Every finding on record at Sayville Nursing And Rehabilitation Center

Based on interviews and record review during an abbreviated survey (Complaint Number: NY00371931), the facility did not ensure resident rights to be free from neglect. Specifically, one (Resident #2) of three residents reviewed for neglect, required two-person assistance for mechanical lift (Hoyer) for transfers as documented in the Comprehensive Care Plan (CCP). A Certified Nursing Assistant (CNA #2) neglected to implement the Comprehensive Care Plan. Certified Nursing Assistant #2 placed a Hoyer sling under Resident #2 by themselves and proceeded to transfer Resident #2 alone. This negligence resulted in Resident #2 's being lowered to the floor. Resident #2 was transferred to the hospital and diagnosed with a contusion. The Findings are: The Review of the facility policy dated 8/2029 entitled Lift, Mechanical documented at least two nursing assistants are needed to safely move a resident with a mechanical lift. The policy and procedure titled Resident Abuse, Mistreatment, Neglect and Exploitation revised 12/2022 defined neglect as failing to provide timely, consistent, safe, adequate and appropriate services, treatment and/or care to a resident of a residential care facility while resident is under the supervision of the facility. The policy also documented a federal definition of neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Resident # 2 was admitted to the facility on [DATE] with diagnoses that included, anemia, (low blood count), peripheral vascular disease (circulation problems) and dementia(confusion). The review of the Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 99 indicating severe impairment for decision making and is dependent on staff for chair to bed transfer. The review of the Comprehensive Care Plan (CCP) titled Risk for Falls dated 11/24/2024 documented at risk for falls, actual fall, mechanical Hoyer lift, the interventions documented bilateral floor mats at bedside bed. Perimeter mattress, yellow star program identified as frequent faller. The review of the [NAME] dated 4/9/2024 documented interventions including chair/bed chair transfer: 2-person mechanical lift, shower transfer: two-person mechanical lift. The review of the progress notes dated 2/3/2025 at 2:00 PM documented the Registered Nurse was called to resident's room. Resident #2 was observed on floor next to bed lying on right side. Certified Nurse's Aide in room and stated, during transfer from bed to wheelchair via Hoyer Resident started to slide out of Hoyer out of Hoyer pad and slid to floor. The Resident complained severe pain to right shoulder and right hip. Resident maintained in same position and 911 was called. 911 responded and placed resident into stretcher from floor. Resident transferred to the hospital. The facility's Investigative Summary dated 2/3/2025 documented on 2/3/2025, the Registered Nurse was called to evaluate Resident #2. Resident #2 was lowered to the floor. The nurse observed Resident#2 on the floor with the Hoyer pad underneath the Resident, the nurse aid was standing beside the Resident. The Resident #2 was lying on right side, alert and awake. The nursing supervisor conducted a full body assessment. The neurological assessment was at baseline, there was no Loss of consciousness noted by the nurse's aide. Vital signs were stable, the Resident was complaining of right hip and right shoulder pain. The primary care physician ordered to send Resident #2 to the emergency room via 911 to rule out any injury. Emergency Medical Services responded to the facility and transferred the Resident to the hospital. The investigation conclusion documented no cause to believe any abuse, mistreatment or neglect. The Facility Investigative Summary also documented that the Certified Nursing Assistant (CNA)#2 was interviewed and ascertained the resident required an assist of two for transfer per plan of care and resident's [NAME]. The caregiver was suspended pending investigation due to the break in resident's plan of care. The Certified Nurse's Aide was given an in-service on the need to follow the comprehensive care plan and resident [NAME] and need to use an assist of 2 when placing on Hoyer pad to transfer with the Hoyer. The review of the Hospital after visit summary dated 2/3/2025 documented CT Brain dated 2/3/2025 no acute intracranial hemorrhage, no acute fracture; CAT scan of spine dated 2/3/2025 vertebral body heights are maintained, no acute fracture; The x-ray of the right knee dated 2/3/2025 documented no acute fracture with degenerative changes and the resident was returned to the facility with diagnosis of urinary tract infection. During the telephone interview dated 4/29/2025 at 2:20PM, with the unit 7:00 AM -3:00 PM shift Certified Nurse's Aide # 2 who was on duty 2/3/2025 and the Certified Nurse's Aide for Resident #2 they stated they were assigned to Resident #2. Resident #2 was trying to stand up on own and they wanted to put the resident into the wheelchair. The Resident is a Hoyer transfer, supposed to have 2 people. The stated the other Certified Nurse's Assistant were busy, and they started to put resident in sling while still in bed, putting feet on the floor, but while lifting the resident the sling broke. Certified Nurses Aid #2 stated they held the resident and lowered the resident to the floor slowly. They called for the Registered Nurse, all the nurses came in. The nurses called 911 and took the resident out of the facility. During the interview dated 4/15/2025 at 11:37AM, with the unit 7:00 AM -3:00 PM per diem, Registered Nurse Supervisor (Nurse) # 3 who was on duty 2/3/2025 Registered Nurse they stated at about 10:30AM, they were called to Resident #2's room by Certified Nurse's Aide, that Resident # 2 slid out of the Hoyer. They stated they assessed the resident and called 911. They started during an investigation they identified the Hoyer pad loop was broken, and the Certified Nurse's Aide stated resident was slid to floor. Does not recalled if the Certified Nurse's Aide examined the loop prior to using the Hoyer. The telephone interview dated 4/15/2025 at 3:30PM with Director of Nursing, they stated the resident was sent via 911 to the hospital. No fractures were identified for the Resident. An investigation was completed for the Certified Nurse's Aide transferring a resident via Hoyer with only one person present. There should have been two staff present to transfer Resident #2 with the Hoyer. 483.12(a)[1]

Based on record review and interviews during the Recertification Survey initiated on 10/3/2024 and completed on 10/10/2024, the facility did not ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was identified for two of the two units reviewed for the Sufficient Nursing Staffing Task. Specifically, 1) a review of the Payroll-Based Journal (PBJ) Staffing Data Report Quarter 2, 2024 (January 1 - March 31) indicated excessively low weekend staffing; 2) a review of the daily staffing sheets revealed the facility did not provide sufficient numbers of Certified Nursing Assistants as indicated in the facility assessment; and 3) during the Resident Council meeting dated 10/4/2024 at 11:00 AM, six of eleven resident attendees verbalized concerns about short staffing on weekends and nights. The finding is: The facility policy titled Staffing Hours, last reviewed 8/2024, documented the facility provides adequate staffing to meet needed care and services for the resident population. Certified Nursing Assistants are available on each shift to provide the needed care and services to each resident as outlined in the resident's comprehensive care plan. The Payroll-Based Journal Staffing Data Report for Fiscal Year Quarter Two 2024 (January 1 - March 31) documented the facility triggered for the metric of excessively low weekend staffing. The Facility Assessment, last updated June 2024, documented the average daily census was 163-173 residents. The Facility Assessment documented the facility required a total of 18-21 Certified Nursing Assistants during the day and evening shifts and a total of 9-12 Certified Nursing Assistants during the night shift. A review of weekend staffing sheets from January 1 - March 31, 2024, revealed the facility had the following number of Certified Nursing Assistants available: During the 7:00 AM-3:00 PM shift: -On 2/3/2024 there were only 16 Certified Nursing Assistants. The Facility Assessment required a total of 18-21 Certified Nursing Assistants. -On 2/11/2024 there were only 15 Certified Nursing Assistants. The Facility Assessment required a total of 18-21 Certified Nursing Assistants. -On 2/25/2024 there were only 14 Certified Nursing Assistants. The Facility Assessment required a total of 18-21 Certified Nursing Assistants. -On 3/9/2024, 3/10/2024, 3/16/2024, and 3/24/2024 there were only 17 Certified Nursing Assistants. The Facility Assessment required a total of 18-21 Certified Nursing Assistants. During the 3:00 PM-11:00 PM shift: -On 1/7/2024, 2/25/2024, 3/3/2024, 3/17/2024, 3/30/2024, and 3/31/2024 there were only 14 Certified Nursing Assistants. The Facility Assessment required a total of 18-21 Certified Nursing Assistants. -On 1/14/2024, 1/21/2024, 2/4/2024, 2/11/2024, and 2/24/2024 there were only 16 Certified Nursing Assistants. The Facility Assessment required a total of 18-21 Certified Nursing Assistants. -On 1/28/2024, 3/2/2024, 3/9/2024, and 3/23/2024 there were only 17 Certified Nursing Assistants. The Facility Assessment required a total of 18-21 Certified Nursing Assistants. -On 2/10/2024, 3/10/2024, and 3/24/2024 there were only 15 Certified Nursing Assistants. The Facility Assessment required a total of 18-21 Certified Nursing Assistants. During the 11:00 PM-7:00 AM shift: -On 1/20/2024, 1/21/2024, and 3/30/2024 there were only eight Certified Nursing Assistants. The Facility Assessment required a total of 9-12 Certified Nursing Assistants. -On 3/24/2024 there were only seven Certified Nursing Assistants. The Facility Assessment required a total of 9-12 Certified Nursing Assistants. Additionally, the weekend staffing sheets for August and September 2024 were reviewed and revealed the facility had the following number of Certified Nursing Assistants available: During the 7:00 AM-3:00 PM shift: -On 8/4/2024, 8/18/2024, 8/25/2024, 9/21/2024, 9/22/2024, and 9/28/2024 there were only 17 Certified Nursing Assistants. The Facility Assessment required a total of 18-21 Certified Nursing Assistants. -On 8/11/2024, 8/17/2024, and 9/15/2024 there were only 16 Certified Nursing Assistants The Facility Assessment required a total of 18-21 Certified Nursing Assistants. During the 3:00 PM-11:00 PM shift: -On 8/3/2024, 8/10/2024, 8/11/2024, 8/24/2024, and 9/29/2024 there were only 16 Certified Nursing Assistants The Facility Assessment required a total of 18-21 Certified Nursing Assistants. -On 8/4/2024, 8/25/2024, 9/1/2024, 9/14/2024, 9/15/2024, and 9/28/2024 there were only 17 Certified Nursing Assistants The Facility Assessment required a total of 18-21 Certified Nursing Assistants. -On 9/22/2024 there were only 14 Certified Nursing Assistants The Facility Assessment required a total of 18-21 Certified Nursing Assistants. During the 11:00 PM-7:00 AM shift: -On 8/3/2024 and 8/11/2024 there were only seven Certified Nursing Assistants. The Facility Assessment required a total of 9-12 Certified Nursing Assistants. -On 8/4/2024 and 8/24/2024 there were only eight Certified Nursing Assistants. The Facility Assessment required a total of 9-12 Certified Nursing Assistants. -On 8/25/2024 there were only six Certified Nursing Assistants. The Facility Assessment required a total of 9-12 Certified Nursing Assistants. In a Resident Council meeting dated 10/4/2024 at 11:00 AM, six of eleven resident attendees verbalized concerns about short staffing on weekends and nights. During an interview on 10/8/2024 at 8:54 AM, the Staffing Coordinator stated the staffing assignments are based on the resident census. They use a staffing generator calculator to determine how many Certified Nursing Assistants are needed per shift. The Staffing Coordinator stated they enter the census number into the calculator and the calculator then determines how many Certified Nursing Assistants are needed per shift. The Staffing Coordinator stated they were not familiar with the Facility Assessment. The Staffing Coordinator stated most of the Certified Nursing Assistants are facility employees; however, the facility also utilizes staffing agencies. The Staffing Coordinator stated that the weekends are generally harder to get the staff. During an interview on 10/8/2024 at 11:14 AM, the Director of Nursing Services stated they were not familiar with the Payroll-Based Journal or staffing generator calculator used by the Staffing Coordinator and were not aware that the facility triggered low weekend staffing. The Director of Nursing Services stated the Facility Assessment is updated by them and the Administrator. The Director of Nursing Services stated the Administrator provides the Staffing Coordinator with the numbers of nursing staff needed. The Director of Nursing Services acknowledged the facility has not hired enough staff for the weekends. During an interview on 10/9/2024 at 1:52 PM, the Administrator and Director of Nursing Services stated the facility utilizes a staffing calculator to generate the number of nursing staff. The Staffing Coordinator enters the census number and the staffing calculator then provides the number of nursing staff needed. The Administrator stated the calculator was designed to meet the New York State minimum nursing staffing standard of 3.5 hours of care per resident per day and the facility is still having a staffing shortage. The Administrator was not sure if the required number of staff estimated in the Facility Assessment was incorporated into the staffing calculator tool. 10 NYCRR 415.13(a)(1)(i-iii)

