Every finding on record at Sodus Rehabilitation & Nursing Center

Based on observations, interview, and record review conducted during the Recertification Survey from 10/07/2024 to 10/11/2024, for one of one main kitchen and one (Cortland/[NAME]) of two satellite serveries, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically: there were dirty food and non-food contact surfaces, perishable food items were kept longer than 3-days per facility policies, and a sanitizer cleaning bucket with solution and a cleaning rag was dirty and not replaced between meals. The findings are: Record review of the undated facility policy Food and Supply Storage included: All perishable items will be disposed of 3 days after opening or on expiration date whichever is earlier. Observations during the initial tour of the main kitchen on 10/07/2024 from 7:45 AM to 8:35 AM included the following: 1. The following covered and labeled perishable food items were located in the walk-in cooler as follows: seafood salad dated 10/3, bologna dated 10/2, a large stainless steel pan with 11 pieces of sliced pork dated 9/29, a pan of approximately 15 cooked chicken thighs dated 10/3, hot dogs dated 10/2, a large stainless pan of cooked roast beef dated 10/1, beets dated 10/2, bacon dated 10/1, two containers of gravy dated 10/1, beef stock dated 10/1, and sliced turkey dated 10/3. 2. There was approximately one cup of frozen mixed vegetables spilled on the floor of the walk-in freezer. 3. The sides of the tilt skillet were heavily soiled with black and white food debris stuck on. There was dried food debris on the handles, knobs, and sides of the range/stove. 4. The robot coupe mixer machine was heavily soiled with yellow dried-on food debris and a white powder-like substance. 5. A drawer in the stainless table contained measuring cups, spoons, and other utensils was heavily soiled with dried-on brown debris and crumbs. 6. The Manitowoc brand ice machine had dried-on food debris on the outer surfaces. During an interview on 10/07/2024 at 10:27 AM, the Food Service Director stated prepared foods generally are held for 5 days, and seafood for 3 days. Observations on 10/07/2024 at 9:56 AM included the dispenser on the ice machine in the [NAME] Unit nourishment room was dirty and had white and brown residue on the inner surfaces of the dispenser. Observations and interviews on 10/09/2024 at 11:55 AM included the sanitizer bucket in the Cortland dining room beneath the steam table was full of gray, dirty liquid and a soiled rag. During an interview at this time, Food Service Worker #1 stated the bucket was for wiping things down and was filled up first thing this morning for the breakfast meal. Food Service Worker #1 stated they change the sanitizer after lunch. The surveyor then asked the Food Service Director to have the sanitizer changed because it was visibly dirty. The Food Service Director stated food service workers in the dining rooms do not have sanitizer test strips and only have them available in the kitchen. Observations on 10/09/2024 at 1:05 PM included the grease traps in the main kitchen hood above the range and tilt-skillet were brown and heavily coated with grease and dust. Additionally, the left side of the grease traps had a section that was damaged and broken. Record review of a hood cleaning report, dated 06/07/2024, included that the hood and ductwork was cleaned, but did not specifically include the grease traps. 10NYCRR: 415.14(h), 10NYCRR: Subpart 14-1.110, 14-1.117, 14-1.175

Based on observations and interviews conducted during the Recertification Survey from [DATE] to [DATE], for 54 of 102 residents, the facility did not ensure residents' right to privacy related to their medical records in that advanced directives wishes were not kept confidential. Specifically, there was a list of advanced directives information (such as wishes for cardiopulmonary resuscitation (CPR) in the event of an acute cardiac or respiratory event) that included the names of 44 residents with their wishes posted in plain sight in the facility library, which all residents and visitors have access to. In addition, there was a large picture frame hanging in the front lobby of the facility with 17 resident's pictures and names in view of the public; nine residents were listed in an elopement group (at risk for unsafe wandering outside the building) and eight residents an explorer group. This is evidenced by the following: During observations on [DATE] at 1:43 PM, [DATE] at 8:37 AM, [DATE] at 12:49 PM, and [DATE] at 10:30 AM in the library on the residential [NAME] Unit, there was a document labeled cardiopulmonary resuscitation CPR List - Updated [DATE] which listed 44 residents by first and last names. On [DATE] at 8:37 AM, there were eight residents in the library for the breakfast meal. During an observation on [DATE] at 10:30 AM, hanging on the wall next to the receptionist in the facility lobby was a picture frame just above eye level approximately 10x13 inches with 17 resident photos and their first and last names, nine of which were listed in an elopement group and the other eight were listed in an explorer group. During an interview on [DATE] at 10:50 AM, Licensed Practical Nurse Manager #1 stated the facility had to abide by the Health Insurance Portability and Accountability Act (HIPPA privacy law) that includes resident information, such as their code status, should not be shared. At this time, two residents and three family members requested to use the library for a visit. Licensed Practical Nurse Manager #1 could not recall if any documents containing resident code status were posted in the facility common areas. During interviews on [DATE] at 11:02 AM and 12:39 PM, the Administrator stated there was a full code list that social work created and maintained. The Administrator stated they thought it was kept in the front office and in the Medical Orders for Life-Sustaining Treatment (MOLST) books. The Administrator stated everything relating to residents, including their names, birth dates, medications, and code status, would fall under the Health Insurance Portability and Accountability Act and cannot be shared. The Administrator said they did not know that the cardiopulmonary resuscitation list (of resident's' wishes) was hung in the library in view of the public, and stated it should not be. The Administrator stated they implemented the elopement and explorer groups because the facility was large and residents from other units walk throughout the facility. The explorer group was created to let staff know which residents like to walk throughout the facility but are not an elopement risk. The Administrator stated they did not realize the first and last names were listed, and stated it should not be in view of the public. 415.3(e)(1)

Based on observations, interviews, and record reviews conducted during the Recertification Survey from 10/07/2024 to 10/11/2024, for one (Resident #35) of three residents reviewed for food and nutrition, the facility did not ensure services were provided to maintain acceptable parameters of nutritional status. Specifically, Resident #35 was not consistently monitored for significant weight loss, and the facility could not provide documented evidence of consistent meal monitoring or interventions despite a significant weight loss. The finding is: The undated facility policy Weights documented each resident will be carefully monitored on a regular basis (monthly or weekly), or as otherwise specified by the provider, so that appropriate timely interventions may be initiated. Interventions will be initiated as needed to track unplanned significant weight variances of 5% weight loss/gain in 30 days, 7.5% weight loss/gain in 90 days, or 10% weight loss/gain in 180 days. The Dietitian/Designee will be responsible for evaluation and transferring the weights recorded by the Certified Nursing Assistant, and must notify the Nurse Manager to verify any weight variance of 5 pounds or more by an immediate reweight. Resident #35 had diagnoses that included Alzheimer's disease, depression, and anxiety. The Minimum Data Set Resident Assessment, dated 07/21/2024, documented that the resident was severely impaired cognitively, and required supervision, verbal cues, or touching assistance as they complete activities. The current Comprehensive Care Plan, last updated 07/30/2024, documented that Resident #35 was at risk for altered nutrition status secondary to poor appetite, leaving greater than 25% of meals uneaten, with variable intake and a goal to maintain current body weight (+/-) 3%. The current Kardex (the care plan used by Certified Nursing Assistants to provide daily care) documented that Resident #35 required limited assistance of one staff to eat and should be in the dining room for all meals. Current Physician's orders as of 10/07/2024 included a regular house diet, thin liquids, and monthly weights. During observations on 10/09/2024 at 12:42 PM, Resident #35 was sitting in dining room with their lunch tray set up. The tray included cut up barbecue chicken, broccoli, mashed potatoes with gravy, a cup of diced pears, a 4-ounce carton of whole milk, lemonade, and coffee. The resident ate two to three bites of the main entree only. During an interview at this time, Licensed Practical Nurse Manager #2 stated they thought Resident #35 ate 25% of their meal. Review of Resident #35's electronic medical record revealed monthly weights as follows: - 06/05/2024: 172 pounds - No weight documented for July 2024. - 08/08/2024: 168 pounds - 09/02/2024: 144 pounds. A request was made for a re-weight on 09/05/2024, was completed on 09/13/2024 and revealed Resident #35 weighed 143 pounds (a 25-pound weight loss or 14.8% loss for approximately one month and a 29-pound weight loss or 16.8% loss for approximately three months). Review of Resident #35 meal intake record in the facility's electronic medical record for August 2024 revealed only 21 out of 90 meals were documented at all with 3 meals documented as refused and 10 meals documented as less than 50%. In a medical progress note, dated 09/19/2024, the Medical Director documented during a routine monthly visit that Resident #35 consumed 75-100% of meals, feeds themself with tray set up, their appetite was satisfactory, and they had no significant weight change. During an interview on 10/09/2024 at 1:03 PM, the Dietary Technician stated they do the weight tracking for the facility and speak daily with Dietitian. They were aware Resident #35 had potential significant weight loss and needed a re-weight, but the resident had fallen off their radar and it was not done timely or followed up on. During an interview on 10/09/2024 at 1:35 PM, Licensed Practical Nurse Manager #2 stated Resident #35 could be stubborn and refuse to eat. It is their expectation that all meals consumed are appropriately documented for all residents. They were not aware that Resident #35 had a significant weight loss as the Resident just moved to this unit on 10/02/2024. During an interview on 10/09/2024 at 4:00 PM, the Registered Dietitian stated they are a consultant to the facility, coming three times a month, and speak regularly, if not daily, with the Dietary Technician. The Registered Dietitian said they were not aware of Resident #35's significant weight loss as the Dietary Technician is mostly responsible for trending weight loss or gain. The Registered Dietitian stated the resident has been receiving fortified oatmeal for breakfast and fortified mashed potatoes for lunch since 07/30/2024. There was no documented evidence that any other interventions or supplements were initiated following the resident's weight loss. During an interview on 10/11/2024 at 10:51 AM, Licensed Practical Nurse Manager #1 stated they were not aware of a significant weight loss for Resident #35, but were not surprised as the resident was requiring more cueing and assistance from nursing staff while eating. During an interview on 10/11/2024 at 11:07 AM, Nurse Practitioner #1 stated they discussed the weight loss at morning meeting and reached out to psychiatry who requested the re-weight. Nurse Practitioner #1 said after reading the Medical Director's note, they did not think the Medical Director was aware of the resident's weight loss. During an interview on 10/10/2024 at 3:18 PM, the Director of Nursing stated that significant weight loss was discussed at morning meetings, including for Resident #35, all meal consumption should be documented by nursing staff, and the provider should be made aware of any significant weight loss greater than 5% in a month. There was no documented evidence of any follow-up following the residents re-weight on 09/13/2024. 10 NYCRR 415.12(i)(1)

Sodus F760D Based on observations, interviews, and record reviews conducted during a Recertification Survey and complaint investigation (NY00338097) from 10/07/2024 to 10/11/2024, the facility did not ensure that two (Residents #43 and #66) of six residents reviewed were free of significant medication errors. Specifically, Resident #43 received several medications prescribed to treat Parkinson's disease and seizures one to three hours after scheduled times and a second medication to treat Parkinson's was administered too closely to the next dose. Resident #66 did not receive their insulin administration as ordered. This is evidenced by the following: The facility policy Administration of Medications, dated September 2020, included that medications will be administered to residents in a timely and accurate manner. Administer medications within one hour before or after prescribed time. Immediately chart medications administered in the proper time and date via initials by signature in designated space on the administration record. If resident refuses to take scheduled medication(s), nurse initials shall be documented with reason for refusal documented on Medication Administration Record. For special considerations for nurse, medication administration record can be flagged to identify residents unavailable to receive medications during the pass or to identify medications given at times other than the established time schedule. 1. Resident #43 had diagnoses including Parkinson's disease, seizures, and dementia. The Minimum Data Set Resident Assessment, dated 09/05/2024, included the resident was moderately impaired cognitively. Review of the Comprehensive Care Plan, dated 08/30/2024, revealed Resident #43 had a seizure disorder and Parkinson's disease. Interventions included, but were not limited to, giving medications as ordered for both diagnoses. Review of active physician orders for Resident #43 included: a. Levetiracetam 500 milligram tablets, give one tablet two times a day for seizures, start date of 08/31/2024. b. Baclofen (muscle relaxant medication used to treat muscle spasms) 10 milligram tablets, give one tablet at bedtime for Parkinson's disease, give at 9:00 PM, start date of 09/18/2024. c. Baclofen 5 milligram tablet, give one tablet two times a day for spasms and pain, start date 09/18/2024. d. Ropinirole 2 milligram tablet, give one tablet two times a day for Parkinson's disease, start date 08/30/2024. e. Carbidopa-levodopa 25-100 milligram tablet, give one tablet six times a day for Parkinson's disease, start date of 08/30/2024. Review of the September 2024 and October (10/01/204 to 10/09/2024) Medication Administration Records and the Medication Administration Audit Report revealed multiple medications were signed off as administered late, including the following: - Levetiracetam was administered 1.5 to 2 hours after scheduled time on four occasions. - Baclofen was administered 1.5 to 2 hours after scheduled time on two occasions. - Ropinirole was administered 1.5 to 3 hours after scheduled time on thirteen occasions. - Carbidopa-levodopa scheduled every three hours was administered 30 minutes to 2.5 hours after scheduled time on seven occasions. Additionally, on two occasions the medication was given just one hour between doses (versus 3 hours as ordered), and on one occasion, there were only 26 minutes between doses (versus 3 hours as ordered). During an interview on 10/07/2024 at 12:10 PM, Resident #43 stated they needed their Parkinson's and seizure medications at specific times, per their doctor and this was not occurring. Resident #43 stated the Parkinson's medication needed to be given every three hours and sometimes the nurses were late, and this throws off their schedule. During an interview on 10/11/2024 at 11:06 AM, Licensed Practical Nurse #1 stated that the policy on medication administration was one hour early or one hour late and if they could not administer a medication within the timeframe, they should let the provider know and document the reasoning. Licensed Practical Nurse #1 stated that seizure medications and Parkinson's disease medications should be given at their scheduled time because there is a balance and timing in which the resident should get the medications. During an interview on 10/11/2024 at 11:22 AM, Nurse Practitioner #1 stated that levetiracetam, baclofen, carbidopa-levodopa, and ropinirole were significant medications and if the medications were administered too closely together, toxicity could be an adverse effect, and if there was a delay in administering the medications, it may not be a therapeutic level. Nurse Practitioner #1 stated they were not aware that Resident #43's medications had not been given as scheduled (greater than one to three hours after scheduled time) or the carbidopa-levodopa had been administered too closely to the next dose, and they should have been made aware. During an interview on 10/11/2024 at 11:52 AM, the Director of Nursing stated they were not aware until the residents' records were requested that Resident #43 had received seizure and Parkinson's disease medication greater than one and one half hours to three hours after the scheduled times. 2. Resident #66 had diagnoses including diabetes, diabetic retinopathy (a complication of diabetes that affects the eyes), and congestive heart failure. The Minimum Data Set Resident Assessment, dated 09/02/2024, included the resident was cognitively intact. Review of active physicians's orders for Resident #66 included: a. Insulin glargine (long-acting insulin) 100 unit per milliliter, inject 26 units subcutaneously at bedtime for diabetes, start date 05/16/2024. b. Insulin aspart (fast-acting insulin used to control high blood sugar) 100 unit per milliliter, inject per sliding scale, start date 07/29/2023. Review of the September 2024 and October 2024 Medication Administration Records revealed no documented evidence that the insulin had been administered at all (blank box on the medication administration record) as ordered on four occasions, administered late (over one hour past the scheduled time) on seven occasions, and administered approximately six hours late on one occasion. During an interview on 10/07/2024 at 12:13 PM, Resident #66 stated when they get their insulin late it makes their blood sugars too high and this makes them mad. During an interview on 10/10/2024 at 3:15 PM, Licensed Practical Nurse Manager #1 stated a blank box on the Medication Administration Record means not completed and Resident #66 should have received their insulin as ordered. During an interview on 10/11/2024 at approximately 11:31 AM, Nurse Practitioner #1 stated insulin was a significant medication and should be given as ordered. 10 NYCRR 415.12(m)(2)

