Every finding on record at St. Ann's Community

Based on interviews and record review conducted during the Abbreviated Survey (NY00345886) for one (1) (Resident #3) of (3) three residents reviewed for pressure ulcers (injury), the facility failed to ensure the resident received the necessary care, treatment and services consistent with professional standards of practice to promote the healing of a pressure ulcer, prevent infection, and prevent new ulcers from developing (unless the individual's clinical condition demonstrates they were unavoidable). Specifically, Resident #3, who was assessed to be at risk for pressure ulcer development, was identified as having an open area on their left buttocks on 06/07/2024. A wound consult was ordered, but the medical team was not notified of the open area for five (5) days and there were no medical treatments ordered. Additionally, the resident's care plan, including interventions, was not updated and implemented promptly to prevent further deterioration of the pressure ulcer. Subsequently, Nurse Practitioner #5 identified deterioration to the pressure ulcer on the left buttocks and multiple new skin injuries were identified. This resulted in actual harm to Resident #3 that is not Immediate Jeopardy and is evidenced by the following: The facility's policy Skin Care Management, dated 06/20/2024, documented that skin care management will be provided to all elders/patients. For any change in skin integrity noted by a nurse, the Altered Skin Observation Form will be completed, and nurses, managers, coordinators, supervisors, and the Assistant Director of Nursing will: review to ensure new skin issues are addressed in a timely manner; if wounds/ulcers are identified, refer to the Skin Integrity and Wound Management Book (Clinical Practice Quick Reference Guide) for care and treatment guidelines; re-review the proactive interventions as outlined on Pressure Ulcer Proactive Interventions per the Braden Scale Score to ensure all appropriate measures are considered; and generate a referral for skin rounds (wound consultant). The Facility's Clinical Practice Quick Reference Guide, revised October 2019, documented that for Stage 2 (superficial opening that often presents itself as an abrasion, blister, or shallow crater) pressure ulcer to the buttock area, use barrier cream or zinc product twice daily and PRN (as needed). For unstageable (unable to determine the depth/extent of the wound due to dead tissue) pressure ulcer, manage exudate (drainage), fill dead space, and debride (remove dead tissue). If wound is dry or with light drainage, then clean the wound with saline, apply no-sting (liquid skin protectant), and apply a bordered gauze dressing every 24 hours and PRN (as needed). Resident #3 was admitted to the facility with diagnoses including a recent urinary tract infection, heart failure and chronic obstructive pulmonary (lung) disease requiring oxygen. The Minimum Data Set (an assessment tool), dated 06/05/2024, documented the resident had moderate impairment of cognitive function, was dependent on staff for transfers, and required partial to moderate assistance with bed mobility. The resident had an indwelling urinary catheter, was always incontinent of bowel, was at risk for pressure ulcer development, had no pressure ulcers or wounds at the time, and had a pressure reducing mattress and/or cushion. Resident #3's Baseline Care Plan for skin integrity, dated 05/29/2024, documented the resident was at risk for alteration in skin integrity. The goal was for the resident to be free from skin breakdown. Interventions included, but were not limited to, nursing treatments per medical orders, preventative skin care products, weekly skin checks by a nurse, daily skin inspection with AM and PM care, encourage and support movement and self-positioning as able, and for staff to promptly report skin integrity changes. A specialty mattress and cushion were added on 06/12/2024. The 05/30/2024 Braden Scale (an assessment tool used to predict a resident's risk of developing pressure ulcers) documented Resident #3 was at mild risk (score of 16) for developing pressure ulcers. Review of the Weekly Skin Observation form, dated 06/03/2024 and signed by Licensed Practical Nurse #6, revealed Resident #3 had no pressure ulcers or skin impairments. The Resident Care Summary Kardex (care plan used by the Certified Nursing Assistants for daily care), dated 06/06/2024, documented Resident #3 was non-ambulatory and required assist of one staff for transfers using a mechanical lift, moderate assist of one for bed mobility, use of a non-skid pad to prevent sliding in their recliner chair, maximum assist for bathing, keep their skin moisturized, and use a specialty cushion (in the chair). In an Altered Skin Integrity Report, dated 06/07/2024, Licensed Practical Nurse #2 documented Resident #3 had an area of broken skin 2 centimeters by 2 centimeters on the left buttocks. The Clinical Coordinator Licensed Practical Nurse #3 was notified, and a wound consult ordered. There was no documented evidence that the medical team was notified or if any new treatments were