assessment further documented that a Gradual Dose Reduction was not attempted, and Physician documented it as clinically contraindicated on 01/20/2025. The Comprehensive Care Plan for Psychotropic Drug Use implemented on 1/2/25 and to be revised 4/25 documented goals of be free of accidents, maintain current level of functioning, have reduced drug induced side effects. Interventions included assess behavior pattern, assess resident response to medication, evaluate action and interaction with other medications, monitor for changes in mood or behavior, observe for side effects. The Current Inpatient Medications Orders signed by the Medical Doctor on 3/10/25 documented that Resident #125 was prescribed medications which included Citalopram 20mg PO daily for Major Depressive Disorder beginning 02/07/25, Diazepam 5mg PO twice daily for Anxiety beginning 02/07/25, and Quetiapine 50mg PO at bedtime for Psychosis 02/07/25. The Nurse Practitioner Psychiatric Consult dated 02/20/24 documented that Resident #125 is calm, reports no problem and wants to go home. The consult also documented that Resident #125 was on psychotropic medications and stable on current regimen. On evaluation, confused, rambling incoherently in response to interview questions. Pt denies depression, suicidal ideations and in no distress. Per staff, patient is unpredictable, agitated and not consistently compliant with care. No recent incident reported. The Mental Status Examination documented no delusions, paranoid ideation or hallucinations. Diagnosis was Major Depression Disorder, Anxiety Disorder, and Insomnia and current medications were Celexa 20 mg daily, Valium 5mg twice daily, Seroquel 25 mg at bedtime and Melatonin 5mg at bedtime. The plan was trial discontinue Seroquel 25 mg at bedtime. The Nurse Practitioner Psychiatric Consult dated 05/21/24 documented that Resident #125 has no complaints and wants to go outside. The consult also documented that Resident #125 was on psychotropic medications and stable on current regimen. On evaluation, confused, rambling incoherently in response to interview questions. Pt denies depression, suicidal ideations and in no distress. Per staff, patient is unpredictable, agitated and not consistently compliant with care. No recent incident reported. The Mental Status Examination documented no delusions, paranoid ideation or hallucinations. Diagnosis was Major Depression Disorder, Anxiety Disorder, and Insomnia and current medications were Celexa 20 mg daily and Valium 5mg twice daily. The plan was continue current regimen. The Nurse Practitioner Psychiatric Consult dated 07/31/24 documented that Resident #125 feels weak a lot but did not elaborate due to cognitive status. The consult also documented that Resident #125 was on psychotropic medications and stable on current regimen. On evaluation, confused, rambling incoherently in response to interview questions. Pt denies depression, suicidal ideations and in no distress. Per staff, patient is unpredictable, agitated and not consistently compliant with care. No recent incident reported. The Mental Status Examination documented no delusions, paranoid ideation or hallucinations. Diagnosis was Major Depression Disorder, Anxiety Disorder, and Insomnia and current medications were Celexa 20 mg daily and Valium 5mg twice daily. The plan was continue current regimen. The Nurse Practitioner Psychiatric Consult dated 09/03/24 documented that Resident #125 reports they want their eyes fixed. Otherwise has no other issues. The consult also documented that Resident #125 was on psychotropic medications and stable on current regimen. On evaluation, confused, rambling incoherently in response to interview questions. Pt denies depression, suicidal ideations and in no distress. Per staff, patient is unpredictable, agitated and not consistently compliant with care. No recent incident reported. The Mental Status Examination documented no delusions, paranoid ideation or hallucinations. Diagnosis was Major Depression Disorder, Anxiety Disorder, and Insomnia and current medications were Celexa 20 mg daily and Valium 5mg twice daily. The plan was start patient on Seroquel 50 mg every bedtime for Psychosis. Review of Progress Notes dated 5/20/24 to 8/29/24 documented an incident on 6/13/2024 when Resident #125 refused to wear their life vest (a device that monitors the heart and delivers a shock if it detects a life-threatening irregular heart beat). Resident #125 was educated and redirected and continued to wear the life vest. A Progress note dated 08/29/2024 documented that Resident #125 verbalized that a person from a certain Caribbean island was trying to kill them. There was no documentation of any other behaviors or an increase in behaviors that supported the re-initiation of an antipsychotic medication on 09/03/2024 at twice the dosage that was prescribed when the medication was discontinued on 02/24/2024. There was no evidence that non-pharmacologic interventions were attempted before the antipsychotic medication was restarted. 2. The Medication Regimen Review dated 09/30/2024 documented that Resident #125 was currently receiving low dose Seroquel for a diagnosis other than an approved chronic psychiatric condition. Please evaluate continued need and efficacy. Consider discontinue, if appropriate. The Physician/Prescriber Response dated 10/03/2024 was Disagree-will update diagnosis. The Current Inpatient Medications Orders dated 09/23/24 and signed by Medical Doctor #2 on 10/15/24 documented that Resident #125 was prescribed Seroquel 50mg by mouth at bedtime for Psychosis. The Medication Regimen Review dated 11/25/2024 documented that Resident #125 was currently receiving low dose Seroquel for a diagnosis other than an approved chronic psychiatric condition. Please evaluate continued need and efficacy. Consider discontinue, if appropriate. The Physician/Prescriber Response dated 01/03/2025 was Disagree-evaluate clinically. The Current Inpatient Medications Orders dated 09/23/24 and signed by Medical Doctor #2 on 12/13/24 documented that Resident #125 was prescribed Seroquel 50mg by mouth at bedtime for Psychosis. The Medication Regimen Review dated 12/28/2024 documented that Resident #125 was currently receiving low dose Seroquel for a diagnosis other than an approved chronic psychiatric condition. Please evaluate continued need and efficacy. Consider discontinue, if appropriate. The Physician/Prescriber Response dated 01/07/2025 was Disagree-review diagnosis. The Current Inpatient Medications Orders dated 09/23/24 and signed by Medical Doctor #2 on 01/08/2025 documented that Resident #125 was prescribed Seroquel 50mg by mouth at bedtime for Psychosis. The Medication Regimen Review dated 02/24/2025 documented that Resident #125 was currently receiving low dose Seroquel for a diagnosis other than an approved chronic psychiatric condition. Please evaluate continued need and efficacy. Consider discontinue, if appropriate. The Physician/Prescriber Response dated 03/17/2025 was Disagree-Psych consult. The Current Inpatient Medications Orders dated 09/23/24 and signed by the Medical Doctor #2 on 03/10/25 documented that Resident #125 was prescribed Seroquel 50mg by mouth at bedtime for Psychosis. There was no documented evidence that the antipsychotic was prescribed with an appropriate diagnosis despite multiple Medication Regimen Reviews indicating that the diagnosis was not an approved chronic psychiatric condition. On 03/31/2025 at 01:07 PM, Licensed Practical Nurse #7 was interviewed and stated that they have worked on the unit for over eleven years and is familiar with Resident #125. Licensed Practical Nurse #7 also stated that Resident #125 may have verbal outbursts at times where they will scream they want to go home to a certain Caribbean island but generally does not have behavioral problems. Licensed Practical Nurse #7 further stated that the screaming behavior might occur once every five months and on occasion Resident #125 might refuse care. Licensed Practical Nurse #7 stated that if Resident #125 was having behaviors problems it would be documented in the progress notes, and there was no recent documentation because Resident #125 has not had behaviors. Licensed Practical Nurse #7 also stated has not been verbally threatening to staff or other residents and prefers to stay in their room with the privacy curtain closed. On 03/31/2025 at 01:16 PM, an interview was conducted with the Nurse Manager, Registered Nurse #11 who stated that Resident #125 has been on psychotropic meds, but it has been a while since they have had an outburst where they start rumbling, are restless and says they want to go home to a certain Caribbean island. Registered Nurse #11 also stated that Resident #125 gets confused sometimes, has a history of depression, and a history of hallucinations in 2022 and 2023. Registered Nurse #11 further stated that the only behavior that that they are aware of is verbal outbursts where they say they want to go to a certain Caribbean island and visual hallucinations in September of 2024 which is documented in the record. On 03/31/2025 at 01:23 PM, Medical Doctor #2 was interviewed and stated that they have provided care for Resident #125 for the past six months and resident has been on Celexa and Valium. Medical Doctor #2 also stated that Resident #125's mood is stable, and they can be noncompliant with vital signs every now and then and wanted to have their Life Vest taken off. Medical Doctor #2 further stated that they have had to counsel Resident #125 who had difficulty in following recommendations from cardiology and verbalizes things that make it difficult for care to be provided so that may have been why Psychiatry made the recommendation to restart antipsychotic medication. Medical Doctor #2 stated that they do look at need for gradual dose reduction and see that Resident #125 has been stable. Medical Doctor #2 also stated that they thought they had written Depression as the indications for Seroquel. Medical Doctor #2 further stated that they do review the pharmacy recommendations and were waiting for psychiatry to make changes for the recommendations. On 03/31/2025 at 02:18 PM, an interview was conducted with the Psychiatric Nurse Practitioner #1 who stated that Resident #125 had been treated at another hospital for depression and anxiety for a while. The Psychiatric Nurse Practitioner #1 also stated that they restarted Resident #125 on Seroquel because when they evaluated Resident #125 on they were having hallucinations, and it was an error that their progress note documented that Resident #125 was stable on medication regimen and did not have hallucinations. Psychiatric Nurse Practitioner #1 further stated that they could not recall what the hallucinations were, how long they had been occurring and why Resident #125 was restarted on that dosage of medication. The Psychiatric Nurse Practitioner #1 further stated that they were not aware that Resident #125 had a diagnosis of Dementia and that they were aware that Psychosis was not an appropriate diagnosis for Seroquel. Psychiatric Nurse Practitioner #1 stated that they did not recall the seeing the Medication Regimen Reviews and that it was not discussed with them Seroquel was being used with an inappropriate indication. On 03/31/2025 at 02:33 PM, an interview was conducted with the Medical Director who stated that if a resident is being placed on psychotropic medication, there should be documentation of the behavior that require use of the medication. The Medical Director also stated that for Resident #125 there is mention of unpredictable behavior, and anxiety, however those behaviors alone would not be an indication for use of antipsychotic medication. The Medical Director further stated that there is a history of Dementia for Resident #125 along with other medical diagnoses, however It seems like there is behavior and it should be consistently documented by nursing and used by the doctor when managing medication, so it seems like nursing and other disciplines are not collaborating in the care of this resident. The Medical Director stated there are inconsistencies with pharmacy and part of the issue is that we are part paper and part Electronic Medical Record, so it makes it difficult to track and remain consistent. The Medical Director also stated that the Medication Regimen Reviews are sent to the physicians for review and return. The Medical Director further stated that there have been several inservices and meetings which include the Nurse Practitioners in which these issues are discussed so the Medical Staff knows what should be done and should be doing it. 10 NYCRR 415.12(l)(2)(i)