Based on observation, interviews, and record review completed during an Abbreviated Survey (#NY00337643), for one (Resident #1) of three residents reviewed, the facility did not ensure that an allegation of abuse was thoroughly investigated. Specifically, a staff member reported on 3/25/24 that they witnessed a potential abuse incident on 3/20/24 between another staff member and Resident #1. The facility's investigation to rule out any abuse, neglect or mistreatment concluded no abuse occurred but did not include any interviews with staff members who were working at the time of the alleged incident and witnessed the incident. Additionally, the facility did not report the alleged abuse until 13 days after it occurred. This was evidenced by the following: Resident #1 had diagnoses including dementia, depression, and diabetes. The Minimum Data Set Resident Assessment, dated 1/10/24, documented the resident was severely impaired cognitively. Review of a facility's Investigation Summary dated 3/25/24 and completed by the Director of Nursing, revealed that an incident occurred on 3/20/24 between Licensed Practical Nurse #1 and Resident #1. Resident #1 was sitting at the nurse's station, appeared upset and threw food at Licensed Practical Nurse #1 and the nurse swatted it away. The report included that the food went back towards the resident but did not hit them. The summary included that interviews were conducted by the Director of Nursing with Licensed Practical Nurse #1, Licensed Practical Nurse Manager #1 and two additional witnesses who were not identified in the report and did not include any statements. The Director of Nursing concluded there was no abuse and no action taken. The Investigation Summary later added that updated interviews (4/4/24 after surveyor intervention) that were conducted with staff members were inconclusive, but that two staff members reported Resident #1 was hit with the food that was thrown back by Licensed Practical Nurse #1. During an interview on 4/4/24 at 11:49 AM and again at 1:11 PM Licensed Practical Nurse Manager #1 stated the incident was reported to them on 3/20/24 via a text from Licensed Practical Nurse #1 that included that Resident #1 threw food at them which they swatted away. The text included that a Staff Member who was present was upset about the incident. Licensed Practical Nurse Manager #1 stated that on 3/25/24 (five days after the incident) they overheard a staff member telling a nurse about the incident that occurred 3/20/24. When questioned at the time, the staff member informed Licensed Practical Nurse Manager #1 that when Resident #1 threw the food, Licensed Practical Nurse #1 threw it back at the resident hitting them in the face causing a red spot. Licensed Practical Nurse Manager #1 stated they obtained written statements from staff regarding the incident at that time but were unable to find any of them. Licensed Practical Nurse Manager #1 said they reported the incident to the Administrator, Director of Nursing and Assistant Administrator but did not complete an Incident/Accident Report. During interviews on 4/4/24, between 2:00 PM to 2:30 PM, Certified Nursing Assistants #1, #2 and #3 each stated they had not been asked to provide a statement regarding their account of the incident that they witnessed on 3/20/24 until that morning (4/4/24). During an interview on 4/4/24 at approximately 1:30 PM the Director of Nursing stated they were unaware Licensed Practical Nurse Manager #1 was unable to find any staff statements regarding the incident and that the investigation should include statements from staff working at the time of the incident. During an interview on 4/9/24, at 8:43 AM the Administrator stated they should be notified immediately of any suspected abuse and that the Nurse Managers are responsible for investigating any alleged incident of possible abuse and notifying Administration. The Administrator stated that on 3/25/24 Licensed Practical Nurse Manager #1 reported an incident to them and told them another resident was a witness. The Administrator stated they interviewed this resident who was alert and oriented and said nothing happened. The Administrator stated staff who were present should have been interviewed regarding the incident and it should have been reported to the Department of Health within five days and it was not. 10 NYCRR 415.4

Based on observations, interviews, and record review conducted during an Abbreviated Survey (#NY00320671) completed 10/12/23 to 10/13/23, it was determined that for one of one main kitchen the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, food service operations were conducted in the area of an active wastewater backup and the incident was not reported to New York State Department of Health (NYSDOH). The findings are: During an interview on 10/12/23 at 8:47 AM, the [NAME] stated that there was a flood in the kitchen in July this year because the septic backed up. The [NAME] further stated that a vendor had to come in because the water from the septic came up to above their shoe line all along the cook line. During an interview on 10/12/23 at 8:56 AM, the Food Service Director (FSD) stated that they had a problem in July this year when there was a flood in the kitchen when the drains backed up, and they had to have plumbers come in for service because the flood was continuous. The FSD further stated that there was flooding mostly over by the three-bay sink where the drains are and that it came over into the cook line. The FSD also stated that chefs cooked in the area of the flood during that time since the water wasn't really deep as they were continuously using a squeegee and a shop vac to get the water up. During an interview on 10/12/23 at 9:35 AM, the Director of Operations (DOP) stated that in July the grease traps in the kitchen backed up because there was a huge clog causing water to go over the floor of the kitchen. The DOP further stated that the grease traps caused the drains to back up onto the kitchen floor and that meal service went on as usual. During an interview on 10/12/23 at 10:26 AM, Certified Nursing Assistant (CNA) #1 stated that there was a septic back up in the kitchen this year. During an interview on 10/12/23 at 10:41 AM, CNA #2 stated that they were not able to use the sinks on the units because there was flooding in the kitchen, and they were told the water in the sinks was not to be used because it could cause backups in other parts of the building. CNA #2 further stated that the kitchen continued to serve food out of the kitchen during the flooding. Record review on 10/12/23 at 2:43 PM revealed a facility disaster drill dated 7/23/23 starting at 2:00 PM and ending 7/24/23 at 11:30 AM which included, but was not limited to, the following: a) Under report question 'Were any outside agencies notified (DOH, Fire, Police, etc.)' the report listed: 'Yes; O'Connor Plumbing & [NAME] Septic & Sewer. No additional outside agencies were notified.' b) At approximately 2:00 PM on July 23, 2023, it was reported that there was a plumbing back up on the [NAME] Unit. Maintenance determined that multiple toilets on the [NAME] wing were not flushing properly. Water was also coming through the floor drains in the kitchen both near the dish machine and near the pot sinks. c) Maintenance called in an outside contractor to troubleshoot the issue. Vendor arrived at approximately 5:00 PM and began to snake the pipes throughout the facility. d) The Administrator briefed the FSD on the current state of the kitchen and requested that they touch base with their team and with the RN Supervisor on duty to determine the risk with utilizing the kitchen until the issue was resolved. It was determined that it was safe to continue with the current meal but to serve on paper dishes to save on running water and to utilize bottled water if necessary. e) Dietary was given the option to move prep tables to an area without water on the floor, but it was determined that staff could continue in place. f) Maintenance utilized a shop vac to continuously remove water from the kitchen. g) The Director of Maintenance (DOM) arrived at the facility at approximately 5:00 AM (7/24/23) and standing water was found in the kitchen. The DOM used a submersion pump to remove standing water in the kitchen so the breakfast meal could be prepared. Record review on 10/12/23 at 2:51 PM revealed facility vendor invoices which included the following: a) A vendor invoice dated 7/21/23 which included in the work done description: 'Snaked line for floor drains and grease trap from floor drain near grease trap. Line was plugged approximately 45 feet out.' b) A vendor invoice dated 7/23/23 which included in the job description: '2nd floor drains are blocked.' c) A vendor invoice dated 7/24/23 which included in the work done description: 'snaked 130 feet from clean out in kitchen to pump station then 30 feet to maintenance garage in to building.' During an interview on 10/13/23 at 8:57 AM, the Administrator stated the following: a) On a Friday a couple days before the water backup issue, the grease traps had been serviced. They have their kitchen grease traps serviced regularly, but because of the shape of them they have had them back up in the last few years. b) On a Sunday in July, they received a phone call from the facility and was told that some toilets were backing up on the [NAME] Unit and that maintenance was able to snake the drains which worked for a while but then they needed a vendor. c) In the kitchen the water was coming up from the drains near where the cooking equipment is, so maintenance didn't leave the area and they were using a shop vac and mopping to keep up with the water. d) When the surveyor asked who deemed food service was safe to continue, the Administrator replied that they assumed the FSD talked with their staff about comfortableness of cooking in the kitchen with water and maintenance said it was fine because they were in there cleaning. e) The incident was not reported to NYSDOH because the facility never lost any services. On 10/13/23 at 9:27 AM the surveyor asked the FSD to show them the grease traps in the kitchen. The FSD pointed to a metal cover in the floor near the dish machine and another metal cover in the floor underneath the handwash sink next to the three-bay sink. A circular drain approximately six-inches in diameter was observed to be located directly in front of the three-bay sink. Further observations included that the main cook line was approximately five feet from the circular drain and included, but was not limited to, an oven, a tilt skillet, a range, and a prep table. In an interview at this time, the FSD stated that the water on the floor during the flood came up from this circular drain. During a telephone interview on 10/13/23 at 12:30 PM, the Regional Registered Nurse (RRN) stated that they were certified in infection prevention. The RRN also stated that if there was standing sewage water, they would expect staff to notify the supervisor immediately and if it happened during meal service or prep, they would have to stop service and go into their emergency plan at that time. The RRN further stated that they would defer to a professional as to whether drains backing up onto the floor would be considered sewage and that when they hear the word sewage, they think of urine and feces. 10NYCRR: 415.14(h); 10NYCRR: Subparts 14-1.10(c)(3), 14-1.140(a), 14-1.200(a)

Based on observations, interviews, and record reviews conducted during the Recertification Survey and complaint investigation (NY 512) completed on 11/2/22, it was determined that for one (Empire) of three residential care units reviewed and one (Resident #27) of three residents reviewed for accidents, the facility did not ensure that the resident environment remained free of accident hazards. Specifically, hot water temperatures exceeding 120 degrees ( ) Fahrenheit (F) were accessible to residents at point of use. Additionally, Resident #27 was observed with unlabeled and unsupervised medications at the resident's bedside. This is evidenced by the following: 1. Observations, interviews, and record reviews on 10/27/22 from 10:33 a.m. to 5:15 p.m. included the following: a. Water temperatures observed in the Empire Unit using a ThermoWorks Thermapen One digital thermometer: 129 F from the handwash sink in bathroom in resident room #230, 130 F from the handwash sink in the shower room next to room #235, 122 F from the shower head in the shower room next to #235. The following water temperatures were observed from handwash sinks in the Empire Unit using a ThermoWorks Super-Fast Thermapen digital thermometer: 129 F in resident room #231, 129 F in resident room #232, 130 F in resident room #234, and 129 F in resident room #235. Each temperature was obtained after running each fixture for 10-15 seconds. b. The surveyor verified that the ThermoWorks Thermapen One digital thermometer and ThermoWorks Super-Fast Thermapen were accurate using the ice-point method. Both thermometers read 32 F after being placed in a cup of ice water. The facilities digital thermometer read 25.8 F after being placed in the same cup of ice water, indicating the thermometer was not calibrated. c. During an interview, Certified Nursing Assistant (CNA) #1 stated that there are several residents on the Empire Unit that wander into other resident's bedrooms and bathrooms. CNA#1 stated that the hot water on Empire Unit comes out scalding and they need mix hot and cold water together in the bathroom. d. During an interview, Licensed Practical Nurse (LPN) #1 stated that there are several residents who wander on the Empire Unit, and they have seen them wander into others' bathrooms. e. During an interview, the Director of Nursing (DON) stated that there are 39 residents on the Empire Unit and several who wander. f. When interviewed, the Empire Unit Nurse Manager (NM) stated that several residents on the Unit wander and some of them, who have dementia go into other resident's rooms. The NM further stated that of the 39 residents on the Empire Unit, approximately 15 of them are capable of using handwash sinks independently. g. The two hot water tanks supplying the Empire Unit and located in the mechanical room in the service wing had two in-line thermometers that displayed 150 F and 138 F. During an interview at this time, the Assistant Director of Maintenance (ADOM) stated that the Empire Unit hot water system is served by a different set of boilers than the other units. The ADOM stated that the hot water tanks for the Empire Unit were currently set at 130 F. The ADOM stated they reduced the temperature setting for the two hot water tanks to 120 F (after surveyor intervention). The ADOM stated that they didn't know much about the hot water system for the building and was not sure if there was anyone working in the building who does. h. The ADOM provided the surveyor with a Room Water Temperatures log which included documented hot water temperatures on four days for the month of October 2022 in eight resident rooms that all ranged from 119 F -120 F. When interviewed at the time, the ADOM stated that the temperatures in the log were probably off just like their thermometer was. The ADOM further stated that they had not calibrated their thermometer since they got it in the beginning of the month. i. During an observation in resident room #247 hand wash sink, the water temperature was 130 F using a ThermoWorks Thermapen One digital thermometer: When interviewed at the time, Resident #107 stated that they have seen other residents wander into their bathroom. j. Review of the Daily Domestic Hot Water Testing policy and procedure provided by the Administrator included that the purpose of this policy was to outline the daily testing of the domestic water supply to ensure it is regulated within 90-120 F. Further review included the thermometers should be checked for calibration using the ice water bath method which stated that if the thermometer does not read between 30 and 34 F adjust to 32 F. 2. Resident #27 was admitted to the facility on [DATE], with diagnoses of cerebral infarction (stroke), diabetes, and [CONDITION(S)] (GERD). The Minimum Data Set Assessment, dated 8/10/22, included that the resident was cognitively intact. Review of the facility's Administration of Medications - General, policy, dated May 2022, included medications are not to be left unattended. The current Comprehensive Care Plan did not include that Resident #27 had been assessed or care planned for self-administration of any medications. Current physician orders included, but not limited to, Senna 8.6 milligrams (mg)-2 tablets at bedtime for constipation, 30 milliliters (mls) of Maalox suspension every six hours as needed for indigestion, and acetaminophen 1,000 mg every 24 hours as needed for pain. There was no order for Resident #27 to self-administer medications. During an observation on 10/27/22 at 11:21 a.m., several medications in separate stacked medication cups for a total of 15 tables (both white and brown) were on Resident #27's bedside tray table. Resident #27 reported that they received the pills from the nurse and had forgotten to take them all. In addition, a medication cup, approximately 75% full, contained a white liquid. Resident #27 stated that it was Maalox. During an interview on 10/27/22 at 10:41 a.m., CNA #1 stated that several residents on the unit wandered into other residents' rooms. During an interview on 10/27/22 at 11:35 a.m., LPN #2 revealed that there were no residents on the unit that were allowed to self-administer medications. LPN #2 stated that they know Resident #27 likes to hang on to medicine cups with medications in them and that they (LPN #2) make sure Resident #27 takes their medications when administered but could not speak for the night shift staff. LPN #2 stated that Resident #27 will keep the medications if they were not ready to take them and then sometimes forget to take them. In a nursing progress note, dated 10/28/22 at 2:56 p.m., the Nurse Manager (Empire Unit) documented that Resident #27 does not self-administer their medications, and that the medications found in the resident's room (by the surveyor) were Senna that had been ordered for bedtime. Review of the medication administration record for October 2022, revealed that Resident #27's Senna was documented as administered daily except for three occasions documented as refused. Maalox was documented as administered on two occasions and acetaminophen on one occasion dated 10/1/22 (26 days prior to the observation). During an interview on 11/2/22 at 9:49 a.m., the NM stated that when administering medications to residents, the nurse should ensure the residents take the medication completely before leaving the room and to retain the medication and document if a resident refuses. 10NYCRR: 415.12(h)(1), 415.29, 415.29(a), 415.29(f)(6) 10 NYCRR 415.12(h)(2)

Based on observations, interviews and record review conducted during the Recertification Survey, completed on 11/2/22, it was determined that for two (Resident #81 and #220) of two residents reviewed for tube feedings (TF), the facility did not provide appropriate treatment and services to prevent potential complications. Specifically, there was no process for tracking and monitoring the daily total intakes of TF for either resident to ensure the resident's nutritional needs were being met. This is evidenced by the following: The facility policy Gastrostomy Tube Feeding, dated April 2022 directed that when an intermittent feeding was completed to document administration in the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 1.Resident # 81 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Assessment, dated 9/22/22, revealed the resident was severely impaired cognitively and that a feeding tube provided nutrition with total calories of 51% or more and average fluid intake of 501 milliliters (mls.) or more per day via the feeding tube. Review of the Current Comprehensive Care plan (CCP) included the resident had a potential risk for altered nutrition, required a feeding tube due to dysphagia and was dependent on staff for nutrition and hydration. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . per hour for 24 hours, increased to 60 mls per hour on 10/11/22 and increased to 65 mls. per hour on 10/21/22. TF water flushes were ordered for 220 mls. every four hours. Review of the MAR for 10/1/22 through 10/20/22 revealed a daily check mark that indicated that TF were administered as ordered but no daily amounts were documented. On 10/21/22 there was no documentation that any tube feeding was administered and from 10/22/22 through 10/31/22, the amounts were documented as N/A on 10/22/22 and ranged from 65 mls to 1560 mls for the daily total amounts 10/23/22 through 10/31/22. Review of Resident #81's weights in the Electronic Medical Record (EMR) revealed the following: 9/26/22= 217 pounds (lbs.), 10/7/22=211.7 lbs., 10/25/22=207.3 lbs. (4.4% weight loss in one month), and on 10/27/22 a re-weigh =210 lbs. In dietary progress notes 10/7/22 through 10/28/22, the Registered Dietitian (RD) documented that Resident #81 had lost weight and was put on a weight gain program, which included increasing the tube feedings provided. The RD note included that the RD had reviewed the tube feed pump history with the nurse manager but was unable to find any daily TF totals in the TF pump history. 2.Resident #220 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment, dated 10/19/22, revealed the resident was severely impaired cognitively, received 51% or more of total calories and an average fluid intake of 501 mls. or more per day via a feeding tube. Review of the current CCP included that Resident #220 had a potential risk for altered nutrition, was NPO, required a feeding tube due to dysphagia, and was dependent on staff for TF and flushes. Interventions included, but not limited to, to monitor and document intake per facility policy. Observations on 10/28/22 at 3:06 p.m., and again on 10/31/22 at 10:44 a.m., Resident #220 was self-propelling their wheelchair. The TF pump was not attached to any feedings or flushes. Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . six times a day and 60 mls. water flushes before and after medication administration every shift for a total volume of 2400 mls. daily. In a dietary progress note, dated 10/28/22, the RD documented a previous weight of 120.8 lbs., then 100 lbs. and then 94lbs. and requested a reweigh due to unrealistic weights which resulted in 108.6 lbs. The RD recommended Diabetisource AC 1440mls. to be run continuously at 120mls. for approximately 12 hours, 150mls. four times a day and 60mls. water flushes before and after medications in order to give the resident time off of the tube feeding pump. Review of the October MARS revealed daily check marks that tube feedings were required but daily amounts were not consistently documented. During an interview on 11/2/22 at 10:00 a.m. and again at 11:50 a.m., the Licensed Practical (LPN)/Nurse Manager (NM) stated they while the RD had previously instructed them how to review the pump history for totals, nursing did not monitor the daily total intakes for residents receiving tube feedings to ensure it was provided as ordered. The LPN/NM stated they thought the RD monitored the daily total intakes. During an interview on 11/2/22 at 10:53 a.m., the RD stated nursing should be recording the total volume infused per shift and that they (the RD) had recommended to NM that they should review the pump history daily for daily totals, and especially if the resident has had weight loss. During an interview on 11/2/22 at 11:02 a.m., the Director of Nursing (DON) stated nursing should monitor daily intake totals. The DON stated nursing documents on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 10 NYCRR 415.12(g)(2)