Based on record review and staff interviews during the Recertification Survey initiated on 10/3/2024 and completed on 10/10/2024, the facility did not ensure its Facility Assessment considered specific staffing needs for each resident unit (first floor and second floor) in the facility. Specifically, the Facility Assessment, last updated June 2024, did not include a breakdown of staffing needs for each of the facility's two units. The finding is: The facility's policy, titled Facility Assessment, dated 9/26/2024, documented a facility assessment is conducted at least annually and as needed to determine and update the facility's capacity to meet the needs of and competently care for residents during both day-to-day operations (including nights and weekends) and emergencies. The facility assessment includes a detailed review of the resources available and/or necessary to meet the needs of the resident population. Data reviewed includes factors that may affect the overall acuity of the residents, such as the number and percentage of residents with a need for assistance with activities of daily living; mobility impairments; incontinence (bowel or bladder); cognitive or behavioral impairments; and conditions or diseases that require specialized care. A review of the Facility Assessment, last updated June 2024, revealed that it did not include a breakdown of staffing needs for each of the facility's two units. The Facility Assessment documented that the facility required 18-21 Certified Nursing Assistants facility-wide for day and evening shifts each; 9-12 Certified Nursing Assistants facility-wide for the night shift; a total of 16-20 licensed nurses facility-wide providing direct care. During an interview on 10/9/2024 at 8:56 AM, the Director of Nursing Services and the Administrator both stated they had worked on the Facility Assessment. The Director of Nursing Services stated the Facility Assessment did not include the breakdown of staffing needs for each unit (first floor and second floor) because there is no difference in acuity between the two units and they are not specialized units. There are short-term and long-term residents on each unit. The Director of Nursing Services acknowledged that there are 20 extra beds on the second floor, which would add to the workload on the second floor. The Administrator stated the Facility Assessment can be updated to show the breakdown of staffing needs for each unit. 10 NYCRR 415.26

Based on observations, record review, and interviews during the Recertification Survey initiated on 10/3/2024 and completed on 10/10/2024, the facility did not ensure that each resident was offered sufficient fluid intake to maintain proper hydration and health. This was identified for one (Resident #127) of two residents reviewed for Hydration. Specifically, Resident #127 received intravenous hydration for 72 hours due to an elevated blood urea nitrogen level (an abnormal blood test result that could indicate dehydration). The resident's nutritional assessment indicated the resident needed 1620 milliliters of fluid per day. The meal tray observation indicated the resident was not offered an adequate amount of fluids as indicated in the nutritional assessment. Additionally, there was no documented evidence that the resident's fluid intake was reassessed by the Dietician after the intravenous hydration therapy was completed. The finding is: The facility's policy titled Hydration, dated 1/24/2024, documented that residents will receive sufficient fluid intake that is consistent with their individual needs and preferences to maintain proper hydration and health. Calculation of the resident's fluid needs will follow current standards of practice. Residents will be encouraged and assisted with fluid intake as needed at meals and throughout the day as per an individualized plan for care. If concerns are observed regarding the resident's intake or hydration status, the resident's plan of care may be revised if indicated, and the nurse shall notify the healthcare provider for changes in orders as appropriate. Resident #127 was admitted with diagnoses including Diabetes Mellitus, Malnutrition, and Osteomyelitis (bone infection). The 8/14/2024 Minimum Data Set assessment documented a Brief Interview for Mental Status score of 14, indicating the resident was cognitively intact. The Minimum Data Set assessment documented the resident received intravenous fluids while a resident. A Comprehensive Care Plan effective 8/8/2024 documented the resident has a nutritional problem or potential nutritional problem. The interventions documented were for the Certified Nursing Assistants to document the resident's dining/fluid intake and for the dietician to review meal/ fluid consumption records. There have been no further updates to this care plan since 8/8/2024. A Comprehensive Care Plan effective 8/8/2024 documented the resident has actual/ potential for fluid deficit. The interventions documented were to encourage the resident to drink fluids of choice. There have been no further updates to this care plan since 8/8/2024. A physician's order dated 8/8/2024 documented a consistent carbohydrate diet, puree texture, with thin (regular) liquids consistency, to facilitate oral intake and Boost Glucose Control supplement, 8 ounces, two times a day. A Comprehensive Nutrition assessment dated [DATE] documented Resident #127's Estimated Fluid Needs were 1,620 milliliters per day. A physician's order dated 8/20/2024 documented Aspiration Precautions. A Basic Metabolic Panel (a blood test to measure fluid balances, kidney function, and metabolism) laboratory report dated 9/30/2024 documented a high Blood Urea Nitrogen level of 71 milligrams per deciliter (normal range 9-23). A nursing progress note dated 10/1/2024 documented that Physician Assistant #1 was aware of the elevated Blood Urea Nitrogen level and an order was placed to start peripheral intravenous with Sodium Chloride 0.45% solution at 70 milliliters per hour for three days for hydration. A Physician's order dated 10/1/2024 documented Sodium Chloride Intravenous Solution 0.45%, 70 milliliters per hour intravenously every shift for hydration for three days. On 10/3/2024 at 10:55 AM Resident #127 was observed in their room sitting in their wheelchair. The 0.45% Sodium Chloride Intravenous Solution was currently being administered. The resident stated they did not feel well and appeared sad. There were no drinkable fluids observed that were accessible to the resident. A medical progress note, written by Physician Assistant #1, dated 10/4/2024 documented under Action/Plan: status-post intravenous fluids, monitoring laboratory reports. During an observation on 10/7/2024 at 10:16 AM Resident #127 was observed in bed. There were no drinkable fluids accessible to the resident. On 10/7/2024 at 11:30 AM Resident #127 was observed ambulating in the hallway with a Rehabilitation Department Therapist. The resident's family member was present in the resident's room. There were no drinkable fluids present in the room. The family member stated the resident does not like to drink anything, maybe some milk at breakfast or lunch. The resident does not drink fluids because they are afraid of wetting the bed. During an interview on 10/7/2024 at 12:55 PM, Certified Nursing Assistant #1 stated the fluid intake is documented in the computer as to how much the resident drinks every shift. The resident does not like water and coffee but will only drink juice and a little milk. A review of the Certified Nursing Assistant documentation of fluid intake from 9/24/2024-10/7/2024 in the electronic medical record revealed that the resident was consistently consuming 76%-100% of fluids served on the meal tray each shift. During an observation and interview on 10/7/2024 at 1:02 PM, Resident #127 was in their room sitting in a wheelchair. There was no drinkable fluid present in the room. The resident stated they would drink juice or water; however, they did not want to drink in fear of wetting the bed. During an interview on 10/7/2024 at 1:17 PM, Licensed Practical Nurse #1 (medication nurse) stated they provide Boost supplement 8 ounces twice a day with a medication pass, and the consumption is recorded on the medication administration record. During an observation on 10/8/2024 at 9:48 AM, Resident #127 was observed in their room sitting in a wheelchair. There were no drinkable fluids present and accessible to the resident in the room. During an observation and interview on 10/8/2024 at 12:55 PM, Resident #127 was observed eating lunch in their room. A family member was present. The resident drank 4 ounces of skim milk. The milk was the only liquid present on the resident's meal tray. The family member stated the resident does not drink coffee or tea. A review of the resident's meal tickets for 10/8/2024 revealed the fluids provided include 8-ounce juice (240 milliliters), 8-ounce milk (240 milliliters), and 6-ounce coffee (180 milliliters) for breakfast; 4-ounce milk (120 milliliters) and 6-ounce coffee (180 milliliters) for lunch; and 4-ounce milk (120 milliliters) and 6-ounce coffee (180 milliliters) for dinner. This would indicate that the resident was being offered 1,260 milliliters of fluids with meals. However, the resident does not drink coffee, which would leave only 720 milliliters of fluids being offered. Adding in the 480 milliliters of Boost supplement provides a total of 1,200 milliliters of fluid being offered to the resident, which is 420 milliliters less than the 1,620 milliliters estimated fluid needed as per the nutritional assessment. During an additional interview on 10/08/2024 at 2:16 PM, Licensed Practical Nurse #1 stated the resident sometimes takes sips of water and sometimes refuses to drink the water. Licensed Practical Nurse #1 stated they have never asked the resident the reason for refusal. During an interview on 10/8/2024 at 2:30 PM, Physician Assistant #1 stated they were not aware that the resident was refusing to drink fluid due to fear of wetting themselves. During an interview on 10/9/2024 at 9:54 AM, Certified Nursing Assistant #1 stated Resident #127 does not like coffee, so they do not give the coffee to the resident. Certified Nursing Assistant #1 does not leave water in Resident #127's room because the resident grabs and shakes the table and it could be a mess if the fluids are left on their table. During an interview on 10/9/2024 at 11:08 AM, Dietician #2 (part-time who did the nutrition assessment on 8/8/2024) stated the 1,620 milliliters estimated fluid needed for Resident #127 included the fluids on the meal tray each day plus the supplements provided by the nurse. Dietician #2 stated since they are a part-time Dietician, it would be the full-time Dietician's responsibility to follow up with the resident and conduct meal rounds to ensure the resident is consuming enough fluids. The nurses and Certified Nursing Assistants are also expected to notify the Dietician when a resident is not eating or drinking enough. During an interview on 10/9/2024 at 11:32 AM, Dietician #1 (full-time), stated they did not know Resident #127 received intravenous fluids for hydration and would expect the nursing staff to notify them. If a resident is not consuming enough fluid, the Certified Nursing Assistant or the unit nurses are expected to notify the Dieticians. Dietician #1 stated if they knew Resident #127 was not consuming enough fluid, they would have reviewed the resident's fluid intake sheets, reviewed recent laboratory reports, provided education to the resident about adequate hydration and the risks of dehydration, and offered other fluid choices. During an interview on 10/9/2024 at 11:55 AM, the Director of Nursing Services stated they did not know that Resident #127 was afraid to wet themselves. When a resident's intravenous therapy is completed, the resident is reassessed, and additional laboratory workup is ordered. The resident's care needs would be discussed in the morning report with the whole team, including the Dietician. The Dietician is then expected to follow up with the resident. 10 NYCRR 415.12(j)