Based on interviews and record review conducted during the Recertification survey from 03/24/2025 to 03/31/2025, the facility did not ensure residents, or their designated representatives were provided appropriate notification via mail at the termination of Medicare Part A benefits. This was evident for 1 (Resident #129) of 3 residents reviewed for Beneficiary Notification out of 39 total sampled residents. Specifically, the facility did not ensure that Notice of Medicare Non-Coverage were mailed to the residents' representatives on the same day telephone notification was made. The findings are: The facility policy titled Medicare Certification, Notice of Medicare Non Coverage/ Skilled Nursing Facility-Advanced Beneficiary Notice of Non-Coverage with an effective date of 2023 and last revision date of 2025 documents that a complete copy of the Notice of Medicare Non Coverage and Skilled Nursing Facility Advanced Beneficiary Notice of Non- Coverage are provided to beneficiaries receiving skilled services and have benefit days remaining but are being discharged from Part A services. The policy also stated that the notice must be validly delivered, which means that the beneficiary must be able to understand the purpose and contents of the notice, it must be delivered to and signed by a representative. A phone call will be made to the representative to inform and explain details of notice on non-coverage. The date of the conversation is the date of receipt of the notice and will also include the name of the representative contacted, time of contact, telephone number called, and name of MDS Assessor initiating the contact. The policy further stated that a copy of the notice will then be mailed via certified mail, and all notices will be kept in a binder in the MDS office. The Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 states that the form must be delivered at least two calendar days before Medicare covered services end and included the requirement that notification of changes in coverage for an institutionalized beneficiary/enrollee who is not competent be made to a representative. The instructions also stated that if the provider is personally unable to deliver a Notice of Medicare Non-Coverage to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise them when the enrollee's services are no longer covered. The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date. The instructions also state that when direct phone contact cannot be made, the notice should be sent to the representative by certified mail, return receipt requested. Resident #129 was discharged from Medicare skilled services on 02/31/2025 with 29 benefit days remaining and remained in the facility. The Notice of Medicare Non-Coverage and the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage documented that Resident #129's designated representative was notified via phone on 01/29/2025 and was informed that Resident #36's coverage would end on 02/31/2025. The United States Postal Service Certified Mail receipt with tracking number of 70081140000221380535 documented that the mail arrived at the United States Postal Service Regional Facility ([NAME] NY Distribution Center) on February 8, 2025, 1:09 PM. There was no documented evidence that the notice was mailed to Resident #129's representative on the same day that telephone notification was made. On 03/31/2025 at 01:50 PM, the Director of Clinical Reimbursement was interviewed and stated that the Minimum Data Set assessors are responsible for notifying the resident about benefit days and notifying the resident or their representatives before the days are cut off. The Director of Clinical Reimbursement also stated that if a resident is unable to understand and handle the Notice of Medicare Non-Coverage and/or the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage letters are completed and handed over with a Certified Mail slip to the mail room. The Director of Clinical Reimbursement further stated that there was a change to the system recently that they were not aware of where there is someone who retrieves mail daily and then takes it over to the hospital where it is sent out daily. On 03/31/2025 at 02:29 PM, an interview was conducted with the Administrator who stated that the letters are handled by the Director of Clinical Reimbursement. The Administrator stated that there had not been a change to the process but that the Director of Clinical Reimbursement was not aware that it has to go to the hospital to be sent out and that the mail room does not handles these letters. 10 NYCRR 415.3(g)(2)(i)

Based on observation, record review, and interviews conducted during the Recertification Survey and Complaint survey (NY00365250) from 03/24/2025 to 03/31/2025, the facility did not ensure that residents' right to a clean, comfortable, and homelike environment was maintained. This was evident in 1 (7th Floor) out of 2 laundry rooms and in 19 out 38 resident rooms and shower rooms on the 7th floor observed during Environmental Task. Specifically, (1) the dryer on the 7th floor resident laundry room was noted with visible gray colored dust vents in the back, (2) multiple room fans were noted to have dusty front and back areas and dusty blades, and (3) water damage on the ceiling, broken wall tiles, and soiled curtains were observed in the bathrooms on both wings. The findings include but are not limited to: The facility policy and procedure titled Washing of Resident Laundry revised 03/16/2024 stated that the nursing home provides a washer and dryer for residents located on the 7th and 10 floors. Residents or family members may use these machines 7 days a week. The facilities department will clean the lint traps and inspect the machine daily Monday to Friday to ensure proper functionality. The environmental services department is responsible for maintaining the cleanliness and overall upkeep of the laundry rooms. The facility policy and procedure titled Cleaning, Disinfecting Patient Care Equipment and Surface effective 9/9/2024 stated that environmental services cleaned fans monthly and when visibly dusty. Facilities will open the fans. Building services clean the fan. 1. On 03/26/2025 at 09:20 AM, 03/27/2025 at 05:23 PM, 03/28/2025 at 10:51 AM and 03/31/2025 at 10:48 AM, the back of the dryer in the laundry room on the 7th floor was observed with thick gray colored lint build-up on all vents and on the floor behind the dryer. 2. On 03/28/2025 from 12:35 PM- 1:05 PM and 03/31/2025 from 10:49 AM - 1:01 PM multiple rooms were observed with mounted room fans. a. In Rooms 718 A and 718 B, 725-B, 727-A and 728 there was gray colored dust on some fan blades, gray or black colored grime on some blades, gray colored dust on the front and back of fan frames. b. In Rooms 708-A, 712-B, 725-B, 725-B, and 727-A there were dusty fan blades. c. In Rooms 707, 708-A, 719-B, 720-A, room [ROOM NUMBER]-P, 723-B, 724-A, and 729B there were wall mounted room fans with dusty front and back covers. d. In Rooms 706-A, 708-A and 714 -A rooms the mounted room fans were running, and gray colored dust was observed on the outside of the fan. e. In room [ROOM NUMBER]-two fans were observed with thick gray colored dust on the front, blades and back of the fan. On 03/28/2025 at 12:40 PM, an interview was conducted with the Resident in room [ROOM NUMBER] who stated that their room fan was not working. On 03/28/2025 at 01:05 PM, an interview was conducted with the Resident in room [ROOM NUMBER] who stated they have been in the room for one month and their room fan has not been cleaned. During an interview on 03/31/25 at 10:37 AM, an interview was conducted with the Resident in room [ROOM NUMBER] who stated they have been in the room for two weeks and no one has come in the room to clean the fan. 3. On 03/27/2025 12:43 PM, 03/28/25 04:08 PM and 03/31/25 12:46 PM, Shower East on the 7th floor was observed with bulging paint on the ceiling. There was a hole near the shower head nozzle on the wall. The training toilet had a brown colored stain under the toilet bowl on the wall and a white and brown colored stain on the back lower wall baseboards. In Shower [NAME] there were multiple areas with cracked and broken tiles. There were brown stains on curtains in both areas. During an interview on 03/31/2025 at 10:43 AM, Housekeeper #1 stated they clean the fans daily on all ten floors to ensure that dust is not blowing on the residents. During an interview on 03/31/2025 11:36 AM, the Facilities Manager was interviewed and stated that they do environmental rounds daily, housekeeping and nursing staff report any issues that need to be addressed, and environmental care concerns are also reported and discussed in the morning huddle. The Facilities Manager also stated that environmental services clean the fans. The Facilities Manager further stated that they looked at the laundry room a few weeks ago when the dryer was not drying properly but they do not check the lint trap daily. Housekeeping staff should be checking and emptying the lint traps daily Monday to Friday, because there is a danger of fire with lint collecting. The Facilities Manager stated they contact environmental services for cleaning the back of the dryer. The Facilities Manager also stated that they plan to replace tiles and freshen up the bathroom. During an interview on 03/31/2025 at 12:42 PM, the Building Services Aide stated once a week they clean the back of the dryer, but it is hard to get to the back of the machine to clean, and they cannot move the washing machine. The Building Services Aide also stated that the have no documentation of when the back of the dryer was last cleaned, and they do not have any checklists for cleaning. The Building Services Aide further stated they do not think the lint buildup poses a hazard. The Building Services Aide stated that the cleaning of fans is done by staff on a special assignment in the evening and they are not responsible for cleaning the fans. During an interview on 03/31/2025 at 12:46 PM, the Assistant Director of Building Services stated that they do daily rounds in the late afternoon and evening. The Assistant Director of Building Services also stated that the Facility Management department checks the vents at the back of the washing machine and dryer back daily, and the last time they looked at the laundry room was last Friday, and they did not notice that the vents were dusty. The Assistant Director of Building Services stated that when it is time for cleaning of the fans, the facilities staff removes the fans, the housekeeper cleans the fan, and facilities staff puts the fan back on the wall. 10 NYCRR 415.5(h)(2)