Based on interviews and record reviews conducted during the Recertification Survey, completed on 11/2/22, it was determined that for one (Resident #54) of five residents reviewed the facility did not ensure that the attending physician documented that the Medication Regimen Review (MRR) that was completed by the pharmacist was reviewed for irregularities/recommendations and action taken if any and/or a rationale if no action taken. Specifically, the pharmacist had consistently noted irregularities on the MRR reports related to a Gradual Dose Reduction (GDR) of an antipsychotic medication and recommendations for other medications and there was no evidence that the irregularities were addressed by the by the physician or the Director of Nursing (DON) per the regulations. This is evidenced by the following: The facility policy, 'Medication Regimen Reviews', effective November 2021, documented that any recommendations are acted upon and documented by the facility staff and/or the prescriber. The Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing. Resident #54 was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)] disorder, depression, and anxiety. The Minimum Data Set (MDS) assessment dated [DATE], documented that the resident was cognitively intact, did not have any behaviors for that period, and received daily antipsychotic, antidepressant, and antianxiety medications during the assessment period. The MDS also indicated that no Gradual Dose Reduction (GDR) of the antipsychotic medication had been attempted or that the physician had documented that a GDR of the medication would be contraindicated. Review of Pharmacy Review forms in the resident's Electronic Medical Record (EMR) from 5/10/22 - 10/14/22 documented that the MRR was completed with each form marked yes for irregularities and instructions to see these reports for the irregularities noted. There was no additional information on the form. The facility was unable to provide the pharmacy reports when requested. Review of the monthly Pharmacy Review reports emailed by the pharmacist (after surveyor request) revealed that there had been recommendations on each of six monthly reviews provided that included, but not limited to, request for a GDR of the antipsychotic medication and the antidepressant or a rationale why one would be contraindicated, and irregularities related to allergy medications, pain medication and a duplicate therapy for gastrointestinal reflux disease (GERD). During an interview on 11/1/22 at 12:52 p.m., and again on 11/2/22 at 8:40 a.m., the consulting pharmacist stated that they document in the resident's Electronic Medical Record (EMR) that the monthly medication review was completed and if there are any recommendations, then send them to the DON. The pharmacist stated that Resident #54 had a couple of irregularities mostly to do with GDRs of several medications. The pharmacist stated that although the resident has the diagnosis of [CONDITION(S)] disorder, a GDR must be recommended or a noted contraindication for a GDR. The pharmacist stated that they would expect to see documentation regarding the GDR being contraindicated but had not. When interviewed on 11/2/22 at 9:45 a.m., and again at 11:02 a.m., the DON stated that there was no evidence that the physician addressed any of the pharmacy recommendations for Resident #54. The DON stated that the MRR process included the pharmacist sending any recommendations via email to the DON who then gives them to either the Medical Director or the Nurse Practitioner and once the medical provider addresses the recommendation, the forms are returned to the DON. The DON stated they keep a copy of the original recommendations until they receive the addressed copy from the medical provider. The DON was unable to provide any of the requested forms for Resident #54. In a telephone interview on 11/2/22 at 11:37 a.m., and again at 12:04 p.m., the Medical Director stated that pharmacy completes the monthly medication reviews and when they receive the recommendations, they review the recommendations and make changes as needed. The Medical Director stated that they would have to work harder on following up on the GDR's and documenting. 10NYCRR415.18(c)(2)

Based on observations and interviews conducted during the Recertification Survey completed on 11/2/22, it was determined that for two (Empire and [NAME]) of three resident units, one of one service wing, and one of one basement, the facility did not provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, and homelike environment. Specifically, exhaust ventilation was not working, a water softener tank and circulating pump was leaking, soiled towels were present on a windowsill, and there was a leak in a water hose behind a washer. The findings are: 1. Observations in the presence of the Assistant Director of Maintenance (ADM) on 11/1/22 from 1:46 p.m. to 1:55 p.m. revealed that the mechanical exhaust ventilation was not drawing air through the ventilation ducts in the following locations on the [NAME] Unit: both shower rooms, the shared bathroom between resident rooms #12 and #14, in the shared bathroom between resident rooms #29 and #31, and in the soiled work room. When a sheet of paper was placed against the exhaust grates, there was no evidence that air was being pulled from the spaces. In an interview at this time, the ADM stated that they did not think the ventilation was working. 2. Observations on 10/27/22 from 9:49 a.m. to 10:15 a.m. included: a) Standing water was present on the floor of the mechanical room in the service wing. In an interview at this time, the ADM stated that the water was coming from a leaking water softener tank that it has been leaking for about three weeks and they can't figure out why. b) Water was leaking from a cold-water hose behind the new washer in the laundry room in the service wing. c) Two soiled towels were present on the windowsill in resident room #225 (Empire). In an interview at the time, Resident #28 stated that their window leaks. 3. In an interview on 11/2/22 at 10:48 a.m. the ADM stated that they could not figure out the issue with the exhaust ventilation, so they contacted a vendor who is coming in later that day. 4) On 11/2/22 at 11:06 a.m. it was observed that a pipe in the basement boiler room was leaking water into a garbage can that was partially full of brown colored liquid. In an interview at this time, the ADM stated that the leak appeared to be coming from a circulating pump. 10NYCRR: 415.29, 415.29(c), 415.29(h)(1), 415.29(i)(1,2), 415.29 (j)(1)

Based on observations, interviews, and record reviews conducted during the Recertification Survey, completed on 11/2/22, it was determined that for one (Resident #22) of one resident reviewed for restraints and one (Resident #117) of one resident reviewed for a discharge from the facility, the facility did not accurately code the Minimum Data Set (MDS) Assessment to reflect the resident's status. Specifically, for Resident #22, the MDS Assessment did not accurately reflect the use of a restraint, and that the resident was on an antipsychotic and antidepressant medication. For Resident #117, the MDS Assessment did not accurately reflect the resident's discharge disposition. This is evidenced by the following: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, Version 3.0, and published by the Centers for Medicare & Medicaid Services (CMS) includes that its purpose is to provide guidance on gathering information about the resident to assess and develop individualized care plans and help provide appropriate care. The Minimum Data Set Assessment (one components of the RAI) is a core set of screening, clinical and functional status elements which forms the foundation of a comprehensive assessment for all residents and assists in gathering information of a resident's strengths and needs and must be addressed in the resident's individualized care plan. The facility policy MDS-Resident Assessments dated November 2021 directed that the assessment must accurately reflect the resident's status at the time of assessment. 1.Resident #22 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment, dated 8/12/22, revealed the resident was severely impaired cognitively, utilized the use of a restraint (identified in the MDS manual as physical or mechanical device, material or equipment attached or adjacent to the resident's body which restricts freedom of movement or normal access to one's body) and that the resident received an antipsychotic and an antidepressant medication daily in the prior seven days (look back period for the MDS Assessment information.) Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no information provided as to when the resident had been on any antidepressant medication. Review of the August 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During observations of Resident #22 on 10/28/22 at 3:08 p.m., 10/31/22 at 10 a.m. and 12:06 p.m. there were no restraints attached to or adjacent to the resident's person observed. The resident did have a perimeter mattress (curved mattress to prevent the resident from rolling out of bed). During an interview on 10/31/22 at 3:09 p.m. the Registered Nurse (RN)/MDS Coordinator stated that after review of the MDS Manual, the perimeter mattress should not have been coded as a restraint but was to prevent the resident from rolling out of bed. The RN/ MDS coordinator stated that Resident #22 was not on an antipsychotic or antidepressant at the time of the MDS Assessment and that a MDS correction would need to be done. 2. Resident #117 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Discharge MDS Assessment, dated 9/2/22, revealed the Resident #117 had been discharged to an acute hospital. Review of progress notes, dated 8/31/22, revealed that Resident #117 had actually been discharged to another nursing home. During an interview on 11/2/22 at 9:55 a.m., the RN/MDS Coordinator stated that Resident #117 had been discharged to another nursing home, that the acute hospital had mistakenly been chosen and that they would have to file a correction. 10NYCRR 415.11(b)

Based on interviews and record review conducted during a Recertification Survey, completed on 11/2/22, it was determined that for one (Resdient #22) of five residents reviewed the facility did not review and revise the resident's care plan to reflect the resident's current status. Specifically, Resident #22's Comprehensive Care Plan (CCP) was not revised to reflect the discontinued use of an antipsychotic medications. This was evidenced by: The facility policy Comprehensive Care Planning, dated 12/5/21, included the interdisciplinary team will review and revise the care plan quarterly following MDS completion, with a significant change, return following hospital admission, annually, and as needed. The CCP will be kept current by all disciplines on an ongoing basis. Disciplines will be responsible for updating their respective care plans on a continual basis. Resident #22 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Assessment, dated 8/12/22, revealed that Resident #22 was severely impaired cognitively, and had received an antipsychotic medication daily for the seven days in the MDS Assessment look back period. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Comprehensive Care Plan (CCP), dated initiated 9/14/21 and revised 10/28/22, revealed that Resident #22 was (as of 10/28/22) receiving an antipsychotic medication with goals and multiple interventions listed, including to monitor for antipsychotic medication side effects. During an interview on 11/2/22 at 10:30 a.m., the Assistant Director of Nursing (ADON) stated the unit managers should bring any medication changes to morning report and they or the Director of Nursing (DON) would update the care plan. During an interview on 11/2/22 at 11:02 a.m., the DON stated they, the ADON or nurse managers should update the CCP. The DON stated as soon as orders are received to discontinue a medication the CCP should be reviewed and revised. 10NYCRR 415.11(c)(2)(iii)

Based on observations, interviews and record review conducted during a Recertification Survey completed 11/2/22 it was determined that for one (Resident #86) of one resident reviewed, the facility did not provide an ongoing program of activities based on the comprehensive assessment, the comprehensive care plan (CCP) and the preferences of each resident in order to support the resident in their choice of activities and to support the physical, mental, and psychosocial well-being of each resident. Specifically, the facility could not provide evidence Resident #86 was provided activities based on their preferences and needs. This is evidenced by the following: The facility policy Activity Programs, dated 3/22/22, included activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident. Activities are offered based on the comprehensive resident-centered assessment of each resident, are offered seven days a week and are documented in the medical record. The activity portion of the CCP is maintained by the Activity Department. Resident #86 was admitted to the facility 9/14/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Assessment, dated 9/26/22, revealed the resident had moderately impaired cognitive function and had little interest or pleasure in doing things. The MDS included activities that were somewhat important to the resident were having reading materials, keeping up with news, being around animals and doing their favorite activities. The Admission Activity assessment dated [DATE] included the activities of importance listed were the same as listed on the MDS Assessment. Questions left blank on the form included asking the resident what helps them feel better when upset, reading material preferences, hobbies and/or other activities. The brief care plan summary part of the assessment was blank. The current CCP identified that Resident #86 had a mood problem related to anxiety and depression (related to a death in their family). The CCP did not address any resident activity preferences, goals, or interventions that may assist with their anxiety or depression. A review of activity logs from 9/30/22 through 10/31/22 revealed the resident received a total of five 1:1 visits (no information regarding who did the visits or why) and no other activities for the month. Observations throughout the day shifts on 10/27/22 and 10/28/22 revealed Resident #86 in their room in bed with lights out and the shades drawn. When interviewed at the time, Resident #86 stated they were concerned about their depression. When interviewed on 11/1/22 at 11:22 a.m. the Activity Director (AD) stated that they completed the Admission Activity Assessment, the activity section of the MDS Assessment and the CCP plan for new admissions. The AD stated an activity care plan for this resident would be important especially with the resident's depression and recent losses but that they had not developed a CCP for activities. The AD said that all questions should have been answered on the Admission Activity Assessment. The AD said that some of the visits are usually just stopping by to check in with the resident. 10NYCRR415.11 (f)(1)

Based on observations, interviews and record review conducted during a Recertification Survey, completed on 11/2/22, it was determined that for one (Resident #92) of two residents reviewed for pressure ulcers, the facility did not ensure that the resident received care consistent with professional standards of practice, and that the resident received the necessary treatment to promote healing of a pressure ulcer, prevent infection and prevent new ulcers from developing. Specifically, the facility did not administer treatments as ordered by the medical team. This was evidenced by the following: Review of the facility policy 'PRESSURE INJURY PREVENTION & MANAGEMENT WOUND ROUNDS' dated December 2021, revealed that the nurse is responsible for the following when a pressure ulcer is identified: To administer the treatment as ordered. Resident #92 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set Assessment, dated 9/3/22, documented that the resident was moderately impaired cognitively and had an unstageable pressure ulcer. The Comprehensive Care Plan dated 6/21/22 documented that Resident #92 had an actual alteration in skin related to a pressure ulcer acquired while in the hospital with a goal that the ulcer will show signs of healing as evidenced per weekly would clinic visits. Current Physician orders for wound care, dated 9/23/22 included to clean the wound with soap and water, pat dry, apply double layer of alginate M (a material used for wound healing to absorb excess drainage) to the wound bed and cover with a dry foam dressing twice daily and as needed. In addition, staff were to apply an antifungal ointment to the surrounding skin twice daily and to check the sacrum dressing for placement every shift (three times a day) and to replace as needed (i.e., soiled or loose) Review of the wound care 'CONSULATION REPORT', dated 10/20/22 revealed the wound measurements for the sacral pressure ulcer were 2.8 centimeters (cm) by 2 cm x 0.2 cm for length by width by depth respectively and to continue the same orders. Review of the wound care 'CONSULATION REPORT', dated 10/27/22 revealed the measurements for the sacral pressure ulcer 4cm by 1 cm by 0.1cm four cm length by width by depth respectively. The report included that the wound was larger than the last measurements and instructions to staff to change Resident #92 briefs more frequently. During observation of wound care on 11/2/22 at 9:06 a.m., the resident's old dressing was loose due to the resident's incontinence (loss of bladder and/or bowel). The Licensed Practical Nurse (LPN)/ Nurse Manager (NM) removed the soiled dressing and applied a clean dressing per physician orders. Review of the Treatment Administration Records (TAR), from 9/23/22 through 10/31/22 revealed that there was no documentation that the dressing changes to the pressure ulcer were completed on 14 of 78 opportunities, no antifungal ointment applied to the surrounding skin on 20 of 78 opportunities and no documentation that the dressing had been checked for placement or integrity (wet or soiled) on 26 of 117 opportunities. During an interview on 11/2/22 at 8:40 a.m. the Director on Nursing (DON) stated that if there is no signature to verify completion on the TAR, it means that the service was not performed. The DON stated that the nurse managers are responsible for checking that the TAR is filled out appropriately. During an interview on 11/02/22 at 9:12 a.m. the LPN/NM stated that they look at the TAR to make sure the dressing is being done per order. When reviewed with the surveyor, the LPN stated that the missing documentation was not acceptable but due to being so busy they had fallen behind. 10NYCRR 415.12(c)(2)

ased on observations, interviews, and record review conducted during the Recertification Survey completed on 11/2/22, it was determined that for one (Resident #220) of one resident reviewed for bowel and bladder incontinence, the facility did not ensure that the resident who required [CONDITION(S)], [MEDICATION(S)], or [CONDITION(S)] services, received such care consistent with professional standards of practice, the resident's comprehensive person-centered care plan and the resident's goals and preferences. Specifically, Resident #220's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #220 had a [CONDITION(S)]. This is evidenced by the following: Review of the facility's [CONDITION(S)], [CONDITION(S)], [MEDICATION(S)] Care, policy, dated March 2011 revealed that an ostomy pouch (bag covering an opening in the abdomen that collects urine or fecal drainage) may be worn from one to seven days, and is usually emptied every four to six hours. The policy included that skin and stoma (the opening in the abdomen) care should be performed each time a pouch is changed, and that documentation should include the date and time of the [CONDITION(S)] care, the condition of the stoma and surrounding skin, and the color, amount, type, and consistency of the drainage. Resident #220 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set Assessment, dated 10/19/22, included that Resident #220 was moderately impaired cognitively, and had an ostomy appliance. In the medical Admission History and Physical, dated 10/13/22, the Nurse Practitioner, documented that Resident #220 had a diverting [CONDITION(S)]. In an observation on 10/31/22 at 10:44 p.m., Resident #220 was up and self-propelling in their wheelchair. The resident was not interviewable at the time. Review of current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current CCP and the Certified Nursing Assistant (CNA) Kardex (care plan used by the CNAs for daily care) revealed a care plan for urine incontinence but no evidence of any plan of care to address Resident #220's [CONDITION(S)] or bowel needs. During an interview on 11/2/22 at 9:48 a.m., the CNA stated that they would know if a resident had a [CONDITION(S)] because the information should be located on the resident's Kardex and care plan. The CNA stated that Resident #220 had a [CONDITION(S)] and that they would clean the resident up if the [CONDITION(S)] blows up. During an interview on 11/2/11 at 10:00 a.m., the Licensed Practical Nurse (LPN)/ Nurse Manager (NM) stated that ostomy care by the nurse consisted of changing the wafer which was a standard appliance in the facility that consisted of a wafer that is cut to fit the resident's stoma. The LPN/NM stated that there should be physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . After review of Resident #220's current orders with the surveyor, the LPN/NM said that were no orders for the resident's [CONDITION(S)] care and no treatments documented on the TAR. The LPN/NM stated the nurse may not be aware that the resident had a [CONDITION(S)] unless they were informed by another staff member. During an interview on 11/2/22 at 11:02 a.m., the Director of Nursing (DON) stated that CCPs were developed by the Assistant Director of Nursing and the DON. The DON stated that there should be physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 10NYCRR 415.12(k)(1)