Based on observations, record review, and interviews during the Recertification Survey initiated on 10/3/2024 and completed on 10/10/2024, the facility did not provide proper respiratory treatments and care consistent with professional standards of practice. This was identified for one (Resident #38) of three residents reviewed for Respiratory Care. Specifically, Resident #38 was utilizing oxygen therapy for Chronic Obstructive Pulmonary Disease (COPD) and did not have a physician's order for the oxygen therapy. The finding is: The policy and procedure for Oxygen Administration dated January 2020 documented the administration of supplemental oxygen is an essential element of appropriate management for a wide range of clinical conditions. Oxygen should be regarded as a drug and therefore, requires prescribing in all but emergency situations. Failure to administer oxygen appropriately can result in serious harm to the patient. Resident #38 was admitted with diagnoses of Chronic Obstructive Pulmonary Disease and Sleep Apnea. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status score of 15 indicating the resident was cognitively intact. The Minimum Data Set assessment did not indicate that the resident was receiving oxygen therapy in the facility. The Comprehensive Care Plan dated 2/19/2024 documented alteration in the respiratory system related to Chronic Obstructive Pulmonary Disease and cough. The resident uses oxygen and has acute and chronic Respiratory Failure with Hypoxia (lack of oxygen). Interventions include providing oxygen as per the physician's orders. Maintain/change oxygen tubing as per the facility protocol. Resident #38 was observed on 10/03/2024 at 12:15 PM, in their room and had the oxygen concentrator at the bedside. The oxygen concentrator was on and the oxygen tubing was placed on the resident's bed. The Resident stated they only use oxygen therapy at night. During an observation on 10/7/2024 at 10:30 AM, Resident #38 was observed in their room. The oxygen concentrator was observed at the bedside. The Resident stated, I need the oxygen at night because I have Sleep Apnea. A review of Resident #38's current physician orders on 10/7/2024 revealed there were no physician orders for oxygen therapy. During an interview on 10/07/2024 at 3:47 PM, Registered Nurse # 1 stated they were not aware that Resident #38 did not have physician orders for oxygen therapy. Registered Nurse # 1 stated all residents on oxygen therapy should have physician orders. During an interview on 10/10/2024 at 10:00 AM, the Director of nursing services stated the resident should have had physician's orders for the use of supplemental oxygen therapy. Resident #38 should not be administered supplemental oxygen without physician orders. During an interview on 10/10/2024 at 11:00 AM, Physician #1 stated that the nurses do not need a physician's order to administer oxygen therapy. During an interview on 10/10/2024 at 3:30 PM, the Medical Director stated all supplemental oxygen therapy should be prescribed by the Physician. The nurses may not need a physician's order in an emergency. 10 NYCRR 415.12(k)(6)

Based on observation, record review, and interviews during the Recertification Survey initiated on 10/03/2024 and completed on 10/10/2024, the facility did not ensure it maintained an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #64) of four residents observed for Pressure Ulcers. Specifically, Resident #64, who resided in a two-bedded room with a roommate, had a sign outside the doorway for Enhanced Barrier Precautions. During Resident #64's wound care observation, Licensed Practical Nurse #2 and Charge Nurse Licensed Practical Nurse #3 did not know which resident in the room was on Enhanced Barrier Precautions and started the wound care without utilizing an isolation gown as indicated on the Enhanced Barrier Precaution Signage. The finding is: The facility's policy titled Enhanced Barrier Precautions last reviewed on 5/27/2024 documented that Enhanced Barrier Precautions require wearing disposable gloves and an isolation gown when performing a high-contact activity. The resident's Care Plan should be updated to reflect the implementation of Enhanced Barrier Precautions. Resident #64 was admitted to the facility with diagnoses that included Encephalopathy, Pulmonary Edema, and Vascular Dementia. The Admission Minimum Data Set, dated dated dated [DATE] documented a Brief Interview for Mental Status score of 3, indicating the resident had severe cognitive impairment. The Minimum Data Set further documented Resident #64 had two unstageable Pressure Ulcers that were present upon admission. A physician's order dated 9/18/2024 documented left heel: paint with Betadine, let dry, apply gauze followed by kling wrap daily and as needed if missing or soiled [for the unstageable pressure ulcer]. During an observation of a double-bedded room and staff interview on 10/09/2024 at 9:33 AM, an Enhanced Barrier Precautions sign was posted outside Resident #64's room door. The sign read: Enhanced Barrier Precautions-Everyone must wear gloves and a gown for high-contact resident care activities including wound care. Licensed Practical Nurse #2 and Charge Nurse #3 were observed in Resident #64's room without wearing a gown and were preparing for Resident #64's wound care. Charge Nurse #3 put on gloves, cleaned the overbed table, washed their hands, put on new gloves, and then lifted the resident's left leg which had a dressing to the heel. Licensed Practical Nurse #2 donned gloves after washing their hands (no gown), and started to unwrap the left-heel dressing. They both stated Resident #64 had a roommate and they did not know which resident in the room was on Enhanced Barrier Precautions. The treatment was stopped. Charge Nurse #3 left the room to check which resident in the room was on isolation precautions. Licensed Practical Nurse #2 stated the residents do not need a physician's order for Enhanced Barrier Precautions, and the Infection Control Nurse provides the unit staff with a list of all residents who are supposed to be on Enhanced Barrier Precautions each day. Charge Nurse #3 came back to Resident #64's room and stated Resident #64 was on the list on 10/9/2024 to be on Enhanced Barrier Precautions for the wounds. Licensed Practical Nurse #2 and Charge Nurse #3 then donned a gown and gloves and re-started the wound care treatment. During an interview on 10/09/2024 at 10:04 AM, Licensed Practical Nurse #2 stated they should have verified if Resident #64 was on the Enhanced Barrier Precautions. Resident #64 has a wound and is on Enhanced Barrier Precautions for that reason. Staff should wear Personal Protective Equipment when providing any hands-on care to Resident #64. Licensed Practical Nurse #2 stated they should have reviewed the Enhanced Barrier Precaution list. On 10/9/2024 at 10:07 AM, Charge Nurse #3 presented an undated list for the second floor, which included residents on isolation precautions for various infections and conditions such as wounds, indicating Resident #64 was on isolation precautions for wounds. During an interview on 10/09/2024 at 10:08 AM, Charge Nurse #3 stated that every day they received a list of residents who were on Enhanced Barrier Precautions and they should have verified if Resident #64 was on that list. Charge Nurse #3 confirmed that the list they received on 10/9/2024 included Resident #64 which meant the resident was on Enhanced Barrier Precautions because of the heel wound. Charge Nurse #3 stated they should have put on a gown and gloves before they started wound care treatment for Resident #64. During an interview on 10/10/2024 at 09:38 AM, the Staff Educator/Infection Prevention Nurse stated Resident #64 was not on Enhanced Barrier Precautions instead the resident's roommate was supposed to be on Enhanced Barrier Precautions and that is why the signage was posted outside the resident's room. The Licensed Practical Nurses should have checked Resident #64's care plan or asked me, the Director of Nursing Services, or the Wound Care Nurse if they were not aware of where to find the Enhanced Barrier Precaution for a resident before performing the wound care. The nurses should not have followed the list because the list was created for their (Staff Educator/Infection Prevention Nurse) personal use to remind them of which residents were on isolation precautions, had a drain, Foley Catheter, or Infection. It was not for staff use. Staff Educator/Infection Prevention Nurse stated that they shredded the list that was observed by the surveyor on 10/9/2024 (which included Resident #64's name for Enhanced Barrier Precautions). During an interview on 10/10/2024 at 10:46 AM, the Director of Nursing Services stated the staff should have checked the resident's Care Plan to see if Resident #64 was on Enhanced Barrier Precautions before going into the resident's room for wound care treatment and should not have used the list made by the Infection Prevention Nurse. 10 NYCRR 415.19(a)(1-3)