Based on observation, interview, and record review conducted during the Recertification survey from 03/24/2025 to 03/31/2025, the facility did not ensure that a copy of all transfers and discharges were sent to a representative of the Office of the State Long-Term Care Ombudsman in a timely manner. This was evident for 1 (Resident #743) of 1 resident reviewed for Discharge. Specifically, Resident #743 was transferred to the hospital on [DATE] and the discharge notice was not sent to the Office of the State Long-Term Care Ombudsman until 03/25/2025. The findings are: Resident #743 had diagnoses which included Respiratory Failure and Tracheostomy. The Quarterly Minimum Data Set, dated [DATE] documented that Resident #743 was a minor, was rarely or never understood, and required dependent-level assistance with all Activities of Daily Living. The Discharge Minimum Data Set assessment dated [DATE] documented that Resident #743 had an unplanned discharge to a short-term general hospital with a return to the facility anticipated. On 03/25/2025 at 10:13 AM, the Ombudsman was interviewed and stated that their office had concerns with the facility's discharge notification process. The Ombudsman also stated they had had not received any hospitalization discharge notices from the facility since October 2024. On 03/28/2025 at 12:01 PM, the Director of Admissions was interviewed and stated that it is their responsibility to send the list of hospitalization discharges to the Ombudsman monthly. The Director of Admissions also stated that they started working for the facility in November 2024 and had not had a chance to send over any discharge notices to the Ombudsman since they began employment in November 2024. The Director of Admissions further stated that they emailed the discharge lists from November 2024 through February 2025 to the Ombudsman on 03/25/2025. The Director of Admissions was unable to provide an explanation for the delay in notifying the Ombudsman and were unable to provide a facility policy related to the discharge notification process. 10 NYCRR 415.3(i)(1)(iii)(a-c)

Based on interview and record review during the recertification survey from 03/24/2025 to 03/31/2025, the facility did not ensure that recommendations in the medication regimen reviews were identified and acted upon by the attending physician. This was evident for 1 (Resident #125) of 5 residents reviewed for Unnecessary Medication out of 39 sampled residents. Specifically, four Medication Regimen Reviews which recommended that an order for psychotropic medications for a diagnosis other than an approved chronic psychiatric condition be evaluated, were not addressed. The findings are: The facility policy and procedure titled Medication Regimen Review effective 11/28/2017 and revised 10/2024 stated that the Pharmacist will document any irregularities and send copies of findings to the Physician, Director of Nursing Services, Medical Director. The policy also documented that these reports must be acted upon in a timely manner and completed forms filed in individual resident's chart. 1. The Medication Regimen Review dated 09/30/2024 documented that Resident #125 was currently receiving low dose Seroquel for a diagnosis other than an approved chronic psychiatric condition. Please evaluate continued need and efficacy. Consider discontinue, if appropriate. The Physician/Prescriber Response dated 10/03/2024 was Disagree-will update diagnosis. The Current Inpatient Medications Orders dated 09/23/24 and signed by Medical Doctor #2 on 10/15/24 documented that Resident #125 was prescribed Seroquel 50mg by mouth at bedtime for Psychosis. 2. The Medication Regimen Review dated 11/25/2024 documented that Resident #125 was currently receiving low dose Seroquel for a diagnosis other than an approved chronic psychiatric condition. Please evaluate continued need and efficacy. Consider discontinue, if appropriate. The Physician/Prescriber Response dated 01/03/2025 was Disagree-evaluate clinically. The Current Inpatient Medications Orders dated 09/23/24 and signed by Medical Doctor #2 on 12/13/24 documented that Resident #125 was prescribed Seroquel 50mg by mouth at bedtime for Psychosis. 3. The Medication Regimen Review dated 12/28/2024 documented that Resident #125 was currently receiving low dose Seroquel for a diagnosis other than an approved chronic psychiatric condition. Please evaluate continued need and efficacy. Consider discontinue, if appropriate. The Physician/Prescriber Response dated 01/07/2025 was Disagree-review diagnosis. The Current Inpatient Medications Orders dated 09/23/24 and signed by Medical Doctor #2 on 01/08/2025 documented that Resident #125 was prescribed Seroquel 50mg by mouth at bedtime for Psychosis. 4. The Medication Regimen Review dated 02/24/2025 documented that Resident #125 was currently receiving low dose Seroquel for a diagnosis other than an approved chronic psychiatric condition. Please evaluate continued need and efficacy. Consider discontinue, if appropriate. The Physician/Prescriber Response dated 03/17/2025 was Disagree-Psych consult. The Current Inpatient Medications Orders dated 09/23/24 and signed by the Medical Doctor #2 on 03/10/25 documented that Resident #125 was prescribed Seroquel 50mg by mouth at bedtime for Psychosis. There was no documented evidence that the Medication Regimen Reviews for Resident #125 regarding an antipsychotic that was not prescribed for an approved chronic psychiatric condition were addressed. On 03/31/2025 at 01:23 PM, Medical Doctor #2 was interviewed and stated that they do look at the need for gradual dose reduction and see that Resident #125 has been stable. Medical Doctor #2 also stated that they thought they had written Depression as the indications for Seroquel. Medical Doctor #2 further stated that they do review the pharmacy recommendations and were waiting for psychiatry to make changes for the recommendations. On 03/31/2025 at 02:18 PM, an interview was conducted with the Psychiatric Nurse Practitioner #1 who stated that they were not aware that Resident #125 had a diagnosis of Dementia and that they were aware that Psychosis was not an appropriate diagnosis for Seroquel. Psychiatric Nurse Practitioner #1 also stated that they did not recall the seeing the Medication Regimen Reviews and that it was not discussed with them Seroquel was being used with an inappropriate indication. On 03/31/2025 at 02:33 PM, an interview was conducted with the Medical Director who stated that there are inconsistencies with pharmacy and part of the issue is that we are part paper and part Electronic Medical Record, so it makes it difficult to track concerns and remain consistent. The Medical Director also stated that the Medication Regimen Reviews are sent to the physicians for review and return. The Medical Director further stated that there have been several in-services and meetings which include the Nurse Practitioners in which these issues are discussed so the Medical Staff knows what should be done and should be doing it. 10 NYCRR 415.18(c)(2)

Based on observation, record review, and interviews conducted during the recertification survey from 03/24/2025 to 03/31/2025, the facility did not ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice. This was evident for 1 (Resident #17) out of 3 residents reviewed for Respiratory Care out of 39 sampled residents. Specifically, Resident #17 was observed using oxygen via an undated nasal cannula at a rate of 3 liters per minute when the Physician's Order was written for oxygen to be received at a rate of 2 liters per minute. The findings are: The facility's policy titled Oxygen Administration last reviewed 01/2025 stated that oxygen is administered to residents who need it, consistent with standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Oxygen is administered under orders of a physician, except in case of an emergency. Staff shall change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Resident #17 had diagnoses that included Chronic Lung Disease and Dementia. The Annual Minimum Data Set assessment dated [DATE] documented that Resident #17 was cognitively intact and received oxygen therapy while residing in the facility. The Interdisciplinary Care Plan titled Breathing Difficulty dated 01/28/2025 documented that Resident #17 had a potential for difficulty breathing related to shortness of breath. It documented that Resident #17 received oxygen at a rate of 2 liters per minute via nasal cannula. The Physician's Order dated 03/14/2025 documented that Resident #17 was to receive oxygen via nasal cannula at a rate of 2 liters per minute. On 03/24/2025 at 09:49 AM, Resident #17 was observed in their room wearing an undated nasal cannula attached to the wall while receiving oxygen at a rate of 2 liters per minute. Resident #17 was interviewed and stated that they could not recall the last time their nasal cannula was changed. Resident #17 further stated that the nasal cannula was only changed when they complained after the nasal prongs became hard and uncomfortable, and that in the past when they had complained about this and requested a new nasal cannula, nurses would refuse to change the cannula due to a lack of tubing supplies. On 03/26/2025 at 11:58 AM, 03/26/2025 at 02:24 PM, and on 03/27/2025 at 09:32 AM, Resident #17 was observed in their room wearing an undated nasal cannula attached to the wall while receiving oxygen at a rate of 3 liters per minute. On 03/27/2025 at 09:40 AM, Licensed Practical Nurse #1 was interviewed and stated that Resident #17 received oxygen therapy due to anxiety induced shortness of breath. Licensed Practical Nurse #1 also stated that nurses change the nasal cannula tubing every day and that they do not label the nasal cannula tubing with the date. Licensed Practical Nurse #1 further stated that instead of dating the nasal cannula, they inform the incoming nurse during shift change that they changed the nasal cannula. Licensed Practical Nurse #1 denied that the facility was low on nasal cannula tubing or that they would ever refuse to change the nasal cannula if the resident requested it. Licensed Practical Nurse #1 further stated that at the start of their shift, they check the oxygen settings to ensure it is running at the rate ordered by the physician. Licensed Practical Nurse #1 stated that they had not checked the oxygen rate yet on 03/27/2025 and stated that the night shift nurse may have been the one to incorrectly set it to 3 liters per minute instead of 2 liters per minute. On 03/27/2025 at 11:13 AM, Registered Nurse #1 who is a Registered Nurse Manager was interviewed and stated that Resident #17 had an order to receive continuous oxygen at a rate of 2 liters per minute. Registered Nurse #1 stated that Licensed Practical Nurse #1 was responsible for ensuring that the oxygen was running at the ordered rate at the start of their shift. Registered Nurse #1 could not provide an explanation for why Resident #17's oxygen was running at an incorrect rate on the observations made on 03/26/2025 and 03/27/2025. Registered Nurse #1 further stated that the nasal cannula should be changed at least once a week for infection control purposes and that it should be dated every time it was changed. Registered Nurse #1 was unable to provide an explanation for why Resident #17's nasal cannula was undated. On 03/28/2025 at 11:20 AM, the Director of Nursing was interviewed and stated that they could not recall how frequently nasal cannula tubing needed to be changed as per the facility's policy. The Director of Nursing also stated that each time the tubing was changed, it should be labeled with the date by the nurse. The Director of Nursing further stated that for a resident on continuous oxygen, the oxygen rate should be verified at least once a shift to ensure it was running at the ordered rate. 10 NYCRR 415.12(k)(6)