Based on observations, interviews and record reviews conducted during the Recertification Survey completed on 11/2/22, it was determined that for one (Resident #54) of five residents reviewed for unnecessary medications, the facility did not ensure that each resident's drug regime was free from unnecessary medications. Specifically, Resident #54 was prescribed an anti-psychotic medication without evidence of implementation of resident specific non-pharmacological interventions, and without evidence that a Gradual Dose Reduction (GDR) of the medication had been attempted or documentation of a clinical contraindication for a GDR. Additionally, current physician documentation did not accurately reflect the resident's currently prescribed medications. This is evidenced by the following: The facility policy, '[CONDITION(S)] Medications, Unnecessary Use', dated 10/24/22, included orders for [CONDITION(S)] medications are used only for the treatment of specific medical and /or psychiatric conditions or when the medication(s) meet the need of the resident to alleviate significant distress for the resident not met by the use of non-psychopharmacological approaches. Medical documents rationale with adequate indications for use and diagnosis for use of the medication and identify target symptoms/diagnosed condition for which the medication is prescribed. In collaboration with psychiatry services, attempts a gradual GDR decrease or discontinuation of [CONDITION(S)] medications per policy. GDR should occur in modest increments over adequate periods to minimize withdrawal symptoms and monitor symptom recurrence. GDR should be attempted within the first year of admission on a [CONDITION(S)] medication in two separate quarters with at least a month in between. Clinical judgement is still relevant in resident-specific GDR decision making; contraindications are still reasonable exemptions. If a GDR is contraindicated, the clinical rationale should be documented. Resident #54 was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)] disorder, major depressive disorder, and anxiety. The Minimum Data Set (MDS) assessment dated [DATE], indicated the resident was cognitively intact, did not have any behaviors for that time period, and received antipsychotic, antidepressant, and antianxiety medications (all [CONDITION(S)] medications) during the assessment period. The MDS included that no GDR had been attempted for the antipsychotic medication and that the physician had not documented that a GDR was contraindicated (as per the regulations). The hospital Physician Handoff Report dated 10/30/20, included [MEDICATION(S)] (anti-psychotic medication) and no additional medications ordered for behaviors. The current physician orders included [MEDICATION(S)] Sprinkles (anti-convulsant medication often used to treat manic episodes in people with [CONDITION(S)] disease) 125mg twice daily for behaviors with a start date of 8/4/21 and [MEDICATION(S)] (anti-psychotic medication) 5mg daily for behaviors with a start date of 8/4/21. The physician orders did not include a rationale with adequate indications for use and diagnosis for use for each of the medications. The current Comprehensive Care Plan (CCP) for [CONDITION(S)] medications included to administer medications as ordered, monitor for side effects and effectiveness every shift, and to monitor and record behaviors. The CCP did not include the target behaviors, any plan for a GDR of any of the medications (including the antipsychotic), or any clinical contraindications for a GDR. The CCP included that the resident had a history of reporting/describing inaccurate and/or false events (i.e., reports that staff members have not visited or assessed them when in fact they had), and that Resident #54 had manipulative behaviors. There were no interventions regarding resident specific non-pharmacological interventions. The current Kardex (used by Certified Nursing Assistants (CNA) to guide daily care) did not include any behaviors or resident specific interventions if there were any. The 5/23/22 medical provider note included that the resident was seen for a medication drug reduction visit. The note did not address the resident's psychiatric condition, behaviors, or symptoms. There was no mention of a GDR for any of the resident's medications nor was a clinical contraindication documented. The 10/25/22 medical Annual Health and Physical (H&P) note did not address the use of [CONDITION(S)] medication, any attempted GDR, or clinical contraindication. Additionally, under the psychiatric heading, the note only listed that the resident was alert and oriented. There was no mention of continued behaviors or symptoms. Both the 5/23/22 Medical provider note and the 10/25/22 Annual H&P note included that the resident was prescribed [MEDICATION(S)] (anti-anxiety medication) and [MEDICATION(S)] 5mg daily as needed (in addition to the daily dose) but did not include that the resident was on [MEDICATION(S)] sprinkles. A review of discontinued medications in Resident #54's Electronic Medical Record (EMR) revealed that the [MEDICATION(S)] order had been discontinued on 3/8/22 and the [MEDICATION(S)] (the as needed dose) order had been discontinued on 8/31/21. A review of documentation in the EMR from 4/1/22 to present did not reveal evidence of the resident having any behavioral disturbances. When observed and interviewed on 10/28/22 at 9:27 a.m., the resident was seated in the common area in their wheelchair reading a paperback book. During an interview on 11/02/22 at 8:40 a.m., the Pharmacist stated that they had made recommendations regarding a GDR of the antipsychotic medications. The Pharmacist stated that although the resident had a specific diagnosis, a GDR or documentation regarding contraindication was required. When interviewed on 11/01/22 12:41 p.m., Social Worker (SW)#1 stated that they had been working with Resident #54 since their admission and that the resident had been very stable for the past 3 to 6 months. SW#1 stated that the resident used to become very upset, and cry hysterically and not know what was upsetting them and previously had some difficulty sharing staff and space with their roommate. SW#1 stated that at times Resident #54 would attempt to leave. After review of the resident's CCP with the surveyor, SW #1 said that if a resident is having behaviors nursing should document this in behavioral notes in the EMR. SW#1 said that they could find nothing in the CCP specifically about such behaviors. SW#1 stated that the resident received outside mental health services. Social Worker #1stated that they were not involved in medications or GDRs and that nursing was responsible for managing the CCP. When interviewed on 11/01/22 at 12:58 p.m., CNA#1 stated that Resident #54 used to cry and yell at staff if they did not get their way but had never seen the resident get physical with anyone and has not seen any behaviors in a while. During an interview on 11/01/22 at 1:13 p.m., Nurse Manager (NM) #1 stated that Resident #54 does not have behaviors until they do not get their way then they will become verbally abusive to staff, threaten and try to leave. NM#1 stated that when the resident was admitted there were issues adjusting. NM#1 stated that often the resident will calm down if taken to their room and that reading and going to activities helps. NM#1 stated that Resident #54 should have a behavioral care plan and that it should carry over to the Kardex for aides to use. NM#1 stated that nursing documents by exception meaning that if a behavior occurs that is when they would chart and stated that Resident #54 had not had any behaviors in a while. During a telephone interview on 11/02/22 at 11:37 a.m., the Physician (also the Medical Director) stated that [MEDICATION(S)] and [MEDICATION(S)] are usually prescribed for [CONDITION(S)] and/or [CONDITION(S)] and added that they believe the medications were ordered due to resident's diagnosis of [CONDITION(S)] disorder. The Physician stated that they usually have nursing link medication orders to a legitimate diagnosis and that they should have documented the diagnosis. The Physician stated that they try to attempt GDRs and review behaviors with the nurses and Behavioral Health Team. Regarding the incorrect documentation of medication in physician's notes, the Physician stated that they do try to keep medications in their notes updated but sometimes mistakes are made and they will need to do a better job at documentation of behaviors 10 NYCRR 415.12(1)(2)(ii)

Based on observations, interviews, and record review conducted during an Abbreviated Survey (Complaint #NY00292306, #NY00292598, #NY00298931, and #NY000302841), it was determined that for 4 (Resident #1, #3, #5, and #6) of 10 residents reviewed, the facility failed to protect each resident's right to be free from abuse that had the likelihood to result in physical harm, pain, or mental anguish. Specifically, the facility failed to thoroughly investigate multiple allegations of resident abuse by Licensed Practical Nurse (LPN) #1 between 2/5/22 and 9/25/22, to remove LPN #1 from direct care following allegations of resident abuse, complete investigations of abuse within five days, and failed to report allegations of abuse to law enforcement and the State Agency. Additionally, the facility was unable to provide documentation that all staff were educated regarding abuse, neglect, and mistreatment prohibition and reporting. This resulted in Immediate Jeopardy to resident health and safety and Substandard Quality of Care. This evidence is: The facility policy Abuse Investigating and Reporting, dated 5/25/21, included all reports of resident abuse including injuries of unknown source shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. The policy also included that the facility would immediately suspend any employee who has been accused of resident abuse pending the outcome of the investigation and ensure any further potential abuse is prevented. 1. Resident #3 had diagnoses that included bipolar disorder, psychotic disorder with delusions, and morbid obesity. The Minimum Data Set (MDS) Assessment, dated 1/27/22, documented that Resident #3 was cognitively intact. Review of the facility's Incident/Accident (I/A) Form, dated 2/25/22, revealed that at 4:45 a.m. Resident #3 was observed to fall to the floor. Review of Certified Nursing Assistant (CNA) #10 and CNA #11 statements revealed that LPN #1 walked Resident #3 towards the resident's own unit and left them there. Resident #3 was then taken by one of the unit CNAs to the nurses' station where they were observed to be upset and cursing. CNA #10 and CNA #11 were calming Resident #3 down when LPN #1 returned to the unit. Resident #3 became verbally aggressive towards LPN #1 and threw a necklace at LPN #1 who then fell on one of the beads. LPN #1 got up, grabbed Resident #3 and shoved Resident #3 to the floor. Resident #3's statement documented that LPN #1 demanded that they leave the unit and return to their own unit. Resident #3 stated that LPN #1 grabbed their walker and slammed them (Resident #3) to the ground. Review of the facility investigation conclusion, dated 2/25/22, revealed that CNA #5 documented they witnessed LPN #1 have a poor interaction with Resident #3 and LPN #1 then physically pushed Resident #3 causing them to fall. The facility concluded that the witness CNAs could not have visualized LPN #1 push Resident #3 to the floor based on review of video footage and reenactment of the incident due to the CNAs' location behind the nurses' station. Documentation included with the I/A form conclusion, dated 2/25/22, documented that the Director of Nursing (DON) provided education via a phone call to LPN #1 on dealing with resident's striking out and handling of future physically disruptive behaviors. The facility did not report the allegations of physical abuse to law enforcement or the New York State Department of Health (NYSDOH) and did not immediately remove LPN #1 from resident care upon the allegations of abuse. The incident was reported to NYSDOH by a third-party complainant. Additionally, the facility was unable to provide the video footage used in making the determination that abuse did not occur. During an interview on 9/27/22 at 12:45 p.m., Resident #3 stated they remembered the incident with LPN #1. Resident #3 stated LPN #1 confronted them and told them that they needed to go back to their unit. Resident #3 stated LPN #1 grabbed their arm and their walker and walked them (Resident #3) back to their room. Resident #3 stated LPN #1 threw them to the ground after they threw a necklace at LPN #1. The resident stated they did not feel safe in the facility because of LPN #1. During an interview on 9/30/22 at 3:40 p.m., the DON stated they or the Administrator were responsible for reporting alleged abuse to the NYSDOH and law enforcement. The DON stated they did not know why the incident with Resident #3 had not been reported or why LPN #1 was not suspended pending the investigation. The DON stated that the investigation had not been completed within 5 days and should have been. 2. Resident #5 had diagnoses including Alzheimer's disease, vascular dementia, and major depressive disorder. The MDS Assessment, dated 1/9/22, documented that Resident #5 was severely impaired of cognitive function. Review of the facility I/A Form, dated 3/6/22, revealed Resident #5 was seated in their wheelchair by the medication cart and was grabbing items off the cart. When LPN #1 asked Resident #5 to stop, Resident #5 began kicking several times. CNA #6 and CNA #7's statements documented that they witnessed Resident #5 kick LPN #1 and then LPN #1 kicked Resident #5's foot (left foot). CNA #6 and CNA #7 stated they then assisted Resident #5 back to their room. Resident#5 had stated their foot hurt and when CNA #6 removed Resident #5's sock, their big toe was bleeding, and the toenail was cracked. Resident #5 continued to state, [They] kicked me. LPN#1's statement included that they had held their leg out but that Resident #5 continued to kick several more times before being removed by staff. The interdisciplinary team review determined that abuse was ruled out. Review of the Investigation Summary, dated 4/5/22, revealed a further investigation into the 3/6/22 incident. CNA #6 and CNA #7 again stated they witnessed Resident #5 kick LPN #1 and then LPN #1 kicked Resident #5. The Investigation Summary documented that the incident would be reported to NYSDOH but did not include as to when and the form was not signed by the investigator, nor the facility Administrator. Facility follow up actions included: LPN #1 would be reeducated on how to effectively redirect residents with behaviors as well as documentation standards and would be counseled on how the situation should have been handled. Additionally, a house wide education for all staff on abuse regulations, reeducation on notification to administration, a communication process would be developed to keep all staff informed of outcomes of investigations, and all supervising staff would be educated on the components of a complete investigation. The facility was unable to provide documentation that any of these follow up actions were completed. The incident was not reported to law enforcement or the NYSDOH by the facility. NYSDOH was notified of the incident by a third-party complainant. LPN #1 was not removed from resident care following the allegation and pending investigation. During an interview on 9/28/22 at 8:33 a.m., CNA #6 stated that on 3/5/22 they observed Resident #5 approach LPN #1 and then they saw LPN #1 kick Resident #5. CNA #6 stated they removed the resident to their room and found blood on the resident's sock and the resident stated, That nurse kicked me. CNA #6 stated they reported the incident to a nursing supervisor from a different unit but was told that neither the Administrator nor the DON would do anything about it. CNA #6 stated they reported the incident to the DON who stated they were not going to report it to the NYSDOH. CNA #6 stated that when the DON and the Administrator found out that they (CNA #6) had reported the incident to the NYSDOH they took a statement from them. During an interview on 9/29/22 at 11:20 a.m., CNA # 7 stated they witnessed Resident #5 at the nurse's cart trying to get LPN #1's attention by kicking, but LPN #1 was on their phone. CNA #7 stated LPN #1 then raised their foot up and kicked Resident #5 in the foot. Resident #5 yelled out in pain stating, [They] kicked me. CNA #7 stated they and CNA #6 took Resident #5 to their room, took off the resident's sock because they could see blood on the toe of the sock and found a vertical crack in the big toenail. CNA #7 stated they are supposed to report incidents of abuse to the supervisor but the only supervisor on duty was LPN #1. CNA #7 stated during the investigation the DON and the Administrator repeatedly asked them the same questions about where LPN #1 was standing and where they were standing during the incident. During an interview on 9/30/22 at 3:40 p.m., the DON stated their corporate office took over the investigation and did not finish the investigation conclusion to state the reason why abuse was ruled out. The DON said that staff reported that Resident #5 had a broken toenail the day before the incident. The DON stated that LPN #1 was provided an in-service on abuse and neglect following the incident. The facility was unable to provide any documentation of an injury to Resident #5's toenail prior to the 3/6/22 incident. 3) Resident #1 diagnoses included suicidal ideations, vascular dementia, and agitation. The MDS Assessment, dated 8/29/22, revealed Resident #1 was moderately impaired of cognitive function and exhibited physical behaviors on one to three days in the prior seven days. Review of an I/A Form revealed that on 9/25/22 at 9:30 a.m. there was a physical altercation between Resident #1 and LPN #1. CNA #1 reported LPN #1 took Resident #1's right hand, held and squeezed it and said to the resident, You will never do that again. Resident #1 began to cry and said okay. Resident #1 then stated to CNA #1 that They took my wrist and broke it. Resident #1's statement included that It hurt like hell, and it hurts today too, but not as bad. I wouldn't trust [LPN #1] again. CNA #1's statement included they reported the incident to an off-duty Supervisor (LPN Supervisor #1) on 9/25/22. LPN Supervisor #1's statement included that they did not notify the Assistant Director of Nursing (ADON) or the Administrator until 9/26/22. LPN #1 was suspended on 9/26/22 and the NYSDOH was notified by the facility. The facility did not notify law enforcement. X-rays were completed and revealed no fracture to Resident #1's hand. Review of the investigative summary completed by the Regional DON, undated and unsigned, revealed that facility staff reported to administration on 9/26/22 at 3:15 p.m., that on 9/25/22 LPN #1 was observed grabbing the hands of Resident #1 in what appeared to be a rough manner and yelled at the resident. The facility suspended LPN #1 pending investigation, a Registered Nurse (RN) assessment of the resident was completed, and staff statements obtained. Based on the investigation the facility was not able to rule out abuse, neglect, mistreatment and or exploitation and reported the allegation to NYSDOH. During an interview on 9/27/22 at 2:33 p.m., CNA #1 stated that on 9/25/22 they heard LPN #1 yelling at Resident #1 and observed LPN #1 holding and squeezing Resident #1's hand and the resident called out. CNA #1 stated they called the off-duty Supervisor (LPN Supervisor #1) because LPN #1 (accused) was the acting supervisor for that shift. During an interview on 9/28/22 at 7:40 a.m., LPN Supervisor #1 stated the last time they had abuse/neglect training was last year. LPN Supervisor #1 stated they knew that when there is a resident-to-resident incident it needed to be reported to the NYSDOH, but they did not think that it translated to staff-to-resident altercations. LPN Supervisor #1 stated they had not been trained on the reporting requirements but now knows it is within two hours. LPN Supervisor #1 stated that LPN #1 would get stern, yell, and get defensive when residents were sundowning (a state of increased confusion/restlessness often seen in late afternoon/early evening), argue, or become combative but that they had never reported this to administration. 4. Resident #6 had diagnoses including spinal stenosis (narrowing of spinal column), anxiety, and depression. The MDS Assessment, dated 6/29/22, documented that Resident #6 was cognitively intact. During an interview on 9/27/22 at 12:00 p.m., Resident #6 stated that LPN #1 constantly instigated arguments with them and that they had witnessed LPN #1 abuse residents. Resident #6 stated while chatting with two other residents in one of their rooms, LPN #1 without permission pulled them out of the room by the wheelchair and pushed them into their own room and slammed the door. Resident #6 said the situation was scary. On a previous occasion, Resident #6 stated they also observed LPN #1 yell at a male resident that was grabbing things off the medication cart, grab the resident's arm and yell at the resident to sit down in a loud and angry tone. Resident #6 stated they and two other residents had a meeting with the Administrator and Social Worker (SW) #1 and explained all the things they had witnessed LPN #1 do, to themself and other residents, and staff did nothing about it. Resident #6 stated they called the police the day they left against medical advice because of the abuse at the facility, that they did not feel safe, and that they were afraid of LPN #1. The police did report to the facility and told Resident #6 they could leave the facility. The facility was unable to provide documented evidence a police report was filed. During an interview on 10/3/22 at 12:45 p.m., SW #1 stated that residents have brought concerns regarding LPN #1 to them. SW #1 said they would fill out an Interdisciplinary Disciplinary Team Communication Form for Concerns and gave the forms to the DON, or the Administrator if the DON was not in. SW #1 stated they were not provided training on the process of filling out the forms and did not follow up on the concerns or track them to ensure they were completed. SW #1 stated they were present during the meeting with Resident #6 and the other residents. SW #1 stated they filled out the grievance form and handed it to the DON. SW #1 stated that they were told that the DON met with each resident individually and they had retracted their statements and that the incidents did not happen the way they initially reported it. SW #1 stated they spent several hours with those residents compiling their complaints and they were strong in their conviction and recollection of the events and did not think they would retract their statements. During an interview on 9/27/22 at 1:16 p.m., the ADON/Staff Educator stated they started at the facility approximately a year and a half ago and they have not conducted any annual abuse trainings as of yet. During another interview on 9/27/22 at 3:14 p.m., the ADON stated any verbal, physical, sexual, or financial abuse is reportable. The ADON stated the decision to report to the NYSDOH was made by the DON, the Administrator, and themselves. The ADON stated if a staff person reported abuse, they would take statements from the staff witnesses and complete an I/A form. The ADON stated the facility had two hours to report the incident to the state and five days to complete the investigation. The ADON stated the resident should be assessed, social work staff notified, and the accused staff should be asked to leave the building to remove any immediate threat to the residents. During an interview on 9/27/22 at 4:07 p.m., the Administrator stated any incident involving abuse needed to be reported to the NYSDOH within 2 hours from when they were made aware of the allegation, and an I/A would immediately be started. The Administrator stated that the determination to notify NYSDOH is made by the DON and ADON. The Administrator stated they did not know why the incidents involving Residents #3 and #5 were not reported to NYSDOH or why LPN#1 had not been suspended pending completion of the investigation, but they should have been. The Administrator stated they were not made aware of the incident involving Resident #1 until 9/26/22 at 3:15 p.m. The Administrator stated they were unaware the investigation was incomplete and not completed within five days. The Administrator stated they just started educating staff on abuse and neglect reporting today. During an interview on 9/28/22 at 2:07 p.m. and again on 9/29/21 at 12:57 p.m., LPN Nurse Manager (NM) #1 stated they had several conversations with the DON regarding LPN #1's verbal and sometimes physical aggression with residents. LPN NM #1 stated that the DON told them they would take care of the concerns but had not. LPN NM #1 said they verbally counselled LPN #1 multiple times related to their demeanor and interactions with residents but did not document any of these counseling discussions. LPN Manager #1 stated they had never had formal training on abuse reporting and were not aware they could report directly to the NYSDOH. During an interview on 9/29/22 at 11:20 a.m., CNA #7 stated that LPN #1 would push residents around and drag them by the arms. CNA #7 stated that they reported these concerns to the DON and the Administrator, but nothing had been done. CNA #7 stated they were not aware they could also report incidents of abuse to the NYSDOH, but that they did report their concerns to the Attorney General's Office. During an interview on 9/30/22 at 9:08 a.m., LPN #1 recalled the incident on 3/6/22 and stated Resident #5 kicked the medication cart but they did not kick the resident. LPN #1 stated that on 9/25/22 they were speaking to Resident #1 about their inappropriate language towards another resident when Resident #1 grabbed them by the throat with their hand and they just moved Resident #1's hand away. LPN #1 stated they had not received any training on dealing with resident behaviors at the facility. During an interview on 9/30/22 at 2:22 p.m., the DON stated staff should report alleged abuse to the supervisor, remove the resident from danger, and remove the accused staff from the resident unit. The DON stated the facility had 2 hours to report alleged abuse to the NYSDOH and the police and had five days to complete an investigation into the allegation. The DON stated that when staff reported the 2/25/22 and 3/6/22 alleged abuse incidents, LPN #1 should have been removed from service and that the Administrator should have reported this to the NYSDOH but this was not done. Additionally, the DON stated that all three incidents should have been reported to the police by the Administrator but were not. Immediate Jeopardy (IJ) was identified and declared 9/30/22 and the facility Administrator was notified at 4:30 p.m. On 10/3/22 at 4:15 p.m., the survey team declared that the IJ was removed based on the following corrective actions taken by the facility: a. LPN #1's employment was terminated on 9/30/22. b. 90% of staff were in-serviced on Abuse Prevention, Abuse Reporting, Dementia training, Aggressive-Behavioral resident training and a plan to educate all other staff prior to working. c. Policies and Procedures will be reviewed and revised to include investigating, reporting, and prevention of Resident Abuse. d. Administrator, DON, Ombudsman, and NYS DOH contact information was posted in employee areas in the facility. 10 NYCRR 415.4(b)(1)(i)