Based on observations, record review and interviews during the Recertification Survey initiated on 3/6/2023 and completed on 3/13/2023, the facility did not ensure that each resident is treated with respect and dignity and cared for in a manner that promotes maintenance or enhancement of their quality of life. This was identified for two (Resident #132 and Resident #85) of four residents reviewed for dignity. Specifically, during a lunch meal observation on date 3/6/2023 two staff members were observed standing over Resident #132 and Resident #85 while feeding the residents their entire lunch meal. The findings are: The facility's Meal Assistance Policy and Procedure dated 7/2019 documented residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: not standing over the resident while assisting them with meals. 1) Resident#132 was admitted on [DATE] with diagnoses of Parkinson's Disease, Dementia with Behavioral Disturbance, and Hypertension. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the Brief Interview for Mental Status (BIMS) score was 4, which indicated the resident had severely impaired cognition. The resident was totally dependent on one person for feeding. The resident had no swallowing concerns and no weight loss. The MDS documented the resident received a mechanically altered diet. Resident #132 was observed in the 1st floor dining room during a lunch meal observation on 3/6/2023 from 12:45 PM to 1:15 PM. The resident was observed being fed by a recreation staff member who was standing over the resident during the entire meal. The current Physician's orders documented to provide a Ground Soft/ Minced and Moist texture diet and thin regular consistency fluids. A Comprehensive Care Plan (CCP) dated 11/25/2022 documented the resident had actual/potential risk for aspiration related to diagnosis of Dysphagia. Interventions included to reinforce proper positioning for meals example (head, body, seating). 28670 2) Resident #85 was admitted with diagnoses that include Dysphagia, Malnutrition, and Failure to Thrive. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the Brief Interview for Mental Status (BIMS) score was 3, which indicated the resident had severely impaired cognition. The resident had no behavior problems and required extensive assistance of one staff member for eating. The MDS documented the resident had no swallowing concerns and had no weight loss or gain. The MDS documented the resident received a therapeutic mechanically altered diet. Resident #85 was observed in the 1st floor dining room during a lunch meal on 3/6/2023 from 12:45 PM to 1:15 PM. The resident was observed being fed by a Recreation staff member who was standing over the resident during the entire meal. A current Physician's order documented the resident's diet was regular puree texture with thin liquids. The Certified Nursing Assistant (CNA) Accountability Record dated 3/2023 documented the resident required extensive assistance of one staff member to feed the resident. A Comprehensive Care Plan (CCP) dated 6/21/2022 documented the resident had actual/potential risk for aspiration related to a diagnosis of Dysphagia. Interventions included to reinforce proper positioning for meals example (head, body, seating). A CCP for Activities of Daily Living (ADL)s dated 6/20/22 documented the resident required assistance with ADLs related to confusion, Dementia, Limited Mobility, Muscle Weakness, and Impaired Vision. Interventions included extensive assistance of one staff member to physically feed the resident. The Director of Recreation and a Recreation aide, who were observed feeding Resident #132 and Resident #85, were interviewed concurrently on 3/6/2023 at 2:23 PM. The Director of Recreation stated that they were feeding Resident #85 and were trained in 2018 to feed residents and they normally assist with feeding the residents on a daily basis. The Recreation aide stated they were feeding Resident #132. The Director of Recreation stated that Resident#85 required total assist for feeding and that they and the Recreation aide should have been seated while feeding the resident. The Director of Recreation stated that they (Director of Recreation) were standing because it was more comfortable for them to stand and feed the resident. The Director of Recreation stated that they understand that it was a dignity concern to stand and feed the residents. The Director of Recreation further stated that staff should sit while feeding the residents their meal. The Director of Nursing Services (DNS) was interviewed on 3/9/2023 at 3:40 PM. The DNS stated all non-clinical staff that assist with feeding are trained to feed the residents who are on aspiration precautions. The DNS stated that dignity of the resident during feeding was included in the in-service education. The DNS stated during meals all staff should be seated while feeding the residents. The DNS further stated that the Director of Recreation and the Recreation aide should have been seated while feeding the residents. 10 NYCRR 415.3(d)(1)(i)

Based on observation, record review and interviews during the Recertification Survey initiated on 3/6/2023 and completed on 3/13/2023 the facility did not ensure that each resident's comprehensive person-centered Care Plan (CCP) was reviewed and revised by the Interdisciplinary Team after each assessment. This was identified for one (Resident #97) of one resident reviewed for Ventilator and Tracheostomy care. Specifically, Resident #97 had a Physician's order to remove the Laryngectomy tube (a clear flexible tube that is placed in the stoma to keep the stoma open and aides in breathing) and cleanse the site with normal saline (NS) once daily and as needed (PRN). A review of the Respiratory CCP lacked documented evidence that the CCP was updated to include the care of the Laryngectomy tube. The finding is: The facility's Policy and Procedure for Comprehensive Care Plan dated 10/2019 documented the Interdisciplinary Team reviews and updates the care plan when the resident has been readmitted to the facility from a hospital stay; and at least quarterly with scheduled quarterly Minimum Data Set (MDS) assessments. Resident #97 was admitted with diagnoses that include Acute and Chronic Respiratory Failure, Malignant Neoplasm of Laryngeal Cartilage and Chronic Obstructive Pulmonary Disease. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15, which indicated the resident had intact cognition. The MDS documented the resident had no behavior problems or rejection of care. The resident required extensive assistance of one staff member for personal hygiene and received Tracheostomy care while a resident at the facility. A CCP for Respiratory Care dated 12/9/2020 and last updated 2/16/2023 documented Resident #97 has an alteration in respiratory system related to Laryngectomy tube and Chronic Obstructive Pulmonary Disease. Interventions included but were not limited to observe for signs and symptoms of poor airway clearance and gas exchange. The CCP did not include the care of the Laryngectomy tube or care of the tube site. A Physician's order dated 2/13/2023 and updated on 3/13/2023 documented to remove the Laryngectomy tube and cleanse the site with normal saline once daily and PRN. Registered Nurse (RN #1), who was in charge of the 2nd floor, was interviewed on 3/13/2023 at 9:57 AM. RN #1 stated that the resident was admitted with a Laryngectomy tube and that care of the Laryngectomy tube is completed twice daily. A subsequent interview with RN #1 was conducted on 3/13/2023 at 10:57 AM and they (RN #1) stated that the care of the resident's Laryngectomy tube should be updated on the resident's CCP. RN #1 stated that the RN Managers are responsible for reviewing and revising the CCP. RN #1 stated that the Respiratory Care CCP should have been updated to include the care of the resident's Laryngectomy tube. The Director of Nursing Service (DNS) was interviewed on 3/13/2023 at 3:10 PM and stated on admission the RN that admits the resident would initiate or update the CCP as needed with the resident's current care. The DNS stated on 3/2/2023 a care plan meeting was conducted. The DNS stated that the RN that attended the meeting should have updated the respiratory care plan to include the care of the resident's Laryngectomy tube. The Assistant Director of Nursing Service (ADNS), who attended the care plan meeting on 3/2/2023, was interviewed on 3/13/2023 at 4:14 PM. The ADNS stated when preparing for a care plan meeting the RN that reviews the CCP is responsible to update the CCP as needed. The ADNS stated the RN manager, or the RN Supervisor should have updated the Respiratory Care CCP at the time they completed the Quarterly MDS note. 10 NYCRR 415.11(c)(2)(i-iii)