Based on record review and staff interviews conducted during a Recertification Survey between 03/24/2025 and 03/31/2025, the facility did not ensure that the resident and their representative were provided with a written summary of the baseline care plan. This was evident for 1 (Residents #379) of 2 residents reviewed for Care Planning out of 39 residents sampled residents. Specifically, Resident #379 and their representative were not provided with a copy of the baseline care plan. The findings are: The facility policy on Baseline Care Plan dated 11/2017, last revised 01/2025 stated that the baseline care plan will be developed within 48 hours of admission. The policy also stated Along with the baseline care plan is a summary of care plan that is provided to the resident and representative in a language that can be understood. Resident #379 was admitted to the facility with diagnoses that included Seizure Disorder, Anxiety Disorder, and Respiratory Failure. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #379 has intact cognitive status, required partial/moderate assistance or supervision of staff for most Activities of Daily Living. The Minimum Data Set assessment also documented that resident and family participated in the assessment and goal setting. On 03/24/2025 at 10:05 AM, Resident #379 was interviewed and stated that they had not been given a written summary of initial baseline care plan. On 03/27/2025 at 12:35 PM, Registered Nurse #4 was interviewed and stated that they have been having care plan meetings with Resident #379 and the family at the bedside where they discuss and explain the plan of care to the resident and the family. Registered Nurse #4 also stated that they do not think a written copy of the initial summary of the care plan was given to Resident #379. Registered Nurse #4 further stated that they are not aware that the resident or their representative should be given a copy of initial base line care plan, and they do not know whether the summary was printed to provide to the family. On 03/27/2025 at 12:49 PM, Social Worker #2 was interviewed and stated that when there is a care plan meeting, they review the plan of care with the resident and their family, and each discipline provides updates to the resident and their family. Social Worker #2 also stated that they only discuss the plan of care with the resident/resident's family, and they have not been giving them a copy of the base line care plan. On 03/31/2025 at 11:37 AM, the Director of Nursing was interviewed and stated that residents and their family should be offered a copy of the baseline care plan during the initial care plan meeting. The Director of Nursing also stated that they were not aware that Resident #379 and their representative were not provided with a copy of baseline care plan. The Director of Nursing further stated that Registered Nurses were educated during their orientation and mandatory training that a copy of the baseline care plan should be provided to the resident and their family members. 10 NYCRR 415.11(c)

Based on record review and interviews conducted during the Recertification Survey from 03/24/2025 to 03/31/2025, the facility did not ensure Minimum Data Set assessments were electronically transmitted to the Centers for Medicare and Medicaid Services Data System within 14 days after assessments were completed. This was evident in 5 (Residents #148, #318, #28, #102, #407) of 5 residents reviewed for Resident Assessment. Specifically, Minimum Data Set assessments were not transmitted within 14 days after the assessments were completed. The findings are: The facility's policy titled Completion Of Minimum Data Set (MDS0) 3.0 with a revised date of 2025 documented that specific information as to completion of the Minimum Data Set 3.0 (MDS) should be done according to the Resident Assessment Instrument (RAI) manual 3.0 version. 1. The Quarterly Minimum Data Set Assessment for Resident #148 with an Assessment Reference Date of 01/29/2025 was documented as submitted to the Centers for Medicare and Medicaid Services Data System on 03/20/2025. 2. The Annual Minimum Data Set Assessment for Resident #318 with an Assessment Reference Date of 02/03/2025 was documented as submitted to the Centers for Medicare and Medicaid Services Data System on 03/25/2025. 3. The Annual Minimum Data Set Assessment for Resident #28 with an Assessment Reference Date of 01/02/2025 was documented as submitted Centers for Medicare and Medicaid Services Data System on 03/26/2025. 4. The Quarterly Minimum Data Set Assessment for Resident #102 with an Assessment Reference Date of 02/06/2025 was documented as submitted to the Centers for Medicare and Medicaid Services Data System on 03/21/2025. 5. The Admission Minimum Data Set Assessment for Resident #407 with an Assessment Reference Date of 11/05/2024 was documented as submitted to the Centers for Medicare and Medicaid Services Data System on 12/09/2024. The MDS 3.0 Final Validation Reports documented that all five assessments were submitted late. On 03/07/2025 at 12:14 PM, the Director of Clinical Reimbursement was interviewed and stated that they are responsible for submitting the Minimum Data Set assessments to the Centers for Medicare and Medicaid Services Data System. The Director of Clinical Reimbursement also stated they are aware that the submissions were late, and due to being short staffed lately they were unable to submit timely. On 03/31/2025 at 02:31 PM, the Administrator was interviewed and stated that they were was not aware that Minimum Data Set assessments had been submitted late and that there were staffing issues Minimum Data Set assessments department. 10 NYCRR 415.11

Based on record review and staff interviews conducted during an abbreviated survey, the facility did not ensure that a resident with a pressure sore was provided with the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Specifically, a resident (Resident #1), who did not have pressure sores but was at-risk for developing pressures sores, developed an unstageable pressure sore on her ankle which deteriorated to a Stage III pressure sore after an order to remove the resident's leg brace was overlooked. This was evident for 1 of 3 sampled residents. This resulted in actual harm that is not Immediate Jeopardy. Complaint ID Number: NY 456 The findings are: Resident # 1 is an [AGE] year-old female with [DIAGNOSES REDACTED]. A progress note dated 10/17/2011 informed the on-call Medical Doctor that an x-ray revealed a left femur fracture as a result of an accident. The progress note also documents an above-the-knee amputation of the right extremity and that resident is unable to move her left lower extremities and has mild [MEDICAL CONDITION]. The family was notified and the resident was transferred to the emergency room . A Nursing Progress Note dated 10/18/2011 at 6:00 A.M. documents that the resident was readmitted to the facility with a [DIAGNOSES REDACTED]. She returned with an immobilizer cast on the left side. A Medical Orthopedic Consultation progress note dated 10/19/2011 at 7:00 P.M. documents that the resident's left lower extremity is in a knee immobilizer. No swelling or ecchymosis. Skin intact. Will order femur fracture brace, prescription in the chart. A Nursing Progress Note dated 10/19/2011 at 10:45 PM documents that leg immobilizer remains in place as per the physician's orders [REDACTED]. Resident was evaluated and a left femur brace was ordered. A Medical Orthopedic Progress Note dated 10/21/2011 at 4:00 P.M. documented that the resident now has a femur fracture brace for her lower left extremity. status [REDACTED]. OK for nurse to remove brace daily for skin checks only. The Minimum Data Set (MDS) 3.0 (a resident assessment tool) completed on 10/29/2011 documented that the resident did not have any pressure ulcers, but was assessed as at high risk for developing pressure ulcers. Nursing Progress Notes from 10/22/2011 at 2:00 P.M. through 12/28/2011 at 6:00 A.M. document that the resident has the left leg brace with stocking in place. Skin checks done and skin intact. A Nursing Progress Note dated 12/28/2011 at 12:00 P.M. documents that the resident was returned to the facility from the hospital via stretcher, in stable condition. The resident had been sent out earlier in the day for an x-ray of the left femur and left knee. The progress note goes on to state that the left leg brace was replaced. Zinc oxide and protective dressing placed on left Achilles for discoloration prior to brace placement. Extra fluids encouraged and reduced appetite remains poor. Resident refused all lunch. Physician was made aware. No complaints of pain at present time. Close monitoring to continue. A Medical Orthopedic Progress Note dated 12/28/2011 documents follow-up for femur fracture. Left distal femur fracture treated in fracture brace, denies pain in knee. Complains of pain in left ankle. An unstageable pressure ulcer is noted on the left lateral ankle, eschar in place 1 x 2 cm wound, no [DIAGNOSES REDACTED], no drainage. Will discontinue fracture brace as it is causing skin breakdown. Exercise caution with turns and transferring patient so as not to refracture. Local wound care with Silverdene on left ankle. Decubiti precautions. An undated facility policy and procedure memorandum entitled "Preventing Injury to Resident," states the following: "If a consult is ordered for a resident with a cast/brace, immobilizer that is causing injury to the resident's skin, then the licensed nurse needs to follow up that a consult is completed. It cannot be accepted that a device is left on that leads to a change in skin integrity." A Weekly Ulcer/Wound Assessment Record documents the onset of resident's ulcer/wound on 12/28/2011. Left Achilles, Stage II (partial thickness skin loss), measuring 5 cm x 2 cm x 0.1 cm in depth. No drainage, color red/black. Leg brace and stocking in place with protective dressing. The Ulcer/Wound Assessment Record also documents that the resident was transferred to the hospital on [DATE]. A Nursing Progress Note dated 01/06/2012 at 8:00 PM documents that the resident was readmitted to the facility with leg stocking and immobilizer still in place. An ulcer was noted to the left ankle. A Weekly Ulcer/Wound Assessment Record for 01/06/12 documents that the resident was