Based on observations, interviews, and record reviews conducted during an Abbreviated Survey (complaint investigation #NY 101) completed on 8/25/22, it was determined that for two (main kitchen and satellite kitchen) of two kitchens, the facility did not prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, food temperatures were not taken to ensure potentially hazardous (PHS) foods/temperature controlled for safety (TCS) foods were served to residents at an appropriate temperature level to kill pathogenic microorganisms that may cause foodborne illness. Record review of the facility policy titled 'Meal Temperature Recording', dated 3/8/22, included the following: To ensure safety and quality of the food items, it is the policy of the facility to obtain and record temperatures of food items prior to serving to residents. During an interview on 8/23/22 at 9:05 a.m., the Certified Nursing Assistant (CNA) stated they are the primary care giver for Resident #4. The CNA stated they have seen some pictures on Resident #4's phone, including a hamburger with a pink center and a brown piece of chicken that was undercooked. During observations on 8/23/22 at 12:15 p.m. in the main kitchen, the facility food temperature logs were reviewed. The logs included that there were no food temperatures taken for the following dates and meal services: 8/1/22 dinner 8/2/22 dinner 8/3/22 dinner 8/4/22 dinner 8/5/22 dinner 8/6/22 breakfast, lunch, dinner 8/7/22 breakfast, lunch, dinner 8/8/22 dinner 8/10/22 breakfast, lunch, dinner 8/12/22 lunch and dinner 8/13/22 breakfast, lunch, dinner 8/14/22 dinner 8/15/22 dinner 8/16/22 lunch, dinner 8/17/22 breakfast, lunch, dinner 8/18/22 breakfast, lunch, dinner 8/19/22 breakfast, lunch, dinner 8/20/22 breakfast, lunch, dinner 8/21/22 breakfast, lunch, dinner 8/23/22 breakfast Further review of these food temperature logs revealed PHS/TCS menu items including, but not limited to, eggs, sausage, roast turkey, chicken, hamburgers, pot roast, and beef stew. In an interview on 8/23/22 at 11:40 a.m. the Kitchen Manager (KM) stated that they have told staff repeatedly to check the food temperatures prior to serving for every meal. Further interview with Cook A, at this time, included that they did not have time to check the food temperatures before breakfast because two staff called off and they were shorthanded. In an interview on 8/23/22 at 12:20 p.m. the KM stated the satellite kitchen is not taking food temperatures and they know they should. The KM stated they are looking for a new temperature log form because they do not like the log they use currently. When asked if the temperature logs are looked at every Monday when they come in, the KM stated they did not. When asked why they did not look over the temperature logs, the KM stated it was because they can't find good people to work. The KM stated they know they are supposed to temp the food before serving it to protect the residents from bacteria and illness but it's not possible every day, every meal. During an interview on 8/23/22 at 2:30 p.m. Resident #4 stated they understand that they are feeding a hundred people, but they should be able to serve better food than what is being served. Further observations of photos on the phone of Resident #4 included what appeared to be: burned meatloaf, burned hotdogs, hot dogs served on hamburger buns, extremely small portions, soup that barely filled the bottom of a coffee cup, a ham sandwich with a tiny piece of ham, and a tuna fish sandwich with a very small amount of tuna on it. 10NYCRR: Subpart 14-1.82, U.S. Food and Drug Administration's (FDA) Food Code, Centers for Disease Control and Prevention's (CDC) food safety guidance

Based on observation, interviews, and record review conducted during an Abbreviated Survey (#NY 256 and #NY 818), completed on 2/1/22, it was determined that the facility did not provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for one of one main kitchen. Specifically, food was not served at safe and appetizing temperatures. This is evidenced by the following: Review of the undated facility policy, Temperature Maintaining Equipment, included that hot and cold food temperatures will be maintained during meal service inside the Dietary Department, dining rooms and during transport to resident units. Hot foods must be maintained at minimum of 140 degrees (°) Fahrenheit (F) and cold food must be maintained at maximum of 41°F. Review of Resident Council meeting minutes, dated 1/5/22, revealed several residents stated concerns that their meals were not warm enough. The meeting minutes documented that the Administrator was present at the meeting and addressed the identified issues. The meeting minutes included that a dietary survey would be conducted. No dietary survey was provided to the surveyor. During observations on 1/31/22 of the lunch meal, the meal cart arrived on the [NAME] Unit at 12:09 p.m. At 1:08 p.m., staff were observed bringing the last meal tray on the cart to a resident's room. At 1:09 p.m., the following food temperatures were measured using both the Surveyor's [NAME] 9842 digital thermometer and a facility standard bimetallic thermometer (unknown brand). Both thermometers had been calibrated: a. Cheese quiche: 104°F on the Surveyor's thermometer and 103°F on the facility thermometer b. Mashed potatoes: 105.5°F on the Surveyor's thermometer and 104°F on the facility thermometer c. California vegetable mix: 100°F on both thermometers d. Custard: 64.5°F on the Surveyor's thermometer and 63°F on the facility thermometer e. Milk: 69.2°F on the Surveyor's thermometer and 68°F on the facility thermometer f. Coffee: 115.6°F on the surveyor's thermometer and 114°F on facility thermometer During an interview on 1/27/22 at 11:53 a.m., Resident #2 stated that the food was always cold. During an interview on 1/27/22 12:20 p.m., the Licensed Practical Nurse (LPN) stated that breakfast was sometimes cold, especially when the kitchen was short staffed. During an interview on 1/27/22 at 12:55 p.m., Resident #1 stated that the temperature of the food is often cold. During an interview 1/27/22 at 1:12 p.m., the LPN Nurse Manager stated that the food is room temperature. During an interview on 1/31/22 at 11:20 a.m., the Administrator stated that the kitchen manager unexpectedly quit a few days ago and they were in the process of developing a new plan to run the kitchen? The Administrator stated that the Registered Dietician was only in the facility twice weekly as a consultant and mostly for the clinical issues. During an interview on 1/31/22 at 12:45 p.m., the Dietetic Technician (DT) stated hot foods should be at 140°F and cold foods should be less than 40°F. The DT stated that the department had some work to do based on the temperatures obtained during the observed lunch meal. During an interview on 1/31/22 at 2:38 p.m., the office manager, currently assisting in the kitchen, stated that the previous director dropped the ball with training and that some of the food temperatures were a large concern. 10NYCRR 415.14(d)(1)(2)

Based on observations and interviews, during an Abbreviated Survey (#NY 256 and #NY 818), completed on 2/1/22, it was determined that for one of one main kitchen, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to store and hold cold foods properly and failed to maintain equipment, floors and surfaces in a sanitary condition. This is evidenced by the following: Review of the undated facility policy, Time and Temperature Control, directs that the temperatures of refrigerator food and storage areas should be checked regularly, and all equipment should have temperatures checks. Review of the undated facility policy, Food and Supply Storage, directs that coolers and freezers are to be thermostatically controlled and monitored for proper temperature control. Refrigerator temperatures should be maintained between 33-41 degrees (°) Fahrenheit (F). During operating hours temperatures are observed throughout the day. Any deviation from the temperature ranges must be reported immediately to the supervisor or director immediately. Observations during the tour of the kitchen on 1/31/22 throughout the dayshift revealed the following: a. At 9:34 a.m., using the surveyor's calibrated thermometer ([NAME] 9842), the back walk-in cooler ambient temperature read 49°F. The back walk-in cooler's digital thermometer read the ambient temperature as 48°F. The door to the back walk-in cooler would also unlatch and did not stay closed. There was no temperature log kept for the back walk-in cooler. The State Sanitary Code Book documents that 'temperature controlled for safety' (TCS) of foods is at or below 45°F. b. At 9:35 a.m., six stacks of boxes and an open bag of frozen pancakes within a box, were stored directly on the freezer floor. c. At 9:54 a.m., the three-bay sink had a significant (up to almost the ceiling) accumulation of dirty pots, pans, cooking utensils and dishes. d. At 10:02 a.m., the stationary commercial manual can opener was covered with thick, black sludge on the track and blade. Additionally, two large 55-gallon garbage cans, in the food prep and cook area, each observed to have an approximate one-foot hole cut out of the lids and fixed to the top of each of the garbage cans. Both were overflowing with debris and lids were covered with thick, dried, multicolored grime and food debris and both remained as such throughout the day shift. e. At 10:13 a.m. and 11:52 a.m., five of five stainless steel food carts, used to transport food to the residents, were unclean with thick dried, white residue inside on the backs of the food carts; white, brown and grey dried residue at the bottom of the food carts and the slats had dried brown and white grime on them. The food carts also had dried white drips down the outside of all the carts. The bottom of all five carts were scattered with food debris. Resident food trays proceeded to be loaded into these food carts for the lunch meal. f. At 10:18 a.m., dirty wiping cloths were observed on the floor next to dry storage area, in main footpath. They remained there throughout the day shift. g. At 11:42 a.m., the tray-line area was visibly soiled with large pieces of food debris and had a buildup of crumbs underneath the conveyor skate wheels. The steam table was soiled with greasy, tan residue and covered with dried, white drippings and dried food and was sticky to the touch. The floors in the cook and prep area were dirty with food scraps, debris, plastic lids, twist ties and used gloves and remained dirty throughout the day shift. h. At 2:40 p.m., the back walk-in cooler revealed the ambient temperature at 53°F. Milk sampled internally using the survey's thermometer registered at 47.4°F. i. At 3:22 p.m., there remained a significant accumulation of dirty dishes. In an interview on 1/31/22, at 10:13 a.m., the Kitchen Assistant #1 reported they had worked here approximately three months and do not know if the food carts should be cleaned. In an interview on 1/31/22 at 11:20 a.m., the Administrator stated they do not currently have a Dietary Director and are planning to train an internal candidate. In an interview on 1/31/22 at 2:38 p.m., Kitchen Assistant #2 stated the kitchen was a mess and was unclean. In an interview on 1/31/22 at 10:18 a.m. and at 2:50 p.m., the Cook stated that the kitchen was not in a clean condition and that dishes had piled up because the kitchen was short staffed all weekend. The Cook said that some kitchen staff walked off, including the Dietary Director. The Cook stated they were unaware that food boxes could not be directly stored on the floor and that the boxes in the freezer were reported to have been delivered four days earlier. The cook also stated that the available temperature log for the walk-in cooler was only for the front walk-in cooler and did not include the back walk-in cooler. In an interview on 1/31/22 at 3:10 p.m. and 4:02 p.m., the Administrator stated that the prospective Dietary Director was to be signed up for the proper coursework and would receive proper training with assistance from other affiliates. The Administrator stated they were aware of the issues with the broken back walk-in cooler. 10 NYCRR 415.14(h), 14-1.31(c), 14-1.40(a), 14.1.43(a), 14-1.95, 14-1.110(b)(d), 14-1.170