implemented. In an Interdisciplinary Progress Note, dated 06/08/2024, Registered Nurse #4 documented Resident #3 had an area of eschar (dead tissue) on their left ankle approximately 2.5 centimeters in diameter with mild redness, which was left open to air and a wound consult ordered. There was no documented evidence that the medical team was notified or if any new treatments were implemented. There was no documented evidence of any care plan updates to include interventions for the open area on the left buttocks or the pressure area on the left ankle to prevent further deterioration and/or additional pressure ulcers from developing. In a Wound Consult note dated 06/12/2024, Nurse Practitioner #5 documented the following skin issues: - Unstageable sacral (buttocks) pressure wound 9.5 centimeters x 9.2 centimeters x 0.2 centimeters. - a right heel blister deep tissue injury 4 centimeters x 7 centimeters - a left ankle stage 3 (full thickness tissue loss) pressure wound 1.5 centimeters x 1 centimeter x 0.2 centimeters. - a right bunion deep tissue injury. - a stage 2 pressure ulcer on the scrotum. - a deep tissue injury to the resident's lower back. Nurse Practitioner #5 documented that Resident #3 was started on antibiotics for infection and all pressure injuries were facility acquired. Resident #3 was discharged to the community on 06/18/2024 and did not return to the facility. During an interview on 01/02/2025 at 1:45 PM, Certified Nursing Assistant #1 stated it was their responsibility to report any new reddened area to the team leader. Certified Nursing Assistant #1 stated they had noticed a red area on Resident #3 (buttocks) and reported the area to Licensed Practical Nurse #2 who told them to put moisturizer cream on the area. During an interview on 01/02/2025 at 2:00 PM, Licensed Practical Nurse #2 stated that as Team Leader, their responsibility was to evaluate the reported reddened area and document any findings in an Altered Skin Integrity Report and to notify Clinical Coordinator Licensed Practical Nurse #3, which they did do. During an interview on 01/07/2025 at 11:30 PM, Clinical Coordinator Licensed Practical Nurse #3 stated they had received a report of a reddened area on Resident #3's sacrum and they placed a wound consult order. Clinical Coordinator Licensed Practical Nurse #3 stated wound consults were completed once a week unless you called and asked for an earlier consult. Clinical Coordinator Licensed Practical Nurse #3 stated no request for an earlier consultation was made and no notification to the provider for any treatments to the area was made. In a follow-up interview at 12:00 PM, Clinical Coordinator Licensed Practical Nurse #3 stated they were made aware of Resident #3's scabbed area on the resident's left ankle on 06/08/2024, but did not notify the medical provider or request any treatments or document it in the electronic medical record. During an interview on 01/07/2025 at 1:30 PM, Nurse Practitioner #5 stated when a wound consult is ordered, wound rounds would be made on the next scheduled day of the week and are then done weekly. If a wound consult is required sooner, staff just need to make a call and they would come and assess the resident sooner. Nurse Practitioner #5 stated there had been no request to come sooner for Resident #3 and that interventions were not followed according to the facility's Clinical Reference Quick Guide (for skin issues). During an interview on 01/07/2025 at 10:00 AM, the Chief Nursing Officer stated Clinical Coordinator Licensed Practical Nurse #3 was responsible for notifying the provider and obtaining an order for the pressure area when it was discovered on 06/07/2024, and had received additional in-house training for the senior nurse role. The Chief Nursing Officer stated they had not focused on Registered Nurse #4's (lack of intervention) during their investigation, just Clinical Coordinator Licensed Practical Nurse #3. 10 NYCRR 415.12(c)(1)

Based on observations, interviews, and record review conducted during a Recertification Survey, for one (Resident #330) of one resident reviewed, the facility did not provide services to meet professional standards of quality.Specifically, multiple doses of a medication were left unattended at the resident's bedside with no assessment completed to ensure the safety of. This is evidenced by the following: The facility policy, Patients on Self-Medication, dated 6/6/20, documented that medical and nursing staff determine if an elder is safe to self-administer medications using nursing admission assessment to identify if patient self-medicated at home. Medical staff orders self-medications based on this information. Elders on self-medication will have a secure area provided. Resident #330 had diagnosis including narrowing of the esophagus, mild cognitive impairment, and gastroesophageal reflux disease (stomach acid repeatedly flowing back into the esophagus). The Minimum Data Set Resident Assessment, dated 3/6/24, revealed Resident #330 was moderately impaired cognitively. Review of Resident #330's current Comprehensive Care Plan revealed no information related to the