readmitted to the facility on that date with a Stage III (full thickness skin loss that presents as a deep crater) pressure sore on the left Achilles measuring 5 cm x 2.8 cm x 0.2 cm in depth. It is also noted that the resident is at risk for skin breakdown due to poor appetite. On 01/30/2012 at 12:30 P.M., the unit Charge Nurse (RN) was interviewed. The RN stated that a skin check was done for the resident every shift per the physician's orders [REDACTED].M. she did a skin check together with the assigned Certified Nurse Aide during morning care. The left leg brace and stocking were removed and the resident was observed with discoloration and abrasion to the left Achilles. Supervisor made aware. A Stage II discoloration of 5 cm x 2 cm was noted with an open, reddened abrasion of 0.8 cm x 0.2 cm. The RN further stated that the resident's care plan was updated to reflect the onset of a new ulcer to left achilles. Medical Doctor made aware. Treatment applied as per the physician's orders [REDACTED]. The RN further stated that, prior to the resident leaving the facility for her appointment at the hospital radiology unit for x-ray of the left leg, the orthopedic student was seen on the unit. The RN stated the orthopedic student was made aware of the abrasion to the left Achilles. The RN said the orthopedic student told her he would discuss Resident #1's condition with the Attending Physician and return to the unit after the resident returned from the hospital. The RN further stated that she did not see the Orthopedic Physician for the remainder of 7:00 AM - 3:00 PM shift on 12/28/2011 and that no consult was flagged in the resident's medical record. Upon her return to the unit the next day, she again noticed that there was no consult flagged for the resident. The RN stated she did not see the Orthopedic Physician during her 7:00 AM - 3:00 PM shift on 12/29/2011. She was not at work on 12/30/2011 and 12/31/2011. The RN said that upon her return to work on 01/01/2012 she learned that the resident had been transferred to the hospital for episodes of vomiting. An interview was conducted with the Unit Physician on 01/30/2012 at 1:15 P.M. The Physician stated she was on vacation from 12/12/2011 until 01/04/2012. On 01/09/2012 the Physician said the Director of Rehabilitation asked her to have a discussion with the orthopedic staff to determine whether Resident #1 still needed the leg brace. The Physician further stated that she reviewed the resident's medical record at that time and did not see an orthopedic consultation in the chart. She further stated she called the orthopedic house staff, who said they would examine the resident. On 01/10/2012 the Physician stated she looked at the resident's medical record again and found the consult dated 12/28/2011, which recommended that the left leg brace be discontinued. The Physician also stated that she asked the nursing staff if they were aware of this recommendation and they indicated they were not. The Physician said the brace was then removed from the resident's leg. An interview was conducted with the facility's Medical Director on 01/30/2012 at 3:45 P.M. The Medical Director stated that it was brought to his attention that some consultants have been placing their completed consultation reports in the residents' medical records without informing the Nursing or Medical staff on the units and not flagging the chart. The Medical Director further stated, this has the potential to cause a significant delay in reviewing the recommendations of medical consultants by the primary care physician or covering medical staff, and hence delay of appropriate delivery of needed medical care. An interview was conducted with the Director of Nursing (DON) on 01/30/2012. The DON stated that during morning report on 01/09/2012 he was notified by physical therapy of Resident #1's skin condition at the brace site. The physical therapist also informed the attending physician and requested that the physician review the chart and get a follow up orthopedic consult for the resident, which was done. The DON further stated that she followed-up with the rehabilitation staff and attending physician to determine if the placement of the resident's leg brace should continue. The DON stated she was told that the recommendation was to remove the leg brace and it was removed. She stated that the facility continues to treat Resident #1 for the pressure ulcer on the resident's left ankle/Achilles heel. 415.12(c)(1)(2)

Based on observation, interview and record review, it was determined that the facility Administrator failed to ensure that the facility operated in a manner in which the safety of all residents is maintained. Specifically, the facility failed to ensure that accurate and timely assessments in care planning occurred for residents who smoke, and that residents who require supervision for smoking, were supervised. The Administrator also failed to ensure that policies and procedures related to smoking were implemented. This practice resulted in harm to resident #1 who sustained a first degree burn to his lower abdomen while smoking without supervision on [DATE]. This was evidenced in 6 of 19 sampled residents. (Resident is #1). This resulted in actual harm for Resident #1 and the potential for serious harm to all 444 residents in the facility that is Immediate Jeopardy to resident health and safety and substandard quality of care. Complaint # NY 5536 The findings are: The Administrator was interviewed on [DATE]at 11:00AM. He stated that he assumed duty as administrator on [DATE] and that the facility ' s Policy and Procedure on Smoking has been updated. He stated that the former Smoking Policy and Procedure was not perfect. He stated that the facility now has a list of all smokers and that a book consisting the listing and pictures of all smokers has been created with copies in the front area and on the smoking cart. He stated that the facility now has a smoking cart in which all cigarettes and lighters are kept and that letters will soon go to all family members informing them not to give cigarettes directly to the residents without informing staff members. He also stated that the smoking area is now supervised ,[DATE] by staff and that later on, smoking periods will be introduced. He stated that effective [DATE]; the facility became a smoke free facility for new admissions. In another interview on [DATE], he stated that prior to [DATE]; he was not able to identify which residents required supervision and monitoring for smoking purposes. The Associate Administrator was interviewed on [DATE] at 11:00AM. She stated that prior to the incident of [DATE]; the facility did not have a Quality Assurance Tool for smokers. The facility only had smoking assessments. She stated that a Quality Assurance Tool has been developed after the incident and that it will be reviewed weekly and that findings will be reported during Quality Assurance meetings. The Director of Social Services was interviewed on [DATE] at 3:00PM. She stated that she has called all family members of the resident smokers to let them know that there is a new safety measure requiring them not to give cigarettes or lighter directly to the residents. They were informed that all smoking paraphernalia must henceforth be deposited with the nursing staff. She stated that all residents were re-assessed by nursing and occupational therapists to ensure they can actually hold cigarette with the required grip. Responding to another question on [DATE], at 12:00PM, the Director of Social Services stated that prior to this incident, all residents were permitted to keep there smoking paraphernalia with the exception of one resident who expired. She stated that resident smokers were not monitored prior to this incident. 415.26

Based on observation, interview, and record review, the facility failed to ensure that the facility operated in a manner in which the safety of all residents is maintained. Specifically, the facility failed to ensure that accurate and timely assessments in care planning occurred for residents who smoke, and that residents who require supervision for smoking were supervised. This was evidenced by a known smoker (Resident #1), assessed as a supervised smoker at risk, dropped a cigarette on his lap sustaining first degree burns to his abdomen. The facility also failed to implement policies and procedures related to the identification and supervision of smokers. This resulted in harm to one resident (resident #1) who received first degree burns to his abdomen on [DATE]. This was evidenced in 6 of 19 sampled residents. This resulted in actual harm for Resident #1 and the potential for serious harm to all 444 residents in the facility that is Immediate Jeopardy to resident health and safety and substandard quality of care. Complaint # NY 536 The findings are: Resident #1 is a [AGE] year old male who was readmitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 dated [DATE] noted that the resident has intact short and long term memory and is independent in cognitive skills for daily decision making. The MDS also indicates that the resident requires total assistance with activities of daily living and that he self propels his wheel chair on the unit. Review of the resident #1 ' s first smoking assessment dated [DATE] documented that the resident required supervision while smoking and is required to wear a smoking apron. A " Smoking " Comprehensive Care Plan initiated on [DATE] and updated on [DATE], and [DATE] documented that " the resident is at risk for a smoking related injury, related to CVA with right Occipital Infarct, Seizure Disorder, CAD, and Depression. Documented Interventions included that the resident will be allowed to smoke un-supervised and will be provided with a smoking poncho or apron. This in direct contradiction to resident #1 ' s, smoking risk assessment and their policy and procedure for supervised smokers. The facilities Policy and Procedure on Smoking dated ,[DATE] document that it is the responsibility of the Registered Nurse / Social Worker to determine whether or not residents are able to smoke safely and whether or not residents can maintain his/her own cigarette and lighter. The facility policy documents that residents deemed unsafe to smoke unsupervised will have their cigarettes and lighters secured in a safe place, will be escorted and monitored in the designated smoking area by a staff member and will be provided with protective garments during the smoking activity. The Nursing Progress Note dated [DATE] documented that resident #1, while smoking in the smoking area got his shirt and abdomen burnt and was transferred to the hospital for evaluation. The notes documented that the resident came back to the facility the same day with treatment for [REDACTED]. The Summary of In-house Investigation documented that, on [DATE], at approximately 1:30PM, the resident was in the designated smoking area, and that two Respiratory Therapists (RTs) observed the resident drop a cigarette onto his abdomen causing it to burn immediately through his shirt. The Summary indicated that the resident was taken to the hospital where he was diagnosed with [REDACTED]. Observations of the smoking area were made on ,[DATE], ,[DATE] and [DATE]. Certified Nurse Assistants were observed supervising smoking during observations however, the video of the smoking area