Based on observations, interviews, and record reviews conducted during the Abbreviated Survey (complaints #NY 758 and #NY 927) completed on 3/14/19, it was determined that for five (Residents #1, #2, #3, #4, and #5) of five residents reviewed for pressure ulcers, the facility did not ensure residents received care consistent with professional standards to promote healing and to prevent new pressure ulcers from developing. Specifically, there was no monitoring of the areas by qualified professionals, treatments and interventions were not ordered timely, and pressure ulcers developed and/or worsened. This resulted in actual harm for Residents #3 and #1 which is not immediate jeopardy. This is evidenced by, but not limited to, the following: The (MONTH) (YEAR) facility policy, Pressure Injury Prevention and Management/Wound Rounds included to assess all residents for the risk of pressure injuries and to have an appropriate interdisciplinary preventive care plan implemented when indicated. Residents with existing pressure injuries will be evaluated and managed in accordance with the facility's established clinical practice guidelines. The procedure included that the Registered Nurse (RN) will conduct a comprehensive skin assessment utilizing the facility's risk scale on admission and readmission from the hospital. When a resident is identified as at risk for development of a pressure injury, the comprehensive care plan (CCP) team will initiate a care plan that recognizes the residents' needs and goals and addresses the same with individualized interventions that are consistent with recognized standards of practice. These preventive interventions may include but are not limited to: turning and positioning schedule when in bed, weight shifting when out of bed in chair, pressure reducing mattress, application of protective/moisture barrier cream following incontinence episodes to reduce excessive moisture, pressure reducing chair cushion and skin observation on a shift to shift basis. The nurse is responsible for the following when a pressure ulcer is identified: notify the physician and obtain an appropriate treatment order, administer the treatment as ordered, initiate a skin tracking assessment sheet, notification of the resident's family/designated representative, include the resident in the 24-hour report, revision of the Certified Nursing Assistant (CNA) accountability record and CNA Kardex, notification of the dietitian, and documenting a comprehensive nurses note on actions taken. The RN Manager/designee is responsible for the following related to the care of a pressure injury: monitor and assess healing/deterioration, minimally on a weekly basis during pressure injury/wound rounds, prevent infection, communicate changes to the physician, provide ongoing communication with the CCP team and direct care staff to implement and/or revise the plan of care and implement changes to the plan of care as ordered by the physician or per the CCP team assessment. The process for wounds/pressure injuries included: designee should review admission assessment and then physically assess the wound themselves to ensure that staging and/or description and sizing of wound is accurate. The wound tracking form should be implemented, and the treatment orders should be obtained on the day the wound is noted. 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 2/11/19 Minimum Data Set (MDS) Assessment included that the resident had severely impaired cognition, required extensive assistance of two staff for bed mobility, was frequently incontinent of bowels, and had one Stage I (intact, non-blanchable skin) pressure ulcer and one Stage II pressure ulcer that were present upon admission to the facility. The 2/4/19 admission orders [REDACTED]. The Nursing Admission Assessment completed by RN Supervisor #1, dated 2/5/19, revealed the resident had a 5 centimeter (cm) x 5 cm area of non-blanchable redness of the coccyx and a Stage II pressure ulcer of the left buttocks measuring 0.5 cm x 0.5 cm x 0.1 cm with a white wound base, scant drainage, and non-blanchable surrounding skin. The Braden scale, dated 2/5/19, included a score of 13 (moderate risk). The Comprehensive Care Plan (CCP), dated 2/6/19, revealed that the resident had the potential for skin impairment related to wounds on the buttocks and coccyx. Interventions included to wash, dry, and lubricate the resident's perineal area and bony prominences after each incontinence episode, turn and position every two to three hours when in bed, assess skin condition during daily cares, an Alternating Pressure Mattress, and a wheelchair cushion. The undated CNA Kardex included routine skin care and under turn and position there was no frequency documented but total was handwritten in. A Dermal Tracker Sheet (Skin Sheet), dated 2/5/19, revealed the resident had a Stage II on the sacral area (buttocks) that measured 0.5 cm x 0.5 cm x 0.1 cm with a non-blanched white base with scant drainage. The 2/6/19 Physician History and Physical did not include a physical examination or document any skin impairment. The (MONTH) 2019 CNA Flow Sheet for skin, completed by the CNAs and reviewed by the LPN, directed to code Y for any new skin impairment and N for no skin impairment each shift. The sheet was blank for 35/70 opportunities, documented N for 34/70 opportunities, and there was one Y on 2/14/19. The 2/14/19 Licensed Practical Nurse (LPN) #1 progress note included that there was a small open area less than a dime size in length and width on the resident's left buttocks. The buttocks area was reddish in color, and skin prep and barrier cream were applied. There was no further documentation of skin or pressure ulcers until 2/27/19 after surveyors entered the facility. The Skin Sheets, dated 2/27/19, revealed that the following pressure ulcers were identified that day and included: an unstageable pressure ulcer of the sacral (buttocks) area that measured 9 cm x 8 cm x 0.1 cm, with 90 percent eschar with redness around the wound; a right posterior inner thigh reddened area (no measurements given); a right inner buttock #1 area that measured 3 cm x 1 cm x 0.1 cm with eschar and redness around the wound; a right inner buttock #2 area that measured 1.5 cm x 1.5 cm x 0.1 cm with eschar and redness around the wound; and a left inner buttock unstageable, eschar that measured 2 cm x 1.2 cm x 0.1 cm. Physician orders, dated 2/27/19, included a treatment order for the resident's buttock (sacral wound) that directed staff to apply skin prep around the wound to intact skin after washed and dried with normal saline, apply hydrogel to the wound base, cover with Opti foam/border gauze, change daily, and as needed. Wounds to the left and right of the inner buttocks towards the scrotum apply barrier cream twice daily and as needed, and the right leg reddened areas apply dry dressing Opti foam or border gauze. During observations of pressure ulcer care on 2/27/19 at 3:25 p.m. with the CNA #1 and LPN #2, the resident's buttocks were noted to have an unstageable pressure ulcer with black eschar (dead tissue) on each buttock estimated to be 9 cm long and 4 cm wide at the widest point on each side and was surrounded by reddened areas. There were also four areas of eschar noted on the right and left inner buttocks, a Stage II pressure ulcer on the scrotum all approximately 1.5 cm round, and a reddened, non-blanchable area on the left posterior thigh estimated to be 4 cm x 2 cm. At 3:53 p.m., the Corporate RN Director of Quality Assurance entered the room and began to assist holding the resident on his side. LPN #2 began to cleanse the wounds and the surveyor asked what he was using. LPN #2 responded sterile water because he could not find any normal saline as per physician order. LPN #2 left the room and came back with syringes of normal saline and applied it on the 4 x 4 gauze and cleaned all the wounds. He then patted the wounds dry with a split gauze sponge. LPN #2 applied skin prep around the wound and then spread hydrogel on the 6 cm x 6 cm Opti foam dressing using his gloved hands. He applied the Opti foam onto the largest wound leaving part of the wound and eschar uncovered by the dressing and part of the wound was covered by the adhesive part of the dressing. The other pressure ulcers were not covered by dressings. The Corporate RN Director of Quality Assurance instructed the LPN to put barrier cream on the rest of the buttocks, thighs and scrotum but staff said there was no barrier cream in the room. The CNA left the room to look for barrier cream and came back saying she could not find any in the building, but she brought Vitamin A and D ointment packets. The Corporate RN Director of Quality Assurance told her not to apply that so nothing else was done to the other wounds. On 2/28/19 at 8:23 a.m., the resident was observed sitting in his wheelchair with a pink incontinence pad folded over so that there were four layers of pad between his buttocks and the pressure relieving wheelchair cushion. During observation of wound care on 2/28/19 at 9:00 a.m., the Corporate RN Director of Quality Assurance cleansed the wounds and applied Hydrogel. A butterfly shaped Opti foam dressing was applied but it was too small, a portion of the wound was covered by adhesive, not the padding. When interviewed on 2/27/19 at 3:49 p.m., RN NM #1 said that she was completing skin rounds on the resident's unit since the ADON resigned a few weeks ago. She said there was no Skin Sheet, so she did not know that the resident had an open area on admission. She said if she had known, she would have seen the resident on skin rounds weekly. RN NM #1 said pink incontinence pads are okay to use but they should not be folded four times in a wheelchair. Interviews conducted on 2/28/19 included the following: a. At 12:28 p.m., LPN #1 said when she worked on 2/21/19 and 2/22/19 she noticed that the resident had an open area about the size of a quarter. She said she reported it to LPN NM #1. She said she did not measure the wound or start a Skin Sheet because that was the responsibility of the NM. She said she applied a barrier cream or [MEDICATION NAME]. b. At 3:18 p.m., CNA #3 said that two to three days a week they do not have barrier cream and the CNAs do not have time to ask the nurses for it. He said he saw the resident on 2/18/19 and there was a big difference in the resident's skin on his buttocks. CNA #3 said it was worse. He said he talked to the nurse but could not remember which nurse. CNA #3 stated that on 2/22/19 he saw the resident again, his bottom looked bad, and he told LPN NM #1. Interviews conducted on 3/1/19 included the following: a. At 8:45 a.m., RN NM #2 said that if a resident was admitted with a Stage II pressure ulcer, she would expect to see a treatment being done, weekly skin checks, Braden scale assessments on shower days, and [MEDICATION NAME] for the buttocks. b. At 1:35 p.m., LPN #3 stated that she saw the resident's buttocks on 2/25/19 or 2/26/19 and told LPN NM #1 that it looked much worse and needed more treatment and a bigger dressing. Interviews conducted on 3/5/19 included the following: a. At 9:25 a.m., the RN Corporate Director of QA stated that LPN #2 asked her to look at the resident's wounds the morning of 2/27/19. She said she did not think the wound care went well on 2/27/19. She said that because the resident was admitted with a Stage II pressure ulcer, he should have been followed by the skin team but he was not. She said he should have had a CCP for an actual pressure ulcer because he had one. She said there were no physician's orders for treatment of [REDACTED]. The RN Corporate Director of QA said she would have expected an order and treatment like Duoderm and barrier cream to protect the intact skin. She said if the barrier cream was being used, it should be documented, and she did not see where anything was documented. b. At 12:23 p.m., LPN NM #1 stated that the RN Supervisor completed the skin assessment on admission, and he could not remember when she told him the resident had a Stage II pressure ulcer on the right buttock. He said it is out of his scope of practice so he has the RNs complete the skin assessment on admission. c. At 3:40 p.m., LPN #2 said that he had never seen the resident's wounds or changed the dressing before 2/27/19. He said he was not pleased with the way the dressing change went because the dressing was not big enough for the wounds, the other wounds were not dressed, and that was unacceptable. He said the stock rooms are often out of barrier cream. When interviewed by telephone on 3/6/19 at 3:09 p.m., the physician stated that in looking at his history and physical note, he did not see the resident when he did the admission on 2/6/19. He said he thinks the resident had a Stage II pressure ulcer on the left buttock that was 1 cm. The physician said the Stage II should have had a treatment, but he does not see one in the orders. He said that on 2/27/19 he was informed that the resident had a large sacral wound and satellite wounds. The physician said it would be hard to say how long it would take for a large unstageable wound like that to form but at least a week and probably longer. He said if the area was not treated, that would contribute to what happened. He said the wounds could have been prevented with treatment. When interviewed by telephone on 3/6/19 at 3:28 p.m., former RN Supervisor #1 stated that she completed the admission skin assessment for the resident on 2/5/19. She said she has not been trained to stage wounds, so she documents the wound information from the hospital discharge papers. She said that if there was an open area that was not noted on the hospital discharge papers, she would document that the resident had an open area. She stated she does not start a Skin Sheet, a CCP, or call the physician for treatment orders. She said she would not have left the wound open but would have applied a dressing, but she did not document that. She said that LPN NM #1 should have followed up to obtain the treatment orders, filled out the skin sheet, and initiated the CCP. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 2/16/19 MDS Assessment included that the resident had severely impaired cognition and Section M for skin conditions was all blank. The Nursing Admission Assessment, dated 1/14/19, revealed that the skin section was completed by ADON #1 and documented moisture associated areas (inflammation or skin erosion caused by prolonged exposure to moisture) on the coccyx. The wound base was pink, the surrounding skin was intact, and there was no drainage. There were no measurements documented. The Braden scale completed by ADON #1 on 1/14/19 documented a score of 11 (high risk). The 1/14/19 Nurse Practitioner (NP) admission note and the 1/16/19 Physician's History and Physical note included no documentation of the buttocks/coccyx area being examined. The CCP, dated 1/18/19, revealed that the resident was incontinent and to apply moisture barrier after each incontinence episode. There was a potential for skin impairment due to impaired mobility, incontinence, and ostomy. Interventions included incontinence care every two to four hours, wash dry and lubricate perineal area and bony prominences after each incontinence episode, assess skin condition during daily cares, turn and position every two to three hours when in bed and an Alternating Pressure Mattress, settings per resident weight. The undated CNA Kardex included an Alternating Pressure Mattress setting per resident weight. There was no specific information about wound care. Progress notes pertinent to skin included the following: a. Medicare daily notes completed by the LPNs, from 1/14/19 to 1/25/19 and 1/27/19 to 2/21/19 almost daily, revealed that no new skin issues were identified, and the resident did not receive skin treatments or dressing changes that day. b. ADON #1's progress note, dated 1/25/19, revealed that skin rounds were completed, and it was noted that the resident had a small moisture associated excoriation open area that measured 0.5 cm x 1 cm. Physician orders were obtained for [MEDICATION NAME] ointment to be applied every shift and monitor for changes. The undated telephone physician's order, signed by the physician on 1/30/19, and written by LPN NM #1 included to apply [MEDICATION NAME] ointment to the resident's right buttocks excoriation every shift. The (MONTH) 2019 Medication Administration Record [REDACTED]. The 2/2/19 NP note included that a physical exam was done, and there was no documentation of a skin assessment. The Skin Sheets, dated 2/14/19, documented that the resident had an unstageable right buttock ulcer that measured 6 cm x 5 cm, and a necrotic eschar base, and the surrounding tissue was bloody, red and excoriated, and the status was worse. Preventive measures included an Alternating Pressure Mattress. The treatment was changed to [MEDICATION NAME] and hydrogel, and was signed by RN NM #1. There were no other skin sheets or skin checks found in the documentation. The 2/14/19 physician's order included to cleanse the right buttock with normal saline gently, pat dry, apply hydrogel to reddened area, and [MEDICATION NAME] to eschar. Cover with large Opti foam daily and as needed if dressing not intact. The 2/14/19 CCP for actual alteration in skin integrity revealed that the resident had an unstageable wound on the right buttock. The interventions included the previous interventions and to provide treatment according to the physician's orders, monitor effectiveness of the treatment plan, pressure relieving chair cushion, and avoid prolonged pressure on bony areas. Review of the (MONTH) 2019 TAR included entries for [MEDICATION NAME] ointment to the resident's right buttocks every shift for excoriation, dated 2/8/19, and was inconsistently signed for starting 2/10/19. A treatment order that started 2/14/19 that directed to cleanse the resident's right buttocks with normal saline gently, pat dry, apply hydrogel to reddened area and [MEDICATION NAME] to eschar, and cover with a large Opti foam every day and as needed if the dressing is not intact was not signed as completed on 2/14/19 and 2/18/19. The 2/22/19 resident information transfer form, completed by LPN #1, revealed that the resident was sent to the hospital for abnormal labwork. Review of the 2/28/19 hospital discharge summary revealed that the resident was admitted to the hospital on [DATE] with left buttock Stage II and right buttock unstageable pressure ulcers. Interviews conducted on 2/27/19 included the following: a. At 1:07 p.m., NP #1 stated that she did not look at the resident's skin and was not made aware that the resident had moisture associated areas on the buttocks on admission. She said if she had known she would have ordered something. NP #1 said that she usually reviews wounds and skin with RNM #2 as to what to order because she was not always aware of what products were available at the facility. NP #1 said she would expect treatments ordered to be started right away. NP #1 stated she has never been a part of the skin team. b. At 3:49 p.m., RNM #1 said she only saw this resident once because there was no skin sheet in the skin book. She said on 2/14/19 the staff called her and told her the resident did not have a dressing on his buttocks and his buttocks looked worse. She said there were no skin sheets on him so she started one and documented that he had an unstageable pressure ulcer on the right buttock. She said it looked like he had protective cream on and it looked like two layers of skin had sloughed off and was very moist. She said she developed a CCP and documented it on the 24-hour report. She said she called the physician for an order but he was at home and did not see the wound. RNM #1 stated that CNAs are the first line of defense against pressure ulcers, and she expects them to report anything different about the skin and report if the resident is refusing to be turned or wear booties or have incontinence care done. RNM #1 said the physician and NP #1 only observe the resident's skin if she asks them to. When interviewed on 2/28/19 at 3:18 p.m., CNA #3 said that the resident's buttocks were not looking very good when he was in the facility. He said he reported the skin condition to the LPN medication nurses and applied barrier cream after incontinence care. However, sometimes there was a shortage of barrier cream and he would have to get it from the nurse. CNA #3 stated that the sores on the resident's buttocks were bleeding. When interviewed on 3/1/19 at 8:45 a.m., RNM #2 said that weekly skin checks and Braden scale assessments should be done on admission and weekly for four weeks and anytime a resident has a skin issue. RNM #2 reviewed the medical record and then said she could not see that skin checks or application of [MEDICATION NAME] were documented for the resident. Interviews conducted on 3/5/19 included the following: a. At 9:25 a.m. the RN Regional Director of Quality Assurance stated that because the resident was admitted with a moisture associated area on the buttocks, she would have expected a treatment such as barrier cream to have been initiated. She said barrier cream does not need to be ordered by the physician but it needs to be documented as administered. She said there was an order for [REDACTED]. b. At 10:34 a.m., LPN #4 said that the resident did not refuse care. She said he had a problem with his coccyx that got worse, and she notified LPN NM #1 several times but nothing changed, nothing happened. LPN #4 said that if there was no treatment order on the computer, she could not do any more than wash the resident and apply barrier cream. She said he needed more than that because he kept getting worse. LPN #4 said there was no one else for her to report to because if she goes to the DON or Administrator, they go to LPN NM #1 and she fears retaliation. She said she does not know how to stage a pressure ulcer but she knew the area went from one spot to several spots. c. At 11:30 a.m., LPN NM #1 stated that he does not remember whether ADON #1, who completed the skin assessment on admission, reported the moisture associated areas on the coccyx. He said the RN completes the CCP and the Braden scale assessments. LPN NM #1 said that he would have expected to see barrier cream ordered for moisture associated areas and that would be on the EMAR/TAR but it was not. LPN NM #1 said he was not notified that the resident had any skin related areas until maybe a day before he was transferred to the hospital. He said he thinks a CNA told an agency nurse, but he does not know who. He said that he was not aware the resident had an unstageable pressure ulcer. LPN NM #1 said he does not go on rounds with the physician or NP, and he does not know if they observe the resident's skin or wounds. When interviewed on 3/6/19 at 9:00 a.m. via telephone, ADON #1 stated that he did the admission assessment for the resident and found moisture associated areas on the coccyx but no open areas. He said barrier cream should have been ordered and a skin sheet should have been started. ADON #1 stated that LPN NM #1 was not able to complete the weekly Braden scale assessments, and he was not sure who was responsible to do them on the Baldwin Unit but he did not do them. He said that the physician never observed pressure ulcers and that he invited NP #1 but it never worked out. When interviewed on 2/27/19 at 12:03 p.m., the physician said that he was not surprised about the skin issues and probably should have been more proactive. 3. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 1/11/19, revealed that the resident was cognitively intact for daily decision-making skills and had one unstageable pressure ulcer upon admission with slough and/or eschar. The acute rehabilitation center discharge summary, dated 12/12/18, revealed that the resident had a Stage II pressure injury to the coccyx, utilized a specialty mattress, turn and positioning schedule, and wound care of Allevyn dressing that was to be changed every other day and as needed. The facility nursing admission assessment completed by the ADON, dated 12/12/18, included that the resident had a 4 cm x 2 cm Stage II pressure ulcer on the coccyx with 100 percent slough, serosanguineous drainage, and pink surrounding skin. The Braden scale completed at that time revealed a total score of 15 (mild risk). The physician history and physical, dated 12/12/18, revealed that the resident had a Stage II coccyx pressure ulcer, but the physician was unable to examine the resident as he was lying in a position of comfort on his back and declined to be rotated. The plan was to continue Allevyn dressing and change it every other day. The physician admission orders [REDACTED]. The orders did not include any wound care treatments. There were no other documented weekly Braden scale assessments completed during the resident's admission as ordered. The actual alteration in skin CCP, initiated on 12/12/18, included that the resident had a Stage II pressure sore. Interventions included to provide treatment in accordance with physician orders, monitor effectiveness of treatment plan, provide adequate nutrition/hydration to promote healing, reposition every two hours, assess skin daily during routine care and report any changes, keep the skin clean and dry, provide perineal care as needed, and monitor weight. On 12/19/18, the treatment was changed to [MEDICATION NAME]. On 12/20/18, interventions of a pressure relieving mattress and chair cushion were added. The Alternating Pressure Mattress was ordered and received on 1/9/19. The undated CNA Kardex included that the resident required a two assist for turning and positioning, a full mechanical lift, had a pressure relieving mattress with settings per the resident's weight, and was blank for routine skin care. A physician telephone order obtained by LPN NM #1, dated 12/20/18, revealed a treatment to the coccyx which included to cleanse the area with normal saline, pat dry, apply [MEDICATION NAME] to the wound bed, and then cover with border gauze daily and as needed. There were no additional orders for wound treatments for the remainder of the resident's admission. Review of the (MONTH) (YEAR) and (MONTH) 2019 TARs revealed that the first wound care was not initiated until 12/21/18. The skin sheets, completed by ADON #1, documented that the resident had an unstageable pressure ulcer to the coccyx that had 100 percent slough, serosanguinous drainage, and was pink around the wound. In addition, the following was included: a. On 12/12/18, the wound was 4 cm x 2 cm, with preventative measures including turn and position every two to three hours and treatment of [REDACTED]. b. On 12/19/18, the wound was 4 cm x 2cm, remained the same, and the treatment was changed to [MEDICATION NAME]. c. On 12/28/18, the wound was 5.5 cm x 3.5 cm, status was worse, and there were no changes to the treatment or preventative measures. d. On 1/4/19, the wound was 4.0 cm x 3.52 cm, status was improved, and there were no changes to treatment or preventative measures. A NP note, dated 12/20/18, included no documented skin issues. A physician note, dated 12/26/18, revealed that the resident had no skin breakdown. The physical exam did not include a review of the coccyx wound. On 12/30/18, LPN #5 documented that the coccyx wound had a foul smell, a large amount of drainage, moderate amount of sloughing skin, and the base was white with exudate. The wound was cleansed with normal saline, [MEDICATION NAME] and border gauze was applied to the wound. There was no documentation that a supervisor or medical provider was notified. The 24 hour report, dated 1/11/19, revealed that wound drainage was purulent, bloody, and mucusy, and the resident was sent to the hospital. A NP note, dated 1/11/19, revealed that the resident's temperature was between 101 to 103 degrees Fahrenheit that morning. The resident had a poor appetite, chills, fatigue, abdominal pain, phlegm in the bedside basin, nausea and vomiting, with [MEDICAL CONDITION] for the last one to two days. He was given 2 liters of normal saline over two days, an extra dose of [MEDICATION NAME] (anti-hypotensive) 5 mg, and [MEDICATION NAME] (antibiotic)1gm IM at 5:00 a.m. that morning. The resident had a history of [REDACTED]. The plan was to send the resident to the hospital for possible urinary tract infection versus upper respiratory infection/pneumonia and most likely the resident had a sacral wound infection. Hospital notes, from 1/11/19 to 2/15/19, revealed that the resident was admitted with fever, fluid responsive [MEDICAL CONDITION], and [MEDICAL CONDITION] to an infected large sacral decubitus ulcer. The wound was debrided in the emergency department revealing a tunneling area the size of a golf ball and foul smelling yellowish drainage. The wound had further excision on 1/14/19 in the operating room. The resident received intravenous (IV) antibiotics and a wound vac to the area. Interviews conducted on 3/4/19 included the following: a. At 8:49 a.m., LPN #1 said that the resident did not get any wound care orders until 12/20/18 and received his first treatment on 12/21/18. The resident had an open wound on his buttocks when he came in and it did get worse. She said there was drainage and an odor right before the resident was sent out to the hospital. LPN #1 said that she worked on 1/10/19, the resident had a fever and received Tylenol, and she contacted medical. The resident did not want to go to the hospital. The next day (1/11/19) the resident had a fever and was shaking, the NP was notified, and the resident was sent to the hospital. b. At 11:35 a.m., LPN NM #1 said that upon admission the RN reviews the discharging facility's wound treatments, assesses the resident's skin, and will alert the physician of wound needs, and then either the RN or he would write the orders. He said if there was a potential or actual skin issues, the RN would generate a skin CCP with specific interventions for prevention and/or promote healing. The RN would also initiate interventions ordered such as a dressing, chair cushion, and/or a specialty mattress. He said if there were to be any changes to the wound/skin later in the admission, LPN NM #1 said he would expect the LPN or RN to alert the supervisor and/or medical provider to determine if new orders/interventions were needed and add those to the TAR. When LPN NM #1 reviewed the resident's TAR he said the first wound care that was documented as being provided was on 12/21/18. He said that he was not sure why there was no wound care documented prior. When interviewed on 3/5/19 at 3:38 p.m., the DON said if a residen