Based on record review and interviews during the Recertification Survey and Abbreviated Survey (NY00274885) initiated on 3/6/2023 and completed on 3/13/2023, the facility did not develop a discharge plan that addressed all of the needs for a resident that was being discharged home. This was identified for one (Resident #249) of one resident reviewed for Discharge Planning. Specifically, Resident #249 had bilateral lower extremity wounds that required wound care. The resident was discharged home on 4/13/2021 and the facility did not confirm that Home Care Services were in place to provide wound care treatments prior to the resident's discharge. Additionally, there was no documented evidence that the resident or their representative were trained to provide wound care prior to the resident's discharge to home The finding is: The facility's Discharge Policy and Procedure updated 6/2022 documented when a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to their new living environment. Every resident will be evaluated for their discharge needs and will have an individualized post discharge plan that includes the resident's diagnoses and special treatments or procedures (treatments and procedures that are not part of basic services provided). The post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and their family and will include referrals that have been made for follow-up care and services. Resident #249 was admitted with diagnoses that included Cellulitis, Venous Insufficiency, and Anxiety Disorder. An Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15, which indicated the resident had intact cognition. The resident required extensive assistance of two staff members for bed mobility, transfer, and toileting. The resident required extensive assistance of one staff member for dressing and hygiene. The resident was non-ambulatory. The resident was at risk for developing Pressure Ulcers, had one unhealed unstageable PU, and two Venous ulcers that was present upon admission. A Comprehensive Care Plan (CCP) dated 1/4/2021 documented the resident's placement is short-term. Interventions included to assist the resident with applications for community resources, assist with obtaining Durable Medical Equipment (DME) and medical supplies prior to discharge, and to educate the resident and/or designated representative about community resources. A CCP for Impaired Skin Integrity dated 1/4/2021 documented the resident has impaired skin integrity related to a left anterior Vascular Ulcer. Interventions included to apply treatment per the Physician's. Monitor/document/report to the Physician as needed (PRN) for signs and symptoms of infection: green drainage, foul odor, redness and swelling, red lines coming from the wound, excessive pain, and fever. Refer to appropriate medical specialist as needed for evaluation and treatment. A Social Work (SW) Discharge Summary titled Late Entry Note dated 5/12/2021 for 4/9/2021 documented Resident #249 was being discharged on [DATE] to home. Licensed Practical Nurse (LPN) #1 had reviewed the discharge instructions (medication, disease management, diet and treatment plan) with the resident and their representative. A Review of the nurses notes for the month of April 2021, lacked documented evidence that the resident or the representative were educated regarding wound care prior to the resident's discharge on 4/13/2021. A Social Work (SW) Late Entry Note dated 4/15/2021 for 4/14/2021 documented the home care nurse called to inform [the SW] that the resident was accepted for home care. The home care agency called to make an appointment with the resident. Resident #249 requested an aide and increase in wound care assistance and then the home care agency denied the resident home care services. The resident was informed prior to discharge that the the family would be trained to do wound care and that home care services would not be available on a daily basis. A SW Note dated 4/15/2021 documented the home care agency declined to provide services to the resident. The SW spoke with the resident, who stated their family member was doing the treatment. The SW encouraged the resident to go to hospital if Resident #249's legs got worse and informed the resident that referrals are still being sent to different home care agencies. A Nursing Late Entry Note, written by Registered Nurse (RN) #3, dated 4/17/2021 for 4/16/2021 documented RN #3 and the SW did a home visit for Resident #249 due to the home care agency denying services for the resident. The resident was educated again on the process of wound care and the signs and symptoms (S/S) of infection. RN #3 educated and supervised the resident's family member performing wound care. The resident's family member performed a return demonstration and verbalized understanding of the S/S of infection. A SW Late Entry note dated 5/5/2021 for 4/19/2021 documented a [new] Home Care Agency accepted the resident's case and the resident was made aware. The Director of Social Services (DSS) was interviewed on 3/9/2023 at 2:19 PM and stated that a home care agency was contacted for wound care for the resident as they had provided services for the resident several times (6) previously; however, the home care agency declined to accept the resident. The DSS stated that another home care agency was contacted after the resident was discharged and accepted the resident for services. The DSS stated that the first home care agency was contacted a week prior to the resident's discharge and that they (DSS) received a verbal acceptance from the first home care agency. The DSS stated that on 4/13/2021 they (DSS) had received a verbal acceptance that the first home care agency would accept the case; but, on 4/14/2021 the home care agency called and declined the case. The DSS stated that they (DSS) and RN #3 who was the Wound Care RN at the time went to the resident's home on 4/14/2021 and trained the resident's family member to provide wound care. The DSS stated that the home care agencies do not provide written acceptance, that they give verbal acceptance only. LPN #1, who completed the nursing section of the Discharge Summary, was interviewed on 3/10/2023 at 1:53 PM. LPN #1 stated that the SW does the referrals for home care services for all residents that were being discharged and required home care. LPN #1 stated after home care services are confirmed the SW should document in the progress note that the home care agency accepted the case. LPN #1 stated that patient teaching was usually completed by either the medication nurse, LPN Manager, or the Wound Care RN. LPN #1 could not recall if wound care training was completed for the resident's family. RN #3, who was the Wound Care RN and visited the resident post-discharge, was interviewed on 3/10/2023 at 2:56 PM. RN #3 stated, to their knowledge, Resident #249 did not perform dressing change or return demonstration prior to the resident's discharge. RN #3 stated that the resident's family member was also a resident at the time; however, was discharged before Resident #249. RN #3 stated that based on the location of the wound they (RN #3) did not believe the resident was able to complete their own wound treatment. RN #3 stated that they visited the resident at home because the resident did not have wound care supplies. An interview was conducted with a home care agency (HCA) staff member on 3/13/2023 at 1:00 PM. The HCA stated that a referral for Resident #249 was received by the home care agency on 4/12/2021 in the afternoon. The HCA stated they spoke to the facility's DSS on 4/13/2021 to inform the nursing facility that they (HCA) were declining to provide services to the resident. The declination was given verbally to the DSS. The HCA stated that the DSS acknowledged the refusal, and that they (HCA) made the facility Administrator aware as well. The agency stated that a referral is not an acceptance and that the facility needed to wait for confirmation from the home care agency that the home care would provide services prior to discharging the resident. A subsequent interview was conducted with the DSS on 3/13/2023 at 2:46 PM. The DSS stated that the agency probably did call on 4/13/2021 but it was probably after the resident had left the facility. The DSS stated that a note is usually written in the progress notes regarding the referral for the home care services and the home care agency's verbal acceptance and confirmation to provide services. The DSS stated there was no note written related to Resident #249's home care service acceptance. The Administrator was interviewed on 3/13/2023 at 4:06 PM. The Administrator stated that they became aware of the delay in providing the home care services to Resident #249 the day after the resident was discharged . The Administrator stated that the SW was responsible for resident discharges and documentation after a verbal confirmation for home care is received. The Medical Director was interviewed on 3/13/2023 at 4:15 PM and stated they (Medical Director) expected that home care services are confirmed prior to the resident's discharge and that the resident or their family member would be educated on wound care. The Medical Director stated that if there was verbal acceptance of the resident by the home care agency the acceptance should be documented. The Medical Director further stated if the resident's family member was trained to administer wound care there should be documentation of the teaching in the medical record. 10 NYCRR 415.11(d)(3)

Based on observation, record review and interviews during the Recertification Survey initiated on 3/6/2023 and completed on 3/13/2023, the facility did not ensure that each resident's environment remains as free of accident hazard as is possible and was provided assistive devices to prevent accidents. This was identified for one (Resident #134) of three residents reviewed for Accidents. Specifically, Resident #134, who was at risk for falls, was to be out of bed after breakfast as per the resident's plan of care. The resident was observed climbing out of their bed on 3/7/2023 at 12:12 PM. There were no floor mats observed on the floor by the resident's bed. The finding is: The facility's Policy and Procedure for Falls dated 11/2022 documented staff will implement interventions based on the resident's individual needs and communicate interventions to the care givers and resident/family. The facility's Care Plan Policy dated 10/2019 documented that the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Resident #134 was admitted with diagnoses of Aphasia, Hemiplegia and Hemiparesis Affecting Right Dominant Side, and Abnormalities of Gait and Mobility. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Metal Status (BIMS) score of 0 which indicated the resident had severely impaired cognition. The MDS documented the resident required extensive assistance of two persons for bed mobility and personal hygiene. The resident required total assistance of two persons for transfers, dressing, and toileting. The Fall Risk Evaluation dated 11/18/2022 documented the resident has a score of 15 which indicated the resident was at moderate risk for falls. The Comprehensive Care plan for Falls dated 10/24/2022 documented interventions included to use floor mats; assist the resident out of the bed (OOB) after breakfast; and to anticipate and meet the resident needs. The Resident Care Profile (provides direction to the Certified Nursing Assistant (CNA) regarding resident care needs) documented to utilize the floor mats during the evening and nighttime. The record review Accident and Incident (A/I) report dated 2/13/2023 revealed that the resident had one incident on February 13th, 2023, at approximately at 1:15 PM. Staff reported the resident was lying in a prone position (face down) on the floor mat next to the bed. As per the staff, the bilateral floor mats were noted next to the bed and the bed was noted to be in the lowest position. The resident reported they (Resident #134) just rolled out of the bed and were okay. During an observation on 3/07/2023 at 12:12 PM Resident #134 was observed in their (Resident#134) bed. There was no staff present in the resident's room. The resident's legs were hanging off the left side of their bed and the resident's head was on the right side of the bed. There were no floor mats on the floor and one of the floor mats was observed folded and stored behind the head of the resident's bed. The Certified Nursing Assistant (CNA) #3 was interviewed on 3/07/2023 at 12:14 PM and stated they (CNA#3) provided morning care to Resident #134 and did not get the resident out of the bed because the resident's tube feeding was not completed. CNA #3 stated that they (CNA#3) put the floor mats on the floor before they left the room and did not know why one of the floor mats was folded and stored behind the head of the bed and did not know where the other floor mat was. CNA #3 stated that the Resident Care Profile documents to put the floor mats down only during the evening and night shift; however, the CNAs also place the floor mats next to the when the resident is in bed during the day, because the resident attempts to get out of their bed. Licensed Practical Nurse (LPN) #3 was interviewed on 3/07/2023 at 12:19 PM and stated they disconnected the resident's feeding tube around 11:45 AM and did not remove the resident's floor mats. LPN #3 stated it was the CNAs responsibility to place the floor mats on the floor. LPN #3 stated the resident is supposed to have floor mats while the resident was in bed because they (resident) climb out of bed. The Registered Nurse Supervisor (RN) #3 was interviewed on 3/07/2023 at 12:29 PM and stated that the resident should have floor mats in place while in bed to prevent injuries since the resident always tries to get out of bed. The Director of Nursing Services (DNS) was interviewed on 3/13/2023 at 12:30 PM and stated that the CNA instructions for the floor mats was for evening and nights because the resident usually falls during the night. The DNS further stated that the floor mats present during the day would be an accident hazard because the resident does not try to get out of bed during the day. 10 NYCRR 415.12(h)(1)