residents' ability to safely self-administer medications. Review of Resident #330's current Physician's orders revealed an order for calcium carbonate 500 milligram chewable tablet one time daily. The orders did not include the resident was able to self-administer medications. Review of Resident #330's April 2024 Medication Administration Record revealed that calcium carbonate 500 milligram chewable tablet was signed off as administered 4/1/24 through 4/11/24. During an observation and interview on 4/9/24 at 3:29 PM, Resident #330 was sitting in recliner in room with a medication cup containing a tablet (identified as calcium carbonate). Resident #330 stated that the medication in the medication cup was Tums and stated the nurse leaves it for them daily. Resident #330 then poured the tablet into another medication cup in their bed side tray table drawer where seven other similar tablets were observed. During an observation on 4/11/24 at 9:38 AM, Resident #330 opened their bed side tray table and displayed another medication cup containing approximately 26 similar tablets. Resident #330 stated at this time that they did not need them anymore. During an interview on 4/11/24 at 4:02 PM Licensed Practical Nurse #1stated there were currently no residents that were able to self-administer medications on the unit. Licensed Practical Nurse #1stated part of the process for administering medications was to ensure the resident swallowed their medications. During an interview on 4/11/24 at 4:15 PM Registered Nurse Manager #1 stated Resident #330 was not able to self-administer medications. Registered Nurse Manager #1 opened Resident #330's bed side table drawers and took out 2 medication cups filled with chewable tablets and stated they should not be in the drawer. In a nursing progress note dated 4/11/24 at 5:12 PM, Registered Nurse Manager #1 documented that 35 calcium carbonate tablets were found in Resident #330's bed side tray and were removed from the room. 10 NYCRR 415.11(c)(3)(i)

Based on observations, interviews, and record review conducted during a Recertification Survey, for one (Resident #78) of two residents reviewed, the facility did not ensure that appropriate treatment and services were provided to prevent urinary tract infections for a resident with an indwelling urinary catheter (tube inserted into the bladder to drain urine). Specifically, Resident #78 was observed on several occasions with their uncovered urinary drainage bag (bag used to collect urine through the indwelling urinary catheter) lying directly on the floor including an observation of their urinary drainage bag resting on a dining room table above the level of their bladder with several staff within view. Additionally Resident #78's Comprehensive Care Plan did not include goals and/or interventions related to any resident behaviors related to their urinary catheter and/or urinary drainage bag. This is evidenced by the following: The current facility policy, Urinary Catheter Use and External Catheter Use Guidelines dated 7/12/22, included maintenance procedure of indwelling urinary catheter: at no time should the tubing be placed above the level of the bladder to allow back flow of urine into the bladder. Secure urinary drainage bag below the level of the bladder on the side of the bed frame and keep off the floor at all times. Use a dignity cover as needed. Resident #78 had diagnosis including neurogenic bladder (bladder with diminished sensation), benign prostatic hyperplasia (enlargement of the prostate), and dementia. The Minimum Data Set Resident Assessment, dated 4/5/24, documented the resident had severely impaired cognition, had an indwelling urinary catheter and had no behaviors identified for that time period. Review of Resident #78's current Comprehensive Care Plan revealed that Resident #78 had a suprapubic catheter (indwelling urinary catheter inserted directly into the bladder via the abdomen) due to urinary retention and neurogenic bladder with interventions to keep the bag below the level of the bladder whether sitting, lying, or walking and to change the urinary drainage bag daily. The Comprehensive Care Plan did not include that Resident #78 had any behaviors related to care of their urinary catheter and/or drainage bag. Review of Resident #78's Resident Care Summary (care plan used by the Certified Nursing Assistants for daily care), dated 4/15/24, revealed the resident had a suprapubic catheter but did not include instructions to staff to keep the bag below the level of the bladder or any resident behaviors related to their urinary catheter and/or drainage bag. Review of the current physician's orders included a suprapubic catheter to gravity drainage, to change the catheter every four weeks and the urinary drainage bag daily if being changed over to a leg bag and to change the leg bag daily. During an observation on 4/9/24 at 12:17 PM, Resident #78's uncovered urinary drainage bag was directly on the floor in the common area. There was no hook on the drainage bag (used to secure the bag to the bedframe or chair and off the floor). During an observation on 4/10/24 at 8:50 AM Resident #78's uncovered urinary drainage bag was directly on the floor in their room. There was no hook on the drainage bag. During observations on 4/11/24 at 9:43 AM Resident #78's uncovered urinary drainage bag was directly on the floor in their room. There was no hook on the drainage bag. During observations on 4/11/24 at 4:08 PM Resident #78's urinary drainage bag was sitting on the dining room table above the level of their bladder. Several staff members were in visibility of the resident in the dining room at the time. During an interview on 4/16/24 at 9:36 AM Certified Nursing Assistant #1 stated they usually cover it (urinary catheter bag) and keep it below the bladder and off the floor. Certified Nursing Assistant #1 stated that if a urinary drainage bag did not have a hook, they would let a nurse know so it (urinary catheter bag) was not dragging on the floor, and we should never put a urinary drainage bag on a table or anywhere above the bladder. Additionally Certified Nursing Assistant #1 stated that Resident #78 sometimes played with their catheter bag and the tubing. During an interview on 4/16/24 at 10:11 AM Licensed Practical Nurse #4 stated staff should never leave the urinary drainage bag sitting on the floor and it should always be covered and hanging below the level of the bladder. Licensed Practical Nurse #4 stated Resident #78 had a history of playing with their urinary drainage bag, taking the cover off and have been known to pick up the drainage bag and put it on the table. During an interview on 4/16/24 at 11:10 AM Registered Nurse Manager #1 stated facility policy and procedures should be followed, and a urinary drainage bag should not be on the floor for infection control reasons. Additionally, Registered Nurse Manager #1 stated Resident #78 has at times moved their drainage bag, pulled the bag off, or emptied the bag. During an interview on 4/16/24 at 1:29 PM the Chief Nursing Officer stated that urinary drainage bags should not be found on the floor without a barrier and should be positioned above the level of the bladder. The Chief Nursing Officer stated it (care of the urinary drainage bag and any behaviors related to it) should be added to their individualized care plan. 10 NYCRR 415.12(d)(1)

Based on observations, interviews, and record review conducted during a Recertification Survey, for two (Residents #62 and #238) of four residents reviewed, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. Specifically, there was a lack of appropriate hand hygiene (washing hands or using alcohol-based hand sanitizer) and lack of appropriate glove use observed during wound care for both residents. This is evidenced by the following. The facility policy, Precautions-Standard and Transmission Based of Infectious Organisms, revised 3/22/24, documented that gloves are to be worn at all times when delivering resident personal care, and when there is contact with blood, body fluids or mucous membranes. Wearing gloves does not replace the need for hand hygiene. Hand hygiene must be performed whenever gloves are removed. Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employs targeted gown and glove use during high contact resident activities. Enhanced Barrier Precautions are used with residents that have wounds or indwelling devices and are utilized when performing wound care (any skin opening requiring a dressing). Review of the facility policy Hand Hygiene, revised 10/21/22, included that hand washing is the single most important means of preventing the spread of infection from one person/environment to another. Hand hygiene should occur after touching secretions (liquids produced by the body) with wound drainage, skin infections, or blood. Alcohol-based hand sanitizer or hand washing should occur after removing gloves, and before and after touching a resident. 1. Resident #238 had diagnoses of diabetes, gangrene (death of body tissue due to lack of blood flow or serious bacterial infection) of the left second toe, and multiple pressure ulcers/injuries. The Minimum Data Set Resident Assessment, dated 2/26/24, documented that Resident # 238 was severely impaired cognitively and had several pressure ulcers/injuries which required care. In a medical wound status report dated 4/10/24, Nurse Practitioner #1 documented that Resident #238 had the following pressure ulcers/injuries: -A deep tissue injury (a localized area of purple or maroon discoloration of intact skin or blood-filled blister indicating underlying soft tissue injury) of the left outer foot (wound #1). -An unstageable pressure ulcer/injury covered with slough or eschar (dead tissue that prevents assessment of the true depth of an ulcer) to the left second toe (wound #2). -An unstageable pressure ulcer to the left third toe (wound #3). -A stage 2 (partial thickness loss of skin that appears as a shallow crater) to the left buttock (wound #4). -A stage 2 pressure ulcer to the natal cleft (the groove between the buttocks) (wound #5). Review of current Physician orders dated 4/10/24 included treatments for all the above pressure ulcers/injuries listed above. Observation of wound care on 4/12/24 at 10:16 