Based on interviews and record reviews conducted during the Abbreviated Survey (complaints #NY 000 and #NY 156) completed on [DATE], it was determined that for one of three residents reviewed for accidents, the facility did not provide the necessary care and services to attain and maintain the resident's highest practicable well-being. Specifically, Resident #5's deteriorating condition following an unwitnessed fall was not consistently monitored or reported to medical in a timely manner resulting in hospitalization and death. This was actual harm for Resident #5. Additionally, four of four residents were reviewed for quality of care related to bowel issues. Residents #1, #2, #3, and #4 were not consistently monitored for bowel movements and bowel medications were not administered per bowel protocol. This is evidenced by, but not limited to, the following: 1. Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated [DATE], revealed that the resident was cognitively intact. The Medical Orders for Life-Sustaining Treatment (MOLST) signed by the resident on [DATE], included Do Not Resuscitate (DNR), Do Not Intubate (DNI), limited medical interventions, and to send to the hospital if necessary. Review of the undated facility policy, Neurological Assessment, revealed the purpose is to provide a continuing assessment of the resident so that change from baseline can be noted immediately. The neurological flow sheet directed neurological checks every 15 minutes x 4; every 30 minutes x 2 hours; every 1-hour x 4 hours; and every shift x 24 hours. The Incident and Accident Report directed that neurological checks should be initiated for all unwitnessed falls. The Falls Risk Assessment, dated [DATE], revealed that the resident was at high risk for falls. The Comprehensive Care Plan (CCP), dated [DATE], included that resident was at risk for falls and had an actual fall within the last 30 days. Review of the Incident/Accident Report and investigation, dated [DATE], revealed that at 2:50 a.m., the staff heard a crash and found the resident on the floor in the unit dining room with a broken overbed table on her lower legs. The resident was assessed by a Registered Nurse (RN) Supervisor #1 and found to have an abrasion on her thumb. It was documented that neurological checks were initated, and the family and physician were notified. There was no documentation that a further investigation was completed as the resident's condition deteriorated over the next two days or documentation that neurological checks were performed. The progress notes written on [DATE] included the following: a. At 2:43 a.m., Licensed Practical Nurse (LPN) #1 documented that the resident was very confused on the evening shift ([DATE]) and slept through dinner. The resident was observed walking around the unit pushing her wheelchair and walking without her wheelchair and redirection did not work. The resident was placed on 1:1 for safety and had to be assisted to bed via a standing lift. The resident was incontinent of urine which had a foul odor and her speech was slurred. RN Supervisor #1 was made aware. At 5:49 a.m., LPN #1 documented that the resident rested quietly in bed the entire night shift and was checked every 30 minutes for safety and behaviors. The resident did not respond to verbal or tactile stimuli. The resident was found to have frothy, bile colored sputum twice on the shift and at 5:15 a.m., LPN #1 entered the room and noted that the resident had a lot of secretions in her mouth. RN Supervisor #1 was called to assess the resident and at 5:20 a.m., the resident was orally suctioned. After being suctioned, the resident seemed to be breathing much easier. A message was left for the family. b. At 10:39 a.m., LPN #2 documented that the resident was unresponsive and the Assistant Director of Nursing (ADON) was made aware. c. At 11:00 a.m., the ADON documented that he was in to see the resident. The resident was unresponsive to voice or painful stimuli, the physician was notified, and an order was received to transfer the resident to the hospital. Review of the hospital records, from [DATE] through [DATE], revealed that on admission to the hospital the resident was unresponsive to verbal or tactile stimuli with a periorbital bruise of the left eye that appeared to be two days old. The resident's left pupil was dilated and both pupils were not reactive to light. The [DATE] CT (computed tomography) scan of the resident's head revealed a large left-sided subdural hematoma (a pool of blood between the brain and outermost covering) with a [DIAGNOSES REDACTED] herniation (potential deadly side effect of very high pressure within the skull that occurs when a part of the brain is squeezed across structures within the skull.) The resident was transferred to a hospice bed and passed away on [DATE]. During an interview on [DATE] at 11:46 a.m., the assigned nurse, LPN #3 said she worked the day shift on [DATE] and was told the resident had a fall which resulted in a scratch on her thumb. She said she was not told to do neurological checks, and there was not a sheet started for neurological checks. LPN #3 said that she heard about the resident's black eye but she did not see it because she was off the weekend ([DATE] and [DATE]). Interviews conducted on [DATE] included the following: a. At 8:11 a.m., the assigned nurse, LPN #4 stated that he worked on [DATE] and [DATE] and knew that the resident had a fall on [DATE]. LPN #4 said he was not asked to do neurological checks for the resident, and he did not see a sheet to document them on so he did not do them. LPN #4 said he does not know the resident very well but she seemed more confused, and he was told by staff that she was more lethargic and confused than usual. LPN #4 said that he does not recall the resident having a black eye. b. At 8:25 a.m. by telephone, RN Supervisor #1 stated that on [DATE] at about 2:40 a.m. he walked onto the Empire Unit and was told that the resident had just fallen. He said he saw the resident on the floor in the unit dining room, on her back, rolling around trying to get up. He said she was not making any sense but was saying help me get up. RN Supervisor #1 said the overbed table was under her feet and the table part was broken off. He said the resident's wheelchair was about 1 to 2 feet away from the resident. RN Supervisor #1 said he did an assessment and found an abrasion on the resident's thumb. He said he completed neurological checks and found the resident's pupils were equal and reactive but did not document his findings including pupil size. He said LPN #5 should have started a neurological check sheet because it was an unwitnessed fall. He said he should have documented on the sheet but did not and did not know why. RN Supervisor #1 said on the evening of [DATE] the resident was in a Geri chair and needed a mechanical lift to be transferred to bed which was unusual for the resident. He said that at about 4:00 a.m., he was called to assist in suctioning the resident. He said he did not notify the physician about the resident's medical status changes because he thought LPN #1 would do that. He said that he does not remember if the resident had a black eye. c. At 12:18 p.m., the ADON stated that on [DATE] staff were talking about the resident having a black eye. He said he looked at the [DATE] Incident/Accident Report and saw that the resident had a fall and attributed the new black eye to the fall but did not document anything and did not notify medical staff. He said no one reported anything to him on [DATE]. The ADON said that when he arrived at work at 6:00 a.m. on [DATE], he thinks RN Supervisor #1 told him there was a resident who was a DNR/DNI who was unresponsive, but their vital signs were stable, however, he was not sure if RN Supervisor #1 was talking about the resident. The ADON said at 10:39 a.m. he was called by the nurse and told that the resident was still not responsive, so he went to the unit to see the resident. He said the resident was not responding to voice or painful stimuli, and he called the physician to get an order to transport the resident to the hospital. The ADON said if there is any change in condition of a resident, he prefers to notify medical staff. He said that he could not find documentation that RN Supervisor #1 had notified medical. d. At 1:31 p.m., the resident's physician was interviewed by telephone, and he said that he was notified on [DATE] that the resident had a fall. He said he was told that the resident's vital signs and neurological checks were stable and that the fall protocol was implemented. He said he does not remember being told there was any injury. The physician said he was not called again about any status changes in the resident until mid-morning on [DATE]. He said the ADON called and told him the resident had mental status changes, and he was quite urgent and wanted the resident immediately transferred to the hospital. The physician said he should have been notified at the time of each change, including the evolving ecchymosis (subcutaneous bleeding) of the face, declining consciousness, and the need for suctioning. He said he would have ordered that the resident be transferred to the hospital for a CT scan of the head because those are urgent symptoms. When interviewed on [DATE] at 11:23 a.m., LPN #5 said that she works per diem and that she does not think she worked [DATE], and does not remember anything unusal about the resident. When interviewed by telephone on [DATE] at 1:15 p.m., LPN #1 said that when she arrived at work on [DATE] at 6:00 p.m., she was not told that the resident fell on [DATE]. She stated that the resident had a black eye and when she asked other staff about it, she was told it was old and was documented but again was not told the resident had a fall. LPN #1 said that the resident was confused, nervous, had garbled speech, and was not acting like her usual self. At about 10:00 p.m., the CNA, RN Supervisor #1, and LPN #1 assisted the resident to bed but she was so tired and weak they had to transfer her with a mechanical stand lift and was incontinent of urine. She stated that was unusual for the resident and she told RN Supervisor #1. LPN #1 said at 5:15 a.m. she found that the resident had frothy bile colored mucous in her mouth. The resident was snoring, she could hear in her breathing that she had phlegm in the back of her throat and was not able to cough or clear the secretions. LPN #1 said she took vital signs and called RN Supervisor #1 who came over and assisted with suctioning the resident's mouth. At that time, the resident did not respond to verbal or tactile stimuli but only moved her eyebrows when she was suctioned. She said she told RN Supervisor #1 that was not normal for the resident and she felt in her gut that something was going on. She asked RN Supervisor #1 to get an order to send the resident to the hospital, but he said she did not need to go. LPN #1 said that the LPNs do not call the medical staff. She said the RN Supervisor does that because they are the ones who complete the assessments. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated [DATE], revealed the resident had severely impaired cognition. The (MONTH) (YEAR) facility policy, Bowel Management Protocol, included that the 7:00 a.m. to 3:00 p.m. nurse will check the bowel records for each resident daily after 2:00 p.m. Any resident noted to have not had a bowel movement in the past two days will be placed on the 24-hour report. The 7:00 a.m. to 3:00 p.m. nurse will report to the 3:00 p.m. to 11:00 p.m. nurse who is on the bowel movement (BM) list. The 3:00 p.m. to 11:00 p.m. nurse will administer 30 cubic centimeters (cc) of Milk of Magnesia (MOM) per documentation on the Medication Administration Record (MAR) and the BM list. Results will be documented on 24-hour report and on the resident's BM record. If no results from the MOM by 6:00 a.m., the 11:00 p.m. to 7:00 a.m. nurse will administer two [MEDICATION NAME] tabs and document on the MAR and 24-hour report. Results will be documented on the BM list and the resident's BM record. If there are no results from the [MEDICATION NAME] tabs by 10:00 a.m., the 7:00 a.m. to 3:00 p.m. nurse will administer a [MEDICATION NAME] suppository and document on the MAR and BM worksheet. If no results from the suppository by the end of the 7:00 a.m. to 3:00 p.m. shift, the 3:00 p.m. to 11:00 p.m. nurse will then administer a Fleet enema. If there are no results from the Fleet enema by 10:00 p.m., the nurse will complete a bowel evaluation, notify the practitioner, and document in the progress notes, 24-hour report the evaluation results, and any new orders from the physician. The bowel evaluation should include, but is not limited to, auscultation of bowel sounds of all four quadrants, palpation of abdomen for firmness and tenderness, visual inspection of the abdomen for distention, and if not contraindicated a digital exam. Review of the CCP and the currently in use CNA Care Plan revealed that the resident was incontinent of bowels and required total assistance with care. There was no mention of constipation in the resident's CCP. Review of physician orders [REDACTED]. a. The [DATE] orders directed [MEDICATION NAME] 17 grams (gm) by mouth daily and Senna-[MEDICATION NAME] 8XXX,[DATE] milligrams (mg) tab by mouth at bedtime. [MEDICATION NAME] 10 mg suppository rectally daily as needed for constipation, and [MEDICATION NAME] 5 mg tablet take two tablets by mouth once daily as needed for constipation. b. The [DATE] orders directed to discontinue the [MEDICATION NAME] due to soft stools. The resident was on three constipation medications. c. The [DATE] orders directed [MEDICATION NAME] 30 cc by mouth now, start Senna S tablets, give two tablets at bedtime, and push fluids 240 cc water every four hours while awake. d. The [DATE] (no time) orders directed prune juice 8 ounces a day, and repeat Fleets enema once that day if no BM. The [DATE] (4:40 p.m.) orders directed a warm soap suds enema (SSE) now for constipation. e. The [DATE] (7:30 p.m.) orders included to release the resident's body to the funeral home. Review of the resident's Bowel Movement Record revealed that the resident went without a BM for greater than three days (nine shifts) on three occasions in (MONTH) (YEAR), on two occasions in (MONTH) (YEAR), and on one occasion in (MONTH) (YEAR). The resident had a small BM documented on [DATE], and there was no further documentation that the resident had a BM until the day shift [DATE]. There was no documentation on ,[DATE] or [DATE]. Review of the progress notes, from [DATE] through [DATE], does not document any evaluation of the resident's BMs or abdomen, the use of as needed bowel medications, pushing fluids or prune juice, results from the bowel medications, or notifying the physician that the resident was not moving her bowels. Review of the medical provider notes revealed the following: a. The notes for NP #1, dated [DATE] and [DATE], revealed that the resident's abdomen was soft, non-tender, non-distended, and she had positive bowel sounds. The resident had recent loose stools so the [MEDICATION NAME] will be discontinued. b. The physician's note, dated [DATE], included that the resident's abdomen was thin, non-tender, non-distended, and she had positive bowel sounds. c. The notes for NP #1, dated [DATE], [DATE], and [DATE], revealed that the resident's abdomen was soft, non-tender, non-distended, and she had positive bowel sounds. d. The note for NP #2, dated [DATE], included that she was asked to see the resident for reports of constipation. The staff reported that the resident had been passing a small amount of stool, her abdomen was distended, and bowel sounds were present. Upon physical exam, the resident's abdomen was soft, nontender and without masses, and bowel sounds were active. NP #2's plan included [MEDICATION NAME] 30 cc once and then Senna S two tablets at bedtime, and push fluids 240 cc of water every four hours while awake. Review of the Medication Administration Records included the following: a. (MONTH) (YEAR): [MEDICATION NAME] 17 gm by mouth daily and Senna S 8XXX,[DATE] mg by mouth at bedtime. There was no documentation that any as needed bowel medications were administered. b. (MONTH) (YEAR): [MEDICATION NAME] 17 gm by mouth daily (last administered [DATE]) and Senna S 8XXX,[DATE] mg by mouth at bedtime. There was no documentation that any as needed bowel medications were administered. c. (MONTH) (YEAR): Senna S 8XXX,[DATE] mg by mouth at bedtime. An as needed [MEDICATION NAME] 10 mg suppository was given on [DATE] with the notation results pending. There was no other documentation of any as needed bowel medications administered. d. (MONTH) 2019: There was no documentation that the following orders were transcribed on the MARs or documented as completed. The orders for [DATE] included [MEDICATION NAME] 30 cc by mouth now, start Senna S tablets, give two tablets at bedtime, and push fluids 240 cc of water every four hours while awake. The orders for [DATE] (no time) included prune juice 8 ounces a day, repeat Fleets enema once today if no BM. e. The order on [DATE] at 4:40 p.m., directed a warm SSE now for constipation and was not transcribed on the MAR. Review of the 24-hour report sheets revealed that in (MONTH) (YEAR), there was no documentation of BMs for the resident. In (MONTH) (YEAR) there was documentation that the resident's [MEDICATION NAME] was discontinued on [DATE]. There was no other documentation related to the resident's bowels. In (MONTH) (YEAR) there was one entry related to the resident's bowels on [DATE] (night shift) that revealed the resident had a very small BM and needed bowel prep. In (MONTH) 2019 it was documented that on [DATE] (night shift) the resident needs stool removed and on the evening shift to increase laxative, NP # 2 aware, and saw the resident. The entry on [DATE] included to repeat the Fleets enema x one day for no BM. The resident expired at 5:44 p.m. An unsigned handwritten progress note, dated [DATE] at 7:15 p.m., revealed that the resident was not responding throughout the day with the BM protocol. After giving the resident a warm SSE, the resident became unresponsive, CPR was started, and 911 and the physician were called. The ambulance crew stopped CPR and the resident was pronounced deceased at 5:44 p.m. Interviews conducted on [DATE] included the following: a. At 11:55 a.m. CNA #1 (full time day shift) stated that CNAs are responsible for documenting BMs every shift on the CNA Kardex. She said she frequently does not have time to complete the documentation. She said she has complained to nurses and administration that they are too busy to document, but nothing has changed. She said that if she knows a resident has not had a BM in a couple of days, she notifies the nurse. She said the nurses are responsible for reviewing the BM sheets. CNA #1 said she took care of the resident on a regular basis and that she had not been moving her bowels for weeks in December. She said she reported to the nurses that the resident was only having smudges of stool, and then the resident stopped having any stool towards the end of December. She said she told whatever nurse was working each day. She said that the resident was barely eating, was moaning in pain, and was not moving her bowels. CNA #1 said that during her last few days of life, the resident's abdomen was getting bigger and bigger and she looked seven months pregnant. She said that on [DATE] the resident was in pain, crying, not breathing right, and hardly eating. She said she reported all that information to the RN Manager and she knew the NP had seen her that day. b. At 12:15 p.m., CNA #2 said she helped transfer the resident to the toilet sometimes and during the last few days before she died , the resident was complaining of belly pain. She said the resident did not talk much but she seemed uncomfortable. CNA #2 said she was present when CNA #1 reported to the nurse that the resident was not moving her bowels. She said it was discussed at rounds that the resident had not gone yet. c. At 12:44 p.m., CNA #4 stated that the resident had not moved her bowels for two weeks and it was reported to the nurses. The resident's stomach became distended, she acted like she was in pain, and towards the end she did not eat that much. During an interview on [DATE] at 10:40 a.m., the RNM #1 said the resident's BMs are documented by the CNAs in the Kardex, and the LPNs are supposed to check to see if the resident is having BMs. She said she was not aware if any other staff members reviewed the bowel record. The RNM #1 said that she does not review the bowel records. The RNM #1 said that the bowel protocol directs that after two days of no BM, the nurse administers prune juice. The RNM #1 said if there was still no BM, the resident should have orders for as needed bowel medications and these should be started, or a medical provider should be notified. She said she was not aware that the resident had chronic issues with her bowels or that the resident was having bowel problems in December. The RNM #1 said that a CNA reported to her that the resident was only having skid marks or a smear of bowels, and she said the nurses were taking care of it. The RNM #1 said she never looked at the resident's BM record even after the resident died . She said that she thinks on the day before the resident passed away, there was an order for [REDACTED]. She said she saw the resident on [DATE] and her abdomen was harder and more distended than normal. The RNM #1 said she attributed that to the fact that the resident was constipated. She said RN Supervisor #2 notified the physician on [DATE] and obtained an order for [REDACTED]. She said the resident was then rolled onto her back and was not breathing, and did not have a pulse. She said that a Code blue was called. She said that resuscitation was unsuccessful, and the resident passed away. The surveyor and RNM #1 reviewed the resident's BM records together. RNM #1 said there are many blanks and she cannot assume when there is a blank, that the resident moved her bowels. She said she can see there are many times since (MONTH) when the bowel protocol should have been started but there was no documentation in the progress notes or on the MAR that it was done. RNM #1 said she would have expected the resident's abdomen to be checked, bowel medications started, results documented, and the RN notified if there were no results. RNM #1 said that she or the ADON were responsible for developing the CCP. She said there should have been a care plan for constipation so that staff are aware of the resident's problems and interventions that are in place. When interviewed on [DATE] at 8:20 a.m. by telephone, LPN #3 said that the bowel protocol in general is that if a resident does not have a BM in two days, the resident is given prune juice. LPN #3 said that if there are no results the next day, the resident is given [MEDICATION NAME] tablets and then the next day they are given a [MEDICATION NAME] suppository. She said the resident's abdomen should also be checked as to whether it is distended or hard. If the resident has still not had any BMs, the physician should be notified. LPN #3 said that all of that information should be documented in the progress notes and 24-hour report. LPN #3 said she was on vacation during the last two weeks of (MONTH) and when she returned to work on [DATE], she found that the resident had not moved her bowels and her abdomen was awfully distended. She said the resident was eating and had not changed behaviorally. She said she believed RNM #1 was calling the physician. LPN #3 said she did not work on [DATE] and when she saw the resident on [DATE], she found her to be more lethargic, not eating as much, her abdomen was more distended, and she groaned when the abdomen was palpated. She said she reported to RNM #1 that the resident's abdomen was getting more distended and harder and harder, and the resident was more lethargic as the day went on. She said RNM #1 told her the resident's gas was building up in her abdomen and she had been given all the oral medications she could be given. LPN #3 said she was pushing prune juice during the day but did not document. She said that at about 5:00 p.m., she went into the resident's room with five other staff members, and RN Supervisor #2 and RNM #1 administered a 1,000 milliliter (ml) SSE while the resident was positioned on her left side. She said after all 1,000 ml went in slowly, the resident was repositioned onto her back, her color changed, and she became unresponsive. LPN #3 said the resident was checked and found to be without a pulse and not breathing. She said CPR was started and a Code blue and 911 were called. She said after the emergency medical technicians arrived and took over CPR, the hospital was contacted and the Code was ended. Interviews conducted on [DATE] included the following: a. At 8:45 a.m., NP #2 said she was filling in for NP #1 who was on vacation. She said when she saw the resident on [DATE] she thought she ordered an x-ray of the abdomen and was not sure why there was no order or x-ray result. She said she wrote several orders, but she cannot see where they were taken off or completed. She said the resident's abdomen was distended but she heard bowel sounds. She said she expected her orders to be carried out and documented. b. At 8:45 a.m., (with NP #2) the Medical Director (also the resident's physician) said he does not look at bowel records but relies on the nursing staff to tell him what is going on. He said he was not made aware that the orders written by NP #2 on [DATE] had not been completed. He said if the orders had been followed, everything would have been done for the resident. He said if he had known the x-ray was not done, he would have ordered it. He said the x-ray could have shown a high obstruction, ileus or partial obstruction. The Medical Director said he would like to hammer down on the documentation and be sure the BM protocol is being followed. The Medical Director said if he had known in (MONTH) that the resident was not moving her bowels, he would have put her back on [MEDICATION NAME]. c. At 10:45 a.m., the RNM #1 stated that on [DATE] she worked with NP #2 and faxed the bowel orders to the pharmacy. She said she gave a copy to the nurse working the unit and expected her to take off the orders and put them on the MAR. She said there was no second check on the orders because they were never taken off. RNM #1 said she does not see any documentation that the orders written on [DATE] and [DATE] were implemented. RNM #1 said she does not remember NP #2 asking for a x-ray of the abdomen. d. At 11:57 a.m., the ADON said that no one reported to him that the resident was not moving her bowels. He said the RNM #1 was responsible to develop and update the CCP and there should have been a care plan for constipation. 3. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated [DATE], included that the resident had moderately impaired cognition. Review of the [DATE] CCP and the currently in use CNA care plan revealed the resident was incontinent of bowels and required assistance of two staff with toileting. Review of physician orders [REDACTED]. If no results in one day from the juice, give two [MEDICATION NAME] tablets on the day shift. If no results on the following day by 6:00 a.m. from the [MEDICATION NAME] tablets, insert one [MEDICATION NAME] suppository rectally. If no results the following day, call the primary physician. Review of the resident's Bowel Movement Record revealed that the resident went without a BM for greater than three days (nine shifts) on two occasions in (MONTH) (YEAR), one occasion in (MONTH) (YEAR), one occasion (MONTH) (YEAR), and one occasion in (MONTH) 2019. Review of the progress notes, from [DATE] through [DATE], does not document any evaluation of the resident's BMs or abdomen, use of as needed bowel medications, pushing fluids or prune juice, results from bowel medications, or physician notification. Review of the MARs, from (MONTH) (YEAR) to (MONTH) 2019, revealed no documentation that the resident's as needed bowel medications were administered. When interviewed on [DATE] at 10:40 a.m., RNM #1 said that she was not made aware that the resident was not moving her bowels regularly. She said that the bowel protocol should have been started after four days without results, and the medical provider should have been notified. Interviews conducted on [DATE] included the following: a. At 2:45 p.m., the DON said she expects the bowel protocol to be followed and documented. She said the facility has been aware for several months that overall there was a lack of CNAs documentation. She said that staff are encouraged to document but the lack of documentation was really a setback for the facility. The DON said she was aware that agency nurses are not reviewing the documentation, but she cannot fire them all. She said she would have expected the RNM to be reviewing documentation. b. At 3:18 p.m., the Administrator stated that he was not made aware of documentation issues until after the surveyor arrived to investigate. He said medical staff should have been notified according to bowel protocol and they were not. (10 NYCRR 415.12)