on [DATE] (the date of the incident) was viewed on [DATE] and showed Resident #1 as well as two other residents observed smoking without any supervision (contrary to resident #1 ' s smoking risk assessment and the policy and procedure for supervised smokers). An individual identified to be a visitor by the facility was observed handing something to the residents. Resident #1 was observed struggling to get rid of something from his clothes. Resident #1 was observed wearing no apron and no supervision. Two staff members were observed wheeling the resident away from the smoking area. The Administrator was interviewed on [DATE] at 11:00AM. He stated that he assumed duty as administrator on [DATE] and that the facility ' s Policy and Procedure on Smoking has been updated. He stated that the former Smoking Policy and Procedure was not perfect. He stated that the facility now has a list of all smokers at risk (prior to the incident of [DATE] there was no list of smokers) and that a book consisting of the list and pictures of all smokers at risk. Copies have been placed in the front area and on the smoking cart. He stated that the facility now has a smoking cart in which all cigarettes and lighters are kept and that letters will soon go to all family members informing them not to give cigarettes directly to the residents without informing staff members. He also stated that the smoking area is now supervised ,[DATE] by staff and that later on, smoking periods will be introduced. He stated that effective [DATE]; the facility became a smoke free facility for new admissions. In another interview on [DATE], he stated that prior to [DATE]; he was not able to identify which residents required supervision and monitoring for smoking purposes. Review of the residents smoking list provided by the Administrator on [DATE], with updated assessments revealed that 6 out of 19 residents required supervision by staff when smoking. The Associate Administrator was interviewed on [DATE] at 11:00AM. She stated that prior to the incident of [DATE]; the facility did not have a Quality Assurance Tool for smokers. The facility only had smoking assessments. She stated that a Quality Assurance Tool has been developed after the incident and that it will be reviewed weekly and that findings will be reported during Quality Assurance meetings. The Director of Nursing (DON) was interviewed on [DATE] at 12:01PM. He stated that prior to the incident under investigation; some identified residents were allowed to keep their cigarette and lighters in their rooms. He stated that the facility now has a central storage for cigarettes and all smoking paraphernalia. He stated that resident #1 was not wearing his apron on the day of the incident and that he was not supervised because he did not tell any staff that he wanted to smoke. He stated new Policy and Procedure and interventions are now in place but no regular in-service has taken place yet. Asked if security is responsible for monitoring the smoking area and he replied that security is not responsible for supervising the smoking area. He stated that supervisors ' meetings were held and that supervisors have discussed the new changes with staff and that staff and residents are now aware of the new interventions. A Security Guard was interviewed on [DATE] at 3:30PM. He stated that all resident smokers were permitted to smoke unsupervised in the designated smoking area. The Nurse Manager on the ninth floor was interviewed on [DATE] at 3:20PM. She agreed that resident #1 needed total assistance in all Activities of Daily Living and that smoking was one of them. She stated that she was made aware that resident was not supervised during smoking on [DATE] and that resident #1 was not wearing protective apron. She stated that resident #1 was required to wear an apron. She stated that she did not know why the resident was not supervised on the day of the incident. She stated that prior to the incident; residents control their cigarette and smoking paraphernalia. Responding to why the care plan states that resident #1 should be allowed to smoke without supervision, she stated that she did not know why and that maybe, it is a mistake. The Charge Nurse on the ninth floor was interviewed on [DATE] at 1:50PM. He stated that resident #1 was not wearing a protective apron on that day because the apron had been laundered and that the C.N.A assigned to the resident did not ask supervisor for another apron. Responding to a question on the unit ' s monitoring observations and how residents are monitored on the unit; he stated that he could not respond to that question. The Director of Social Work was interviewed on [DATE] at 3:00PM. She stated that prior to the incident on [DATE]; all residents were permitted to keep their smoking paraphernalia with the exception of one resident who had expired. Upon further inquiry, she stated that smokers were not monitored prior to the incident. The two Respiratory Therapists that observed the accident were interviewed on [DATE] at 4:00PM. They stated that at about 1:25PM on [DATE], they both observed resident #1 in the smoking area screaming and that when they approached him, he stated that he was on fire. They stated that they saw smoke coming out from his shirt covering the lower abdomen near the belly button. They stated that the resident was not wearing any protective apron and that there was nobody supervising the area at that time. They stated that they removed the resident 's shirt and wheeled him to the hospital unit of the establishment. They stated that they could not answer the question relating to how often was the smoking area was supervised prior to this incident. The Certified Nursing Assistant assigned to resident #1 on the day of the incident was interviewed on [DATE] at 1:00PM. She stated that, it was her duty to ensure that all resident smokers wear apron. She stated that resident #1 did not wear an apron on the day of the incident because his apron was dirty and it was being laundered. She stated that he never had cigarettes in his drawer and that she did not know how he gets his cigarettes. She stated that she was doing feeding on another resident when resident #1 left the unit and that she was on lunch hour when the incident happened. She stated that resident was allowed to go down stairs to smoke because he wheels himself. She stated that, residents were allowed to keep their cigarettes in their rooms prior to the incident. Resident #1 was interviewed on [DATE]. He stated that he has been a resident in the facility for more than four years. He stated that he wears a protective apron daily but that he did not wear it on the day he burned his abdomen. He stated that the apron was in the washing machine when the incident occurred. He stated that he started wearing an apron last year (first smoking risk assessment for resident #1 was completed on [DATE]). He stated that whenever his apron is in the laundry, he does not wear an apron and that it has been like that for the past two years. He stated that they used to have a room for smoking on the fourth floor but that now smoking takes place outside of the building. He stated that residents can go out to smoke at any time without supervision. He stated that he only gets supervised if a C.N.A was there smoking at the same time and that if there is no C.N.A smoking, there will be nobody to supervise resident smokers. He stated that he smokes between 5 cigarettes to one packet per day. He stated that he may occasionally sell his cigarettes or give them away. He stated that he used to keep his cigarettes in his drawers but now keeps them in his pockets because of thieves (contrary to smoking risk assessment and policy and procedure for supervised smokers). He stated that all cigarettes are now kept in the smoking cart and that the smoking area is now supervised ,[DATE]. Narrating how he burned his abdomen, he stated that he was smoking and dozed off and did not realize when the cigarette dropped on his body. He stated that he usually did not tell staff when he was going to smoke because they never supervised him when smoking. Resident #2, a [AGE] year old male was readmitted to the facility [DATE]. His [DIAGNOSES REDACTED]. The Smoking Risk assessment dated , [DATE] documented that the resident was assessed as an unsupervised smoker. A Rutland Nursing Home Interdisciplinary Family Education record dated, [DATE], documents, " barriers to learning " ; limited cognitive ability and impaired memory. There was no care plan in place provided for this resident for smoking. An updated care plan dated [DATE], documents resident at risk for smoking related injury secondary to Diabetes Mellitus (DM) and Schizophrenia. There are no interventions listed in this care plan. An interview with Resident #2 was conducted on [DATE] at 11:40AM. He stated that before today, he could smoke cigarettes without supervision. He also stated that now, every smoker is supervised, and that there is always a staff in the smoking area ,[DATE]. He showed the investigator his apron and that he wears it only when he is smoking. Resident # 2's smoking risk assessment was updated on [DATE] and documents that resident #2 is a supervised smoker with no apron. Resident #3 [AGE] years old male was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Smoking Risk assessment dated [DATE] documents the resident is an unsupervised smoker. A " Resident Kardex " dated [DATE]-[DATE], was reviewed and it is documented in " additional information " ; resident is a social smoker supervised with an apron. There is no Care Plan provided for smoking noted for this resident prior to the incident of [DATE]. An updated smoking risk assessment dated [DATE], documents that resident #3 is now a supervised smoker with a protective garment. Resident #3 was interviewed on [DATE] at 12:00PM. He stated that before today, smoking was not controlled in the facility. He stated that a resident can go downstairs and smoke cigarettes at any time with no supervision. He stated residents used to keep their cigarettes and lighters in their rooms. He stated that now, all cigarettes and lighters are kept downstairs, and that the smoking area is now supervised ,[DATE]. Resident #4 a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Smoking Risk assessment dated [DATE] documents resident # 4 as a " supervised smoker " with an apron. Medical Record review revealed that there is no care plan in place for this supervised smoker. Resident #5, a [AGE] year old male was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. His smoking risk assessment dated [DATE] and updated on [DATE], [DATE] documents that the resident is an unsupervised smoker. Resident #5 was interviewed on [DATE]. He stated; " I have always kept my cigarettes and lighter in my possession, now they took them away and I have to go to the smoking area to ask for a cigarette and the person will give it to me. Now they are there all the time but before, there was no one monitoring. " The facility has taken the necessary steps to remove the immediacy of risk to resident health and safety. Since the [DATE] incident, the facility has developed a QA audit tool to monitor compliance with the facility's policies and procedures and conducted a comprehensive review of the smoking program. The audit tool will be reviewed weekly and discussed at quarterly QA meetings. All smokers were reassessed, including an assessment by an occupational therapist for identification of residents who can smoke safely. Resident lists were developed to indicate the safe and unsafe smokers, and designate which residents require protective clothing. Facility staff now secures all smoking materials and monitor the smoking area ,[DATE]. Family members have been directed not to bring smoking materials into the facility. Facility staff were trained on the policies and procedures. During follow up interviews, they accurately responded to questions regarding the facility's smoking policy. The Immediate Jeopardy was determined to be removed as of [DATE]. The Smoking Policy updated post [DATE] documented that, effective [DATE]; the facility became smoke free for new residents. All current residents will be grandfathered and be allowed to smoke within the facility guidelines and procedures. The new Policy places the responsibility for assessing residents for smoking on Nurses and Occupational Therapists. The new Policy also documented that effective [DATE], the facility developed a smoking cart which will contain all cigarettes and lighters of each resident smoker for enhanced safety, and that all residents who smoke will be supervised by staff at all times in the designated smoking area. 415.12(h) (1)