AM for Resident #238 included the following: -Licensed Practical Nurse #2 put on a disposable gown and gloves. Licensed Practical Nurse #2 did not complete any hand hygiene prior to applying the gloves. -Licensed Practical Nurse #2 removed the soiled dressing from wound #1. Licensed Practical Nurse #2 did not change gloves or perform hand hygiene after touching the soiled dressing prior to applying the prescribed treatment and a clean dressing. -Wearing the same gloves, Licensed Practical Nurse #2 then removed the soiled dressing from wound #2 (gangrenous toe wound) and applied the prescribed treatment and a clean dressing without performing hand hygiene or changing their gloves. -Wearing the same gloves and without performing hand hygiene, Licensed Practical Nurse #2 applied clean gauze between wound #2 and wound #3. -Licensed Practical Nurse #2 removed their soiled gloves and without performing hand hygiene, applied clean gloves and removed the soiled dressing from wound #4 and wound #5. Treatments and new dressings were again provided to both wounds without completing hand hygiene or changing gloves. -Wearing soiled gloves, Licensed Practical Nurse #2 assisted Resident #238 with repositioning then removed their gloves, and placed a tube of cream in their shirt pocket without performing hand hygiene. During an interview on 4/12/24 at 11:10 AM, Licensed Practical Nurse #2 stated that they should have performed hand hygiene and re-glove between wounds, but they were in a hurry. During an interview on 4/12/24 at 12:55 PM, Registered Nurse Manager #2 stated that hand hygiene and changing of gloves should be performed after removing the old dressing before applying a new dressing and between care of different wound sites. 2. Resident #62 had diagnoses including a recent periprosthetic fracture (broken bone that occurs around the prothesis following knee or hip surgery) and a stage 3 pressure ulcer/injury (full thickness wound involving damage to or necrosis of tissue). The Minimum Data Set Resident assessment dated [DATE], documented the resident was moderately impaired cognitively and had a stage 3 pressure ulcer/injury. Current Physician orders included treatments to the stage 3 natal cleft area daily and as needed. During an observation & interview on 4/12/24 at 9:41 AM, Licensed Practical Nurse #3 put on a pair of gloves and removed the soiled dressing from Resident #62's pressure ulcer/injury. Without changing gloves or completing hand hygiene, Licensed Practical Nurse #3 applied the prescribed treatment and a clean dressing. Using the same pair of gloves used to change the resident's dressing, Licensed Practical Nurse #3 then touched the Apex machine (a device to assist a resident with transferring), Resident #62's clothing, their own face mask and multiple environmental surfaces. Licensed Practical Nurse #3 stated at that time that they did not change their gloves after removing the soiled dressing but should have. In an interview on 4/12/24 at 2:22 PM. the Infection Control Nurse stated hand hygiene should be performed prior to resident care and after taking off their gloves. The Infection Control Nurse said gloves should be changed and hand hygiene performed after removing the old dressings between each wound area on the body and nurses should not touch anything else (in the room) with the same pair of gloves after a dressing change. During an interview on 4/16/24 at 10:31 AM, the Chief Nursing Officer stated they would expect the nurses to remove gloves, perform hand hygiene and apply new gloves before proceeding to another wound and should also administer care from the cleanest wound first then proceed to the dirtiest wounds to prevent contamination. 10 NYCRR 415.19(b)(4)

Based on record review and interview conducted during the Recertification Survey completed on 9/22/22, it was determined that for three (Employees #1, #4 and #5) of five employee files reviewed, the facility did not implement written policies and procedures to prevent abuse, neglect, exploitation, and misappropriation of resident property related to screening prospective employees. Specifically, a nurse aide registry (NAR) abuse screening was not completed prior to new employees beginning work. The findings are: On 9/19/22 from 2:00 p.m. to 3:27 p.m., documentation related to five recently hired employees was reviewed. The records included: 1. Employee #1 was hired as an Environmental Services Assistant on 8/8/22. The documentation provided included a NAR abuse screening for employee #1 dated 8/24/22. Further record review included a fingerprinting consent form signed by employee #1 marked as having a final finding of patient or resident abuse. When interviewed via email regarding this statement by Employee #1, the Director of Human Resources stated that Employee #1 said this was a mistake and was asked to come in and fix it but did not. Further record review included Employee #1 did not complete the fingerprinting process and was terminated from service on 8/29/22. 2. Additionally, Employee #4 was hired on 8/22/22 as a Household Dining Cook and the NAR screening was dated 8/24/22. 