Based on observation, record review, and interview during COVID-19 Focused Infection Control Survey conducted on 11/9/2020, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of COVID-19. Specifically, the facility failed to implement Transmission-Based Precautions (TBP) and utilize required personal protective equipment (PPE) in a timely manner on all rooms on Units 2B and 2C after Licensed Practical Nurse (LPN) #3 tested positive for COVID-19 on 11/7/2020. The finding is: The Centers for Disease Control and Prevention (CDC) guidance titled Responding to Coronavirus (COVID-19) in Nursing Homes, dated 4/30/2020, documented that if residents have received direct care from Health Care Professional (HCP) who worked with symptoms consistent with COVID-19 or in the 48 hours prior to symptom onset, such residents should be restricted to their room and be cared for using all recommended COVID-19 PPE until results of HCP COVID-19 testing are known. If the HCP is diagnosed with [REDACTED]. The New York State Department of Health (NYSDOH) Revised Health Advisory entitled COVID-19 Cases in Nursing Homes and Adult Care Facilities, dated 7/10/2020, documented that if there are confirmed cases of COVID-19 in a Nursing Home, all residents on the affected units should be placed on droplet and contact precautions, regardless of the presence of symptoms and regardless of their COVID-19 status. HCP and other direct care providers should wear gown, gloves, eye protection (goggles or a face shield), and N95 respirators (or equivalent) if the facility has a respiratory program with fit tested staff and N95s. Otherwise, HCP and other direct care providers should wear gown, gloves, eye protection, and facemasks. Facilities may implement extended use of eye protection and facemasks/N95s when moving from resident to resident (i.e. do not change between residents) unless other medical conditions which necessitate droplet precautions are present. However, gloves and gowns must be changed and hand hygiene must be performed. Executive Order 202.11 dated 3/27/2020, as codified in 9 NYCRR 8.202.11, documented the following: Any guidance issued by the New York State Department of Health related to prevention and infection control of COVID-19 shall be effective immediately and shall supersede any prior conflicting guidance issued by the New York State Department of Health and any guidance issued by any local board of health, any local department of health, or any other political subdivision of the State related to the same subject. The facility Management of COVID-19 Policy and Procedure, revised on 4/26/2020, documented a COVID-19 outbreak is defined as one Confirmed laboratory case in the center .Procedures include to initiate droplet and contact precautions. The facility staffing schedule documented LPN #3 worked on 11/4/2020 provided medications and treatment for [REDACTED]. LPN #3 was tested for COVID-19 on 11/4/2020 and the Polymerase Chain Reaction (PCR) laboratory results were positive for COVID-19 on 11/7/2020. Units 2A, 2B, and 2C were observed on 11/9/2020 from 10:50 AM to 11:40 AM. Units 2B and 2C had no transmission-based precautions signs with exception of 1 room on unit 2B. The signage on the closed double doors for Unit 2A documented Contact/Droplet precautions- gown, full PPE. Certified Nursing Assistant (CNA) #8 was interviewed on 11/9/2020 at 11:45 AM. CNA #8 stated the Droplet/Contact precautions are only for Unit 2A and 1 room on Unit 2B. No other units were on Droplet/ Contact precautions. CNA #8 further stated that PPE, such as the gowns and goggles/face shields, are worn only for residents on Droplet/Contact precautions. Registered Nurse (RN) Supervisor #1 was interviewed on 11/9/2020 at 10:50 AM. The RN Supervisor stated that only the residents on Unit 2A, as well as 1 room on Unit 2B, were on Droplet and Contact precautions. LPN # 10 was interviewed on 11/9/2020 at 11:15 AM. The LPN stated that only the residents on Unit 2A and 1 room on Unit 2B were currently on Contact and Droplet precautions. The Director of Nursing Services (DNS) was interviewed on 11/9/2020 at 3:15 PM. The DNS stated that LPN #3 tested positive for COVID-19 on 11/7/20. The LPN #3 had worked with residents on Units 2A, 2B, and 2C. The DNS stated that as per the guidance, the facility should have implemented Droplet and Contact precautions for all the units that were affected by the exposure from LPN #3. The Infection Control Preventionist was interviewed on 11/9/2020 at 4:06 PM. The Infection Control Preventionist stated that on 11/7/2020 LPN # 3's test results were positive for COVID-19; however, Units 2B and 2C were not placed on Contact and Droplet precautions. The Infection Control Preventionist stated that TBP should have been implemented on 11/7/2020 on Unit 2A, 2B, and 2C. The facility had only implemented Contact and Droplet Precautions for Unit 2A and 1 room on Unit 2B on 11/7/2020. The Infection Control Preventionist stated all three units should have been placed on TBP effective 11/7/2020. 415.19(a)(1-3), (b)(1); 400.2

Based on record review and staff interviews during the Recertification Survey, the facility did not ensure that the comprehensive person-centered care plan for each resident was implemented to meet the residents' medical needs. This was identified for 1 (Resident #58) of 5 residents reviewed for unnecessary medications. Specifically, Resident #58 had a physician's orders [REDACTED]. The physician's orders [REDACTED]. The facility staff did not obtain Resident #58's heart rate or BP before administering the medication on multiple occasions in July 2020. The finding is: Resident #58 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14 indicating an intact cognitive response. The Comprehensive Care Plan (CCP) dated 1/12/19 documented the resident with alteration in Cardiovascular Function related to [MEDICAL CONDITIONS], HTN/[MEDICAL CONDITION]. Interventions included to administer medications as prescribed, monitor BP and vital signs. The Physician (MD) Order dated 7/8/20 documented to give Metropolol Extended-Release (ER) 50 milligram (mg) daily and to hold for a heart rate of less than 60 bpm or systolic BP of less than 110 mmHg. The MD Order dated 7/20/20 documented to give Taztia-Xt Capsule 24 hours 240 mg and to hold for heart rate less than 60 bpm or systolic BP less than 110 mmHg. The Medication Administration Record (MAR) for July 2020 documented: On 7/21/20, 7/22/20, 7/24/20, 7/25/20, 7/26/20, Metropolol ER 50mg and Taztia Xt Capsule 240 mg were administered at 9 AM daily. The MAR did not indicate that the heart rate or BP was obtained for the resident before administering these medications. The Physician's Assistant (PA) was interviewed on 9/11/20 at 2:37 PM and stated the heart rate and BP should be checked before administering [MEDICATION NAME] and Taztia Xt as these medications could cause [MEDICAL CONDITION] (slower than normal heart rate). PA stated that Resident #58 had a history of [REDACTED]. The medication nurse, LPN #3, was interviewed on 9/14/20 at 1:33 PM and stated that Residents #58 was on Cardiac medications with a specific physician order [REDACTED]. LPN #3 stated that the heart rate and BP should have been checked and documented on the MAR as per the MD orders. LPN #3 reviewed the MAR and stated that she administered the above-mentioned medications to Resident #58 and did not document the vital signs and was unable to recall why the heart rate and BP were not documented. The Director of Nursing Services (DNS) was interviewed on 9/15/20 at 10:35 AM and stated that it is necessary to check for vitals before administration the [MEDICATION NAME] and Taztia as ordered by the physician and should then be documented in either the MAR. DNS stated that she expected the staff to document vital signs prior to administering the above-mentioned medications. 415.11(c)(1)

Based on observation and staff interviews during the Recertification Survey, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional standards. Specifically, an inspection of one (Unit 1) of two medication rooms revealed an opened multidose vial of [MEDICATION NAME] (Diagnostic [MEDICATION NAME] used for detecting [MEDICAL CONDITION] infection), that was undated and not discarded 30 days after opening. The finding is: On 09/10/20 at 3:57 PM, during the Unit 1 medication storage room observation, a multi-dose [MEDICAL CONDITION] vaccine vial was opened and undated. The Medication Licensed Practical Nurse (LPN # 1) was interviewed on 9/10/20 at 4:00 PM and stated that she did not know when the multi-dose vial of the [MEDICATION NAME] was opened. LPN #1 further stated that the vial should be dated when opened and discarded 30 days after opening. An interview with the Associate Director of Nursing and the Registered Nurse Risk Manager on 09/10/20 4:45 PM revealed all [MEDICATION NAME] vials should be dated once opened and should be discarded 30 days after opening. 10 NYCRR 415.18(d)

Based on record reviews and staff interviews during an abbreviated survey (Complaint #NY 066) the facility did not ensure that a resident's comprehensive person-centered care plan was implemented that included measurable objectives and timeframes to meet the needs of a resident's medical, nursing, and mental and psychological needs that were identified in the comprehensive assessment. This was identified in 3 (Residents #1, #2, and #3) of 3 residents reviewed for a resident to resident altercation. Specifically, 1) the Accident/Incident (A/I) Reports dated 7/18/18, for Residents #1 and #2, had a documented preventive action that included one to one supervision. The medical records lacked documented evidence that one to one supervision was implemented for both residents. 2) The A/I Reports dated 7/29/18, for Residents #1 and #3, had a documented preventive action that included every 15 minutes safety checks for 72 hours. The medical records lacked documented evidence that every 15 minutes monitoring was implemented for both residents. The findings were: The facility's policy and procedure dated 6/2019 titled Management of Behavioral Emergencies documented . 5) If at any time the resident presents as a danger to self or others assign one staff to monitor the resident. The Team Leader (nursing supervisor) should coordinate staff involvement as well as one staff to notify the nurse in charge to assist in monitoring interventions. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 8/20/18 that Resident #1 had moderately impaired cognition. The resident had no physical or verbal behaviors. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented Resident #2 had severely impaired cognition. Resident #2 had physical behavioral symptoms directed towards others (e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually), this behavior occurred 1 to 3 days; Resident #2 did not have verbal behavioral symptoms. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented Resident #3 had intact cognition. Resident #3 had no physical or verbal behaviors. 1) The Accident/Incident (A/I) Reports for Residents #1 and #2, occurrence date 7/18/18 at 8:50 AM, documented physical altercation between Resident 1 and Resident #2. The investigation revealed that the incident was unavoidable. The new intervention was to place both residents on 1:1 supervision. The medical records lacked documented evidence that 1:1 supervision was implemented for both residents. An interview with the CNA, assigned to Resident #2 on 7/18/18, was conducted 7/11/19 at 5:52 PM. The CNA stated that the resident's name seems to be familiar, but she could not remember about the 7/18/18 incident or doing 1:1 supervision on Resident #2. The CNA stated that there was no specific place where she could document that a resident was provided 1:1 supervision. An interview with the Director of Nursing Services (DNS) was conducted on 7/12/19 At 3:45 PM. The DNS stated that there was no documentation of the 1:1 supervision on Residents #1 and #2. The DNS stated that the facility did not have a 1:1 supervision documentation form that the CNA staff could document on. The DNS stated that moving forward, the facility would start using the 1:1 supervision form. 2) The A/I Reports, for Residents #1 and #3, occurrence date 7/29/18 documented physical altercation between the two residents. The investigation concluded that the incident was unavoidable. The plan was to keep the residents separated and monitor every 15 minutes for 72 hours. The medical records lacked documented evidence that every 15 minutes monitoring for both residents was implemented. An interview with the Assistant Director of Nursing (ADNS) was conducted on 7/11/19 at 4:00 PM. The ADNS stated that although there was a Physician order [REDACTED]. An interview with CNA, assigned to Resident #1 on 7/29/18, was conducted on 7/11/19 at 5:59 PM. The CNA stated that she could not recall the incident and could not recall if she had conducted the 15-minute monitoring for Resident #1. 415.11(c)(1)