Based on record review and staff interviews, the facility did not ensure that a resident who was admitted with a history of falls and assessed as high risk for falls was supervised. Specifically, the resident was not provided assistance with dressing as per care plan, subsequently the resident fell , complained of pain in the right arm and was diagnose with a fracture of the right proximal humerus. This was evident for 1 of 6 residents reviewed for accidents in a sample of 30 residents. (Resident #2). This resulted in actual harm that is not immediate jeopardy. The finding is: Resident #2 is a [AGE] years old with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] documented that the resident has a short term memory problem and long term memory intact. The resident requires limited assistance in dressing, hygiene and toilet use. The Comprehensive Care Plan for dressing and grooming needs as evidenced by assistance needed in dressing dated 2/7/10, revised 5/10 documented: to assist the resident with dressing. The comprehensive care plan dated 2/7/10, and updated 5/10 documented that the resident needs assistance with transfer and ambulation. The "Resident Kardex" (a document that the licensed nurses used to indicate to the Certified Nursing Assistants the resident's care needs) dated 12/1/10 to 12/31/10 did not include instructions for dressing. On 12/3/10, the physician progress notes [REDACTED]. The x-ray report dated 12/3/10 documented "Displaced fracture of the surgical neck of the right humerus is noted." The "Progress notes" by nursing dated 12/3/10 at 1:00 P.M. documented "... Found on the floor beside her bed. Resident stated that she was putting on her clothing when she slipped and fell . Resident complained of pain to the right arm..." This note further documented that the resident was seen by the Physician and transferred to the emergency room . The facility's investigation included a statement written by the Recreation Therapist (RT) dated 12/3/10 documented that he was making room visits at noon, to distribute news papers to residents. At 12.25 PM, he knocked at the room...(resident's room #) and received no answer and left the paper on the table. As he was leaving the room he heard a voice coming from behind the curtain of bed ...(resident's room #), calling out, " ..... RT, I am here on the floor, had an accident, but I don't have all the clothes on...." The RT saw the resident on the floor with her head on the floor of the closet, her shoulder up against the outside frame of the closet and the RT immediately called the nurses." The nursing note dated 12/7/10 documented that the resident was readmitted to the facility with a right proximal humerus fracture and a right arm sling. On 2/11/11 at 12:00 Noon, the CNA assigned to the resident at the time of the accident was interviewed and stated that she gave shower to the resident between 8:30 AM and 9:00 AM. She further stated " On that day after I had given the resident a shower, I wheeled her to her room and placed her chosen clothes within her reach and left to take care of other resident." The CNA also stated that she did not check on the resident until lunch time, when she did not see the resident in the dining room. She went to the resident's room and found the resident lying on the floor. The CNA said the resident stated that she fell while trying to get dressed. The CNA stated that she should have remained with the resident while the resident was dressing. On 2/11/11 at 3:30 P.M, the RN (Registered Nurse) charge nurse was interviewed and stated that the staff believe that the resident can function more than she can. The RN further stated that as written in the care plan, the resident requires supervision in dressing and assitance in mobility. 415.12(h)

Based on observations, record review and staff interviews, the facility did not ensure that a resident admitted with pressure ulcers was continually assess, monitor and re-evaluated to prevent further breakdown. Specifically, a resident 's skin, admitted with bilateral leg casts and brace/splints, did not receive ongoing assessments, monitoring and re-evaluation to prevent new pressure ulcer development. This was evident for 1 out of 8 residents reviewed for pressure ulcer in a of 30 residents. (Resident #16). This resulted in actual harm that is not immediate jeopardy. The finding is: Resident #16 is a [AGE] years old with [DIAGNOSES REDACTED]. The nursing note dated 7/20/10 documented that the resident was admitted from the hospital with bilateral leg casts and a [DIAGNOSES REDACTED]. Additionally, this note stated "...Scar noted @ (at) the R (right) knee..." The Pressure Ulcer Risk Assessment (Braden Scale) dated 7/20/10, 8/20/10, 9/20/10, 11/17/10, 11/17/10, 12/20/10 documented a score of 12. This document indicates "... RESIDENTS WHO SCORE 18 OR LESS ARE AT RISK FOR PRESSURE ULCERS..." The Comprehensive Care Plan dated 7/20/10 documented "Presence of skin breakdown or at high risk for skin breakdown. Assess skin every shift... Assess risk factors on an ongoing basis. Protect bony prominences..." The resident kardex (used by the Certified Nursing Assistants to provide care) dated 7/20/10 to 7/31/10 did not document the presence of the right leg brace/splint. The Occupational Therapy/Physical Therapy note dated 7/21/10 documented "... BLE (bilateral lower extremity) hard leg cast. L (left) side long leg cast. RLE (right lower extremity) c (with) short leg cast with spica splint. R (right) leg is also externally rotated and knee flexed (approximately) 30 (degrees)..." The nurses progress notes dated 7/22/10 to 8/18/10 did not document any evidence of the assessment, monitoring and re-evaluation of the resident's right leg scar observed on admission or the presence of a right leg splint/brace. The orthopedic note dated 8/19/10 documented that the resident developed a wound underneath the right cast. This note documented "...Partial thickness wound underneath R ... tib (tibia) underneath Prox. (proximal) Cast c (with) eschar partially covered (approx) 2 cm (centimeters) x (by) 1 cm o (no) drainage Surrounding [DIAGNOSES REDACTED] (redness) ... Affected area - windowed... Cont (continue) Urienke boots..." The nursing progress note dated 8/19/10 documented "Resident had orthopedic consult this shift, since admission scar was noted by right knee lat (lateral) aspect under the cast. Orthopedic MD was notified and a window as made on the cast an a wound with scar 2cm x 2 cm was noted, no drainage noted..." The weekly ulcer/wound assessment record dated 8/19/10 documented that the right knew lateral aspect wound was a stage 4 pressure ulcer with eschar. The comprehensive care plan for the presence of skin breakdown or at high risk for skin breakdown did not document the presence of the right lateral knee wound. The nursing note dated 11/4/10 at 3:10pm documented "...Orthopedic left in the room removing resident bilateral cast to lower extremities. Endorsed to 3-11 Nurse to assess skin after removal of cast..." There is no documented evidence that the resident's skin was assessed by the nurse on the 3-11pm shift on 11/4/10 and the next nursing note was written on 11/5/10. The nursing note dated 11/5/10 at 2pm documented " ...Cast was removed 11/4/10 after 3:00pm, No Notes from Orthopedic dep.(department) PT was notified, but waiting for Ortho- Notes to evaluate resident..." There is no documented progress note from the orthopedic physician. There is no documented physician orders [REDACTED]. The comprehensive care plan for presence of skin break down or at high risk for skin breakdown was revised on 11/5/10 and documented "...To open brace for care and check skin..." The Medical/Renal Attending Progress notes dated 11/8/10 documented "No [MEDICAL CONDITION] cast was removed...". This note did not address that resident had any type of device in place on the lower extremities. There is no documented evidence in nursing notes from 11/5/10 to 11/16/10 that resident's skin was assessed after the removal of the bilateral casts. There is no documented evidence in the nursing notes that the resident is utilizing a brace as documented in the care plan dated 11/5/10. The next progress note by nursing was dated 12/8/10 which documented that a skin break was noted on the resident's left malleolus stage 3 measuring 4.0 cm.(centimeters) x (by) 3.2 cm. red in color with a blackish discoloration. Foul smelling secretion noted and on the left achilles a stage 2 pressure ulcer measuring 2.0 cm. x 2.0 cm. The physician was notified, [MEDICATION NAME] and Zinc Oxide ordered. Air Mattress and cradle boots in place. The Pressure Ulcer alert form documented that the resident developed a pressure ulcer in-house on 12/8/10 on the left malleolus, size- 4.0 cm. x3.2 cm stage 3. and the left achilles measuring 2.0 x 2.0 centimeters Special treatment: clean site with wound cleanser, apply [MEDICATION NAME] and dressing daily. Type of mattress: air mattress. The Weekly Ulcer/Wound Assessment Record documented that on 12/8/10 the resident developed 2 sites nosocomial pressure ulcer. 1.) left malleolus- unstageable pressure ulcer measuring 4.0 cm. x 3.2 cm.x 0 cm., with small drainage, the color: red -blackish, support surface use: cradle boots. Treatment: Clean site with wound cleanser, apply [MEDICATION NAME] dressing daily. 2.) Left achilles- stage 2 measuring 1.6 cm. x 1.2 cm. x0.1 cm. with small drainage. Support surface: cradle boots. On 12/15/10 the left malleolus became remarkable stage 4 measuring 3.6 cm. x 3.2 cm. x 0 cm. with small drainage, color is red/yellowish. Support surface: cradle boots. At the same time the left achilles still stage 2 but the size increased to 2.8 cm. x 2.0 cm. Review of the Orthopedic consult dated 12/12/10 regarding the resident's left leg external rotation documented "post cast removal and recommended to reschedule pelvic and left knee x-ray to evaluate internal healing.....continue brace." The nursing progress notes dated 12/13/10 documented "....The new D.U. 