3. Employee #5 was hired as a Mechanic on 8/8/22 and the NAR screening was dated 8/24/22. 4. During subsequent interview via email correspondence, the Director of Human Resources stated that for employees #1, #4, and #5, a monthly audit revealed that a few checks were not done, so we did it immediately after we noticed. On 9/19/22 at 3:30 p.m., a review of the facility policy NSG-07 'Resident Abuse/Neglect/Mistreatment' policy, dated as revised 7/22/22, revealed under Employee screening: During the pre-employment process, the Human Resources Department clears potential employees through the Nursing home Nurse Aide Registry. On 9/22/22 at 12:58 p.m., the Director of Human Resources provided the surveyor with documentation to show the past non-compliance related to NAR screening had been corrected and included: a. An audit performed on 8/24/22 showing all new employees hired within the past 5-months were reviewed to ensure a NAR screening had been performed. b. Documentation that education was provided during a Human Resources team meeting on 9/9/22 with a list of staff who attended. c. A Human Resources onboarding checklist including NAR screening. 10 NYCRR: 415.4(b)(1)(ii)(b)

Based on observations, interviews, and record reviews conducted during a Recertification Survey completed on 9/22/22, it was determined that for 7 (Residents #178, #187, #245, #247, #281, #298 or #357) of 35 residents reviewed, the facility did not ensure that a Baseline Care Plan (BCP) was developed and implemented within 48 hours of admission that included the minimum healthcare information necessary to properly care for the immediate needs of the resident and that a written summary of the care plan, that they were able to understand, was provided and reviewed with the resident and/or their representative in a timely manner per the regulations. This was evidenced by, but not limited to, the following: The facility policy Care Planning - Interdisciplinary, dated as last revised on 7/12/22, documented that the policy of the facility was to initiate and complete a BCP within 48 hours of admission and address, at a minimum, initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The BCP will transition to a comprehensive care plan (CCP) based on the needs of the elder/patient utilizing, at a minimum, the use of the Minimum Data Set (MDS) Assessment to assess the elder's clinical condition, cognitive and functional status, and use of services. In addition, the policy mentioned that prior to the scheduled care plan meeting, the elder's BCP or CCP, medication list and Certified Nursing Assistant (CNA) care card (care plan used by CNAs for daily care) would be offered to the elder and/or designated family member. The policy included that a copy of the BCP or CCP, the elder's CNA care card and a list of the elder's current medications would be provided to the elder or their representative, if applicable, and a note would be written into the electronic health record to confirm this information was provided. 1.Resident #187 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS Assessment, dated 8/1/22, documented that the resident was severely impaired cognitively, required extensive assist of staff with most of their activities of daily living, that English was not the resident's preferred language, and that the resident required an interpreter. Review of Resident #187's Electronic Medical Record (EMR) revealed a 19-page 'Care Plan Report' dated effective 7/25/22 to 9/20/22 that included problems, goals, and interventions. There was no care plan summary or documented evidence that a care plan or a summary was provided to or reviewed with Resident #187's representative, that they were able to understand, prior the care plan meeting. 2. Resident #245 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #245's EMR revealed a 7-page 'Care Plan Report' dated effective 8/17/22 to 8/24/22 that included problems, goals, and interventions. There was no care plan summary or documented evidence that a care plan or a summary was provided to or reviewed with Resident #245 or their representative, that they were able to understand, prior the care plan meeting. 3. Resident #298 was admitted to the facility 8/31/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS assessment dated [DATE], included that the resident was severely impaired cognitively and required extensive assist of staff for most of their activities of daily living. Review of the resident's EMR revealed a 12-page 'Care Plan Report' dated effective 8/31/22 to 9/7/22 that included problems, goals, and interventions. The facility could not provide evidence that the care plan or a care plan summary was provided to or reviewed with Resident #298 or their representative, in a manner they could understand, prior to the care plan meeting. During an interview on 9/20/22 at 9:36 a.m., Social Worker (SW) #1 stated that BCPs should be completed as soon as possible (within 14 days) and are not discussed with the family. Once the BCP is completed, it is converted to the CCP, which is then printed and sent to families (via mail or e-mail), along with the medications and care