Based on observation, interview and record review during an abbreviated survey (Complaint # NY 027) the facility did not ensure that services provided to one (Resident #1) of three residents reviewed for Quality of Care met professional standards. Specifically, the primary medical doctor (MD #11) texted orders to the off duty Registered Nurse (RN#12) for an electrocardiogram (EKG) and blood work for Resident #1. The Licensed Practical Nurse (LPN) accepted those medical orders from the RN. The LPN documented the telephone orders on the Physicians' Order Form as received from the PMD. Furthermore, the EKG orders were not carried out until the resident was transferred out to the hospital. The findings were The policy and procedure titled Physician order [REDACTED]. At no time can an order be communicated via text message. The LPN or the RN, entering a diagnostic or lab test, the nurse entering the order is responsible to complete the requisition form to the outside agency to ensure the exam is completed. Resident#1, was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition for Resident#1. The Progress Note (PN) dated 3/18/19 at 22:32 documented at 10:28PM labs ordered for tomorrow and an EKG also ordered. The text message from MD#11 to RN#12 dated 3/18/19 documented for Resident #1 Hey, please order CBC, CMP, Troponin, EKG for (Resident #1). (NP#16) can follow up in the morning. Thank you. The RN#12 response documented I am off shift. I will tell 3:00PM-11:00PM manager now. The Medication Review Report (MRR-MD orders) dated 3/18/19 at 19:43, documented a verbal order by the MD for EKG and blood work. The medical record lacked documented evidence of an EKG report. The Progress Note dated 3/19/19 at 21:42:00 documented by the LPN at 10:00PM the resident was alert and responsive, EKG to be done. All tests called in and confirmation received. The Physician H&P dated 3/20/19 at 12:04, the MD documented EKG ordered yesterday: not done. No EKG available. The Progress Notes dated 3/20/19 at 12:31 documented actual observation dated 3/20/19 at 12:15 PM 911 called and resident transferred to hospital as per MD orders. The Facility Summary of Investigation dated 3/20/19 documented no reason to believe at this time that any abuse, mistreatment, neglect or misappropriation occurred on the part of facility staff. RN #12 was interviewed on 4/12/19 at 4:36PM and stated on 3/18/19 the resident complained of difficulty breathing with a pain in her left breast. The MD was made aware and he examined the resident. The RN left work after 3:30PM. At approximately 6:40 PM MD#11 texted her to obtain CBC (complete blood count), CMP (complete metabolic panel), Troponin level and EKG for Resident #1. The RN texted the MD#11 off duty and but would tell the 3:00PM-11:00PM unit manager. The RN called the unit and spoke to the LPN#13 and forwarded the text message from the MD#11. The LPN saw the message. The RN advised the LPN to call the EKG company and the LPN stated OK, I will do that. The RN could not recall if she told the LPN to call the MD to obtain the orders. The RN stated she should have told the MD to call the LPN on the unit. The RN stated that a text message was not a legitimate order from any medical provider. The RN stated she did not follow up on the EKG. The Licensed Practical Nurse (LPN) #13) was interviewed on 4/15/19 at 11:58 PM via telephone and stated that on 3/18/19 at about 6:30 PM-7:30 PM she got a telephone call from RN#12. The RN told her that the MD wanted to order a troponin level and an EKG for Resident #1. The MD did not call the LPN. LPN took the order over the telephone from the RN. The LPN thought that the RN also forwarded the MD's text to her personal phone. The LPN stated she can take an MD order from an RN. The LPN stated she did not recall calling the EKG company. The LPN did not recall if she ever called the company to obtain an EKG. She got distracted and was called away from the desk. It was an oversight that she did not follow up on the order for the EKG. The RN (Registered Nurse) Unit Manager #7 was interviewed on 4/15/19 at 2:54PM, and stated she was on duty 3/19,20/19. The RN called the EKG company on 3/19/19and was told that the EKG was never called in. The RN filled out the requisition form and got the confirmation number. The MD (Medical Doctor) # 11 was interviewed on 4/15/19 at 4:30PM and stated he saw the resident on 3/18/19. He texted orders for CBC, CMP, Troponin EKG. The MD stated he usually spoke on the phone to give orders. The MD did not know texting orders was a problem. The MD did not know if the EKG was obtained for the resident. During Director of Nursing (DON)#9 was interviewed on 4/12/19 at 3:00PM and stated with there was an issue with the timeliness of obtaining the EKG. The order for EKG was placed 3/18/19 at 9:00PM. The 3/19/19 the morning RN #7 called the EKG company to follow-up for the results of the EKG. The EKG was never called to the company. The DON stated LPN#13 and RN#12 were satisfactory employees and were disciplined for taking an MD order via text. The nurses should communicate verbally with a physician in order to obtain telephone orders. 415.11( c )(3)(i)

Based on record review and interviews during the recertification survey, the facility did not provide the Resident Council with a private space for monthly meetings. Specifically, during the Resident Council meeting, the residents in attendance (9 residents including the President of resident council) verbalized that the facility arranges monthly Resident Council meetings in the dining room where staff were also present. The finding is: During a meeting conducted with the Resident Council on 11/16/18 at 10:30 AM, the Resident Council President stated that the monthly Resident Council meetings are not held in a private space. Eight out of nine council members corroborated that the monthly meetings are held in the dining room where staff may come in and out. The council members stated that there is a television in the dining room. There are residents who are present in the dining room, watching television and not actively participating in the resident council meeting, who can be disruptive. The residents who wish to participate in the council meeting stated that they do not feel comfortable discussing grievances because staff are present in the space, bringing other residents into the dining room to watch television and providing care as needed to these residents. Eight of nine residents stated they were concerned that the staff can overhear their meeting discussions and may become disgruntled. The Resident Council members were not aware they could request a private space without staff interrupting. The recreation calendars for the month of (MONTH) and (MONTH) (YEAR) documented that the Resident Council Meetings were held in the 1st floor dining room on 9/19/2018 and 10/22/2018 at 2:15 PM respectively. There was also a Leaf Etching recreation activity scheduled on 10/22/2018 at 2:15 PM in the 1st floor dining room. The Recreation Director was interviewed on 11/16/18 at 11:30 AM, and stated that the Resident Council meetings are regularly held in the dining room. The Recreation Director leaves the space open for passive participants to come in and out and stated that there may be staff present to assist residents who are not actively participating in the Resident Council meeting. 415.5(c)(1-5)

Based on record review and interviews during the Recertification Survey, the facility did not develop a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. This was identified for 1 (Resident #472) of 3 residents reviewed for infections. Specifically, Resident #472 was admitted to the facility on [DATE] with a Peripherally Inserted Central Catheter (PICC) line for antibiotic administration. However, there was no care plan created for PICC line care and monitoring. The finding is: Resident #472 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 11/13/2018 Admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS documented that the resident was receiving IV medications. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Resident #472 was observed in bed on 11/15/2018 at 9:11 AM. The resident had a PICC line to his right upper arm. The resident stated he was getting antibiotics following surgery to his right foot. Review of the medical record revealed that there was no care plan addressing care and monitoring of the PICC line. The unit Registered Nurse (RN#3) supervisor was interviewed on 11/16/2018 at 8:27 AM. She stated that there was a care plan for the infection, but it did not include any information or interventions related to the PICC line. She stated there should be a care plan for the PICC line. In addition, she stated that she had previously changed the PICC dressing, but there was no order to change the dressing. An order to change the PICC line dressing weekly and to monitor for infection every day shift was obtained on 11/16/2018 at 8:39 AM. The RN #3 unit supervisor was re-interviewed on 11/16/2018 at 2:34 PM. She stated that she did not write a progress note when she changed the PICC line dressing and because there was no order, she did not document the dressing change in the Treatment Administration Record (TAR). She said it is nursing practice to change the dressing once a week, and she should have documented this in a note. The Director of Nursing Services (DNS) was interviewed on 11/19/2018 at 9:12 AM. She stated there should be a care plan addressing the PICC, and that the nurse (RN #3) should have documented that she changed the dressing. 415.11