's (decubitus ulcers) are secondary to brace in resident's left leg. At the present time also resident noted with left leg rotated externally after the cast removal. M.D. (medical doctor) ordered Orthopedic consult..... Staff was notified to open brace (Immobilizer) when giving care to the resident and for skin assessment every shift and to notify nurse of any change with resident skin....." The Minimum Data Set (MDS) 3.0 dated 2/7/11 documented that the resident has short and long term memory problems with severely impaired decision making skills and requires total care with activities of daily living. On 2/9/11 at 9:20 A.M., during the initial tour of the 4th floor and on 2/10/11 at 10:00 A.M., the resident was observed lying in bed wearing a left knee immobilizer with cradle boots in place. There were two metal rods observed inside the lining of the knee immobilizer. The dressing on the resident's left achilles and left malleolus were observed to be in direct contact with the metal rods on the immobilizer. The podiatry consult dated 2/14/11 re: (regarding) lesion on the left malleolus documented "Lesion left malleolus size- 1.5cm x 1.0 peri-wound tissue is healthy. Brace noted on left leg, lesion may be cause by brace. Recommended: Foam dressing, and abdominal pads." On 2/14/11at 11:30 AM, the Rehabilitation Director was interviewed and stated: "When a device is provided by my department in-services on how to apply with return demonstration is given to nursing staff on all shift. The immobilizer that the resident is currently using was provided by Orthopedic". On 2/14/11 12:00 Noon the CNA (Certified Nurses Aide) was interviewed and stated that she provides total care to the resident but, the nurse removes and re-apply the immobilizer. On 2/14/11 at 2:15 P.M. the R.N. (Registered Nurse) was interviewed and stated: " The ulcer to the left achilles and left malleolus was due to the tight immobilizer. I was not in-serviced with regards to the proper application. I thought it is so simple and easy to apply. The foam dressing and the padding was just recommended by the Podiatrist on 2/14/11." On 2/16/11 at 2:00 P.M. the Orthopedic Physician was interviewed and stated: "The resident is not a candidate for surgery due to Osteopenia. Cast was applied for a number of months, it healed slowly. I discussed with nursing to look around the edges.I did not come back to check. I did not know about the open wound on the left achilles and the left malleolus. I should have communicated properly with detailed instruction for them to understand in the progress notes." 415.12(c)

Based on observations, record reviews and staff interviews, the facility failed to ensure that a resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychological well-being in accordance with the comprehensive assessment and plan of care. Specifically, a resident with a stage 4 pressure ulcer, who displayed evidence of pain, was not re-assessed for pain prior to or during a pressure ulcer dressing change. This was evident for 1 of 30 sampled residents. (Resident #12) This resulted in actual harm to the resident that is not immediate jeopardy. The finding is: Resident #12 is an [AGE] year old female with a history of Venous [MEDICAL CONDITION], Hypertension, Diabetes Mellitus, [MEDICAL CONDITION] & B, [MEDICAL CONDITION]-Resistant Staphylococcus Aureus Infection, Urinary Tract Infection, Hypertension, [MEDICAL CONDITION], Right Above the Knee Amputation, [MEDICAL CONDITION] and Stage IV Sacral Pressure Ulcer. The Minimum Data Set ((MDS) dated [DATE] documented the resident's mental status as having a short and long term memory problems and severely impaired cognitive skills for daily decision making. It also documents her speech as unclear, with rarely / never able to make self understood or understand others. The resident was transferred to the hospital on [DATE] for [MEDICAL CONDITION] admitted . She returned on 2/8/11 with a primary [DIAGNOSES REDACTED]. The hospital discharge records show that the resident was discharged on Tylenol 650mg Q6 hours (standing order) as of 2/8/11. The physician's orders [REDACTED]. The Physician orders [REDACTED].apply [MEDICATION NAME] to DSD (dry sterile dressing) daily. " The Medication Administration Record (MAR) dated 2/8/11 to 2/15/11 was incorrectly transcribed and documented administration of Tylenol 650mg via GT Q8hrs given at three 8 hour intervals: 5AM, 1PM, and 9PM instead of every six hours as ordered by the physician on 2/8/11. It was signed by the same Registered Nurse who signed the physician order [REDACTED]. The Medication Administration Record (MAR) for December and January, 2010 documented that the resident was receiving Tylenol 650mg via gastrostomy tube Q6 hrs PRN prior to the hospital transfer on 2/4/11. An Interdisciplinary Progress Note dated 2/13/11 documented that that Tylenol was given for pain, and that the resident tolerated dressing changes without any noted difficulty. The Pain Assessment and Reassessment record for the month of February, 2011 left blank. The Policy and Procedure for Pain Assessment, management and reassessment dated ,[DATE] documents that "an initial assessment (be) done by physicians and the RN on all patients to (the facility)." The evaluation and re-assessment of pain documented that "... pain reassessment and evaluation of therapy is done weekly on Pain Management Progress Notes, and....the physician is notified if management is ineffective as indicated by the patient's response to interventions." The Policy and Procedure for Wound Dressing Change dated 7/2/07 documented that the nurse should "check physician's orders [REDACTED].and to make resident comfortable." The Annual Competency Validation record for Long Term Care dated 6/30/10 documented that the RN has demonstrated the knowledge and skills necessary to assess and intervene when the resident experiences pain. On 2/15/11 at approximately 10:15AM, during a pressure ulcer observation, the RN and the certified nursing assistant (CNA) assisting the wound care procedure with the presence of the Nursing Supervisor, positioned the resident on her right side and raised the bed in order to gain access to the sacral area. At this point the resident began to groan, whimper and uttered a soft crying sound. There was no pain assessment performed on the resident since her re-admission. The nurse did not ask the resident if she was experiencing any pain or discomfort. After the positioning was complete, the resident quieted down. The nurse then proceeded with the removal of the soiled wound dressing. As the nurse sprayed [MEDICATION NAME] on the wound site and began to remove the adhesive tape, the resident was again heard groaning and whimpering. The nurse, CNA, and Nursing Supervisor watched as the nurse continued the dressing change without acknowledging or addressing the resident's discomfort. She did not offer any reassurance or comforting words to the resident at any point during the dressing change. The wound was noted to be quarter sized, with the full thickness of a stage IV sacral ulcer. It contained reddish tissue interspersed with yellowish slough occupying the wound bed. The wound was moist with yellowish drainage, no signs of tunneling, infection, or tissue [MEDICAL CONDITION], with a foul odor present. The surrounding skin is comprised of raised pink tissue. The nurse applied Zinc Oxide ointment to the periwound area and then added [MEDICATION NAME] to the wound site. As the ointments were applied, the resident started for the third time to moan and whimper intermittently and then, settled down as the final gauze dressing was applied. At 11:30AM, after the aforementioned wound care observation, the RN was interviewed regarding the resident's discomfort during the procedure. The RN stated that the previous shift had administered Tylenol 650mg to the resident at 5AM that morning as per physician's orders [REDACTED]. She went on to state that she had always performed a pain assessment in the past before the pressure ulcer change and administered Tylenol appropriately, as the resident had a PRN (as needed) Tylenol order. The nurse also stated that she had not documented her observation of the resident experiencing discomfort during the wound change on 2/15/11. She stated, however, that she had verbally told the physician but, did not document it in the progress notes, or in the verification checklist. She went on to state that she normally performed the dressing change around 9AM to 10AM in the morning, after the resident finished her tube feeding. She stated that this was beyond the 4-6 hour dosage-window and that she should have re-assessed the resident for pain or discomfort. On 2/16/11, at approximately 1:30PM, via telephone, the RN that signed both the physician's orders [REDACTED]. She stated that she picked up the readmission orders [REDACTED]. She stated that she did not realize that she wrote the order incorrectly onto the MAR. She stated that the nurse picking up orders will document the new order in the "checklist for verification of new physician orders" book for validation by 2 subsequent shift nurses. This book was reviewed and no entry for this patient was documented on that date (2/8/11) by any staff member. She stated that she may have forgotten to write it in the "book." On 2/15/11, at approximately 4:00PM, the Registered Nurse Unit Supervisor was asked to review the readmission orders [REDACTED]. He was not aware that it was written incorrectly on the MAR and given incorrectly from 2/8/11 to 2/15/11. He stated that resident was experiencing discomfort due to her stage IV pressure ulcer. He went on to state that her discomfort was likely due to positioning of the resident on her right side, the removal of the tape securing her dressing, and the cold sensation of the [MEDICATION NAME] spray. He also stated that a re-assessment should have been done by the nurse at the time that the resident's discomfort was noted. He stated that an order for [REDACTED]. On 2/15/11 at approximately 4PM the resident's primary care physician was interviewed. She stated that it is the nurse's responsibility is to contact the physician if she determines that the resident is experiencing discomfort during a dressing change. The physician also reviewed the readmission order for the Tylenol, written on 2/8/11 by the "on call " physician, and identified the documented Tylenol order as " Tylenol 650mg GT Q6HR. " She stated that she is the attending physician and was also covering the physician while she was in the hospital for her 2/4/11 stay. She stated that she changed the order for Tylenol from Tylenol 650mg GT Q6HR PRN, to Q6HR (Standing), to make sure that the patient was covered for pain during anticipated examinations. Her understanding was that this order was to be continued. She did review the physician orders [REDACTED]. She stated that she does not typically review the MAR and was unaware that the resident was receiving the Tylenol Q 8HRS. On 2/15/10 at approximately 4:30PM, the CNA was interviewed. She stated that the resident did not moan, groan, or cry out during her morning care or when her position was changed. She stated that it is her responsibility to inform the nurse if the resident experienced any discomfort. She also stated that she noted that the resident appeared to be in pain during the dressing change that the nurse and she performed that morning.. 415.12