card. The social worker stated that it is expected that the resident or family bring the provided information to the first care plan meeting which is usually within two to three weeks. During an interview on 9/20/22 at 11:15 a.m., Nurse Manager (NM) #1 stated that when a resident is admitted , a BCP is obtained within 24 hours by the Registered Nurse (RN). NM #1 stated that if the resident is alert and oriented, the resident will be included in the baseline care plan process. If there is an issue or concern with the BCP, it will be discussed with the resident's family. Once the BCP is completed, it is converted to a CCP by Social Work. The CCP is then reviewed with the resident and family during the care plan meeting, which is held after two weeks. During an interview on 9/20/22 at 11:51 a.m., SW #2 stated that information for the BCP is gathered when residents first come in. The involved disciplines gather and provide the information needed for their assigned parts of the care plan, which is usually within a week. SW #2 stated that stated that neither residents nor the representatives are provided a copy of the BCP. During a follow-up interview on 9/21/22 at 9:03 a.m., SW #1 stated that copies of the BCPs are not given to residents or their representative. SW #1 stated that the CCP, medication list and care card are provided to the resident or representative via regular mail, e-mail or are left in the resident's room and this should be documented on a form in the EMR records that the care plan, medication list and care card were sent to the resident or representative. During an interview on 9/22/22 at 10:19 a.m., the Assistant Director of Nursing (ADON) stated that BCPs are initiated within 48 hours, or a CCP if all the necessary information is available. The ADON stated that residents or their representative are offered a copy of the care plan, the medication list, and the CNA care card, which is provided in-person, via regular mail or e-mail. The ADON stated that the expectation is that those items are provided to the resident or representative before the care plan meeting. When asked if either a BCP or CCP summary was reviewed with Residents #178, #187, #245, #247, #281, #298 or #357 prior to their initial care plan meeting, the ADON was unable to provide any documented evidence that this was done. 10NYCRR 415.11

Based on record reviews and interviews conducted during a Recertification Survey and complaint investigation (#NY 538 and #NY 375) completed 9/22/22, it was determined that for two (Residents #121 and #608) of seven residents reviewed for abuse, neglect and mistreatment, the facility did not ensure that the resident's environment remained as free of accident hazards as possible. Specifically, both resident's care plans were updated indicating a need for increased assist during transfers, but the change was not made on the Certified Nursing Assistant (CNA) Resident Care Summary (care cards used by the CNAs for daily care) that were posted in the residents' rooms resulting in falls with injuries. The findings are: Facility policy # NSG-03, titled, 'care cards' (also known as Resident Care Summary), included: review care cards with CNAs that are floats, new to assignment, unit, or St. Ann's Community and when cafe plans have been changed. Interdisciplinary team will update care cards as needed. When plan of care is changed the care card is updated and distributed to designated areas. 1.Resident #608 had diagnosis that included metastatic [CONDITION(S)] and a recent a recent [CONDITION(S)] with surgical repair, upper extremity tremors and an impaired gait. Record review of Resident #608's Admission Minimum Data Set (MDS) Assessment, dated 10/24/22, revealed that the resident was severely impaired of cognitive function and required extensive assist of two staff for most of their activities of daily living, including transfers and toileting. Review of Resident #608's Comprehensive Care Plan (CCP) revealed that the resident was at risk for falls related to weakness and impaired mobility. Review of the CNA Resident Care Summary in the Electronic Medical Record (EMR), dated 10/19/21, revealed that Resident #608 required extensive assist of one staff with a stand-pivot for transfers and extensive assist of one for toileting + transfer and may require 2nd person assist depending on fatigue. Review of the CNA Resident Care Summary in the EMR, dated 10/21/22 revealed that Certified Occupation Therapy Assistant (COTA) changed Resident #608's transfer status on 10/21/21 to include a total mechanical lift with two staff assistance for transfers, and under toileting + toileting transfer, the Resident Care Summary documented extensive assist of one staff for toileting routine and may require 2nd person if fatigued and use of a bedpan. The facility 'Incident/Accident Report' dated as time of incident 10/24/22 at 4:30 p.m., included that the on-call medical team was notified at 4:52 p.m., that Resident #608 was unable to move their entire right arm due to pain from elbow to shoulder and that the arm was warm to the touch and pink. Per family, the resident had slipped on the toilet