Based on observation, record review, and staff interviews during the recertification survey, the facility did not ensure that a comprehensive care plan (CCP) was reviewed and revised to reflect the resident's current status. This was evident for 1 (Resident #13) of 1 resident reviewed for catheter care. Specifically, Resident #13 had a Suprapubic catheter in place on 10/25/18. There was no revision of the Comprehensive Care Plan (CCP) developed for catheter care to reflect the change from a Foley catheter to a Suprapubic Catheter. The finding is: The facility's policy and procedure dated 5/2018 titled Catheter: Closed Urinary Drainage System documented . The purpose of procedure for care of a urinary catheter is to prevent catheter-associated urinary infections . Resident #13 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The resident was sent to the hospital on [DATE] and returned the same day (10/25/18) with a Suprapubic Catheter in place. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 10 indicating the resident was moderately impaired in cognitive skills for daily decision making. The MDS also documented active [DIAGNOSES REDACTED]. The CCP developed for Foley catheter, dated 7/30/18, documented Foley catheter care. Upon return from the hospital on [DATE] there was no CCP developed for the care of the newly inserted Suprapubic catheter. The CCP developed for Suprapubic catheter secondary to Urinary Hydro[DIAGNOSES REDACTED] and [MEDICAL CONDITION] Bladder secondary to [MEDICAL CONDITION] (MS), dated 11/10/18, documented to ensure tubing is anchored to prevent pulling, to maintain collection bag below the level of the bladder, to monitor/document for pain/discomfort due to catheter, to monitor/record/report to the Physician (MD) for signs and symptoms of Urinary Tract Infection [MEDICAL CONDITION], pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, chills, altered mental status, change in behavior, and change in eating pattern. The resident was observed in bed on 11/15/18 at 8:00 AM with a Suprapubic catheter with a collection bag hanging at the bedside. An interview with the Director of Nursing Services (DNS) was conducted on 11/15/18 at 11:03 AM. The DNS stated that the resident had a CCP for Foley catheter, but the CCP for catheter care should have been revised to Suprapubic catheter to reflect that the resident now had a Suprapubic catheter in place. An interview with the Assistant Director of Nursing Services (ADNS) and the Registered Nurse (RN) Charge Unit Nurse was conducted concurrently on 11/20/18 at 9:15 AM. Both stated that the CCP for catheter care should have been updated or revised once the resident had the Suprapubic catheter in place on 10/25/18. 415.11(c)(2)(i-iii)

Based on observation, record review, and interviews during the Recertification Survey the facility did not ensure that each resident received care, consistent with professional standards of practice, to prevent pressure ulcers for one (Resident #148) of 5 residents reviewed for pressure ulcers. Specifically, Resident #148 developed a Stage 2 pressure ulcer to the right heel; however, there was no documented evidence that the resident's heels were being offloaded and no documented evidence of timely follow-up after the resident complained about right heel pain. The finding is: Resident #148 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission 10/27/2018 Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS documented that the resident required extensive assistance of two staff members for bed mobility, was at risk for pressure ulcer development, and had no pressure ulcers upon admission. The nursing admission assessment, dated 10/20/2018, documented that there was bruising to the right arm and discoloration to the front of the right lower leg. There were no other skin abnormalities identified. The Braden score (a scale for determining pressure ulcer risk) in the nursing admission assessment documented a score of 16, indicating the resident was at risk for pressure ulcer development. A Comprehensive Care Plan (CCP), effective 10/21/2018, titled Resident is at Risk for Impaired Skin Integrity Related to Disease Process included to report to the physician any signs of deterioration or significant changes, minimize exposure to moisture, and avoid mechanical trauma. A wound documentation note written by the Registered Nurse (RN) wound care nurse (RN#5) dated 10/22/2018 documented that a vascular wound was identified to the resident's right great toe. Interventions included repositioning to raise the heels while in bed. The treatment implemented for the toe wound was to paint the toe with [MEDICATION NAME] and leave open to air. A CCP created on 10/22/2018, titled Impaired Skin Integrity Related to Arterial Right Great Toe did not include interventions to reposition and raise the heels while in bed. Additionally, the CCP for At Risk for Impaired Skin Integrity was not updated with the new interventions. Review of the Certified Nursing Assistant (CNA) accountability tasks, from 10/1/18-10/31/18, revealed that there was no instruction to reposition the resident and to elevate the heels while in bed. A nursing note dated 10/29/2018, written by a 3PM-11PM RN (RN#7), documented that the resident had right heel soreness and the heel was elevated with a pillow to relieve pain. There was no documentation in the note regarding the skin integrity of the heel. There was no documented follow-up regarding the resident's heel pain on 10/30/2018. A wound documentation note, written by the RN wound care nurse (RN#5) dated 10/31/2018, documented that the resident was identified with a right heel Stage 2 pressure ulcer. Interventions included a right posterior offloading Darco shoe and bilateral heel lifts to wear when in bed instead of offloading the heels with pillows. A physician's orders [REDACTED]. A wound documentation note, written by the RN wound care nurse (RN#5) on 11/6/2018, documented that the resident had increased pain to the right heel since initiation of the Darco shoe and that the resident wanted to wear her regular moccasin. The resident was educated regarding the possible adverse outcomes of not wearing the Darco shoe. The resident verbalized understanding, but still requested that the Darco shoe be removed. Resident #148 was observed on 11/15/2018 at 8:34 AM sitting in her wheelchair. She was wearing moccasins on both feet. She stated that she had wounds on her right foot and she removed her right moccasin. A blackened area was observed at the tip of her right great toe. She stated that there was also a wound on her right heel. There was no dressing in place for the heel. The right heel wound care was observed on 11/19/2018 at 9:21 AM, which was performed by the RN wound care nurse. The heel was observed to be reddish and dry, without drainage. The resident and her husband were interviewed concurrently on 11/19/2018 at 12:39 PM. They both stated they could not recall if pillows were being used to offload the resident's heels prior to the initiation of heel lift boots on 10/31/2018. The RN (RN#7) who had written the note on 10/29/2018 regarding the right heel pain was interviewed on 11/19/2018 at 2:19 PM. She stated that she placed a pillow under the resident's right heel and that there was no pillow there previously. She stated that she looked at the heel and there was no redness and that she wrote her progress note thinking it would be seen by others. She further stated she did not know that there was a communication board utilized to communicate findings. The resident's regular 11PM-7AM CNA (CNA#1) was interviewed on 11/19/2018 at 2:48 PM. She stated that she would place pillows under the resident's feet to make her more comfortable, but she was not really sure when she began placing pillows under the resident's feet. She stated that if the intervention was not a CNA task, then it would not be documented. The RN wound care nurse (RN#5) was interviewed on 11/20/2018 at 9:11 AM. She stated she did not add that the heels should be offloaded to the CNA tasks and to the care plans following the identification of the toe wound on 10/22/2018. She stated it was an oversight. In addition, she stated the nurse who documented that the resident had heel pain on 10/29/2018 should have communicated through the electronic communication board that the resident needed follow up. She further stated that she became aware of the heel pressure ulcer during normal wound rounds on 10/31/2018. The RN unit supervisor (RN#3) was interviewed on 11/20/2018 at 10:38 AM. She stated it is the wound care nurse's responsibility to update the care plans and add the CNA tasks. 415.12(c)(1)

Based on observation, record review, and staff interviews during the recertification survey, the facility did not ensure that a resident with a Suprapubic catheter received appropriate treatment and services based on the resident's current needs. This was evident for 1 (Resident #13) of 1 resident reviewed for catheter use. Specifically, Resident #13 had a Suprapubic catheter in place on 10/25/18. There was no documented evidence that Suprapubic care was initiated timely. There was no monitoring of the Suprapubic site for signs and symptoms of infection. Additionally, the resident's output from the Suprapubic collection bag was not consistently documented. The finding is: The facility's policy and procedure dated 5/2018 titled Catheter: Closed Urinary Drainage System documented . The purpose of procedure for care of a urinary catheter is to prevent catheter-associated urinary infections . Documentation of output will be done by the CNA on the Plan of Care (P[NAME]) every (q) shift . Resident #13 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The resident was sent to the hospital on [DATE] and returned the same day (10/25/18) with a Suprapubic catheter in place. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 10 indicating the resident was moderately impaired in cognitive skills for daily decision making. The MDS also documented active [DIAGNOSES REDACTED]. The Physician's History and Physical dated 10/25/18 documented status [REDACTED]. The resident was observed in bed on 11/15/18 at 8:00 AM with a Suprapubic catheter with a collection bag hanging at bedside in place. Review of the medical record revealed that there was no Physician's Order for Suprapubic site care from 10/25/18 through 11/4/18. There was no documented evidence in the Treatment Administration Record (TAR) that Suprapubic site care was done from 10/25/18 through 11/4/18. Review of the Certified Nursing Assistant (CNA) Accountability Record (CNAAR) from (MONTH) (YEAR) through (MONTH) (YEAR) revealed that the urinary output from the collection bag was inconsistently documented on some shifts. An interview with the Director of Nursing Services (DNS) was conducted on 11/20/18 at 8:30 AM. The DNS stated that there was no Suprapubic site care ordered until 11/4/18. An interview with the Licensed Practical Nurse (LPN) was conducted on 11/20/18 at 9:00 AM. The LPN stated that there was no order for Suprapubic care and monitoring of the site, s/p Suprapubic placement on 10/25/18. The LPN also stated that care and monitoring of the Suprapubic catheter should have started on 10/25/18. An interview with the Assistant Director of Nursing Services (ADNS) and Registered Nurse (RN) Charge Unit Nurse was conducted concurrently on 11/20/18 at 9:15 AM. Both the ADNS and RN stated that there was no record of the nurses providing the Suprapubic care and monitoring of the site every shift. Both the DNS and the RN stated that there was no Suprapubic care ordered until 11/4/18. The ADNS stated that Suprapubic catheter monitoring and care should have been started on 10/25/18. The ADNS stated that the urine output is to be documented by the CNA in the electronic Plan of Care (P[NAME]) form as required per policy. An interview with the Attending Physician was conducted on 11/20/18 at 9:17 AM. The Physician stated that she believed there was no Suprapubic care and monitoring ordered since 10/25/18 when the resident had the Suprapubic catheter in place. The Physician stated that an order should have been written. An interview with the 7:00 AM-3:00 PM shift assigned CNA, who did not document the urine output on 11/3/18, was conducted on 11/20/18 at 12:15 PM in the presence of the ADNS. The CNA stated that she did not document the urine output on 11/3/18. An interview with the RN Staff Inservice Coordinator was conducted on 11/20/18 at 1:00 PM. The RN stated the CNAs have been inserviced as to how to document the urine output in the P[NAME]s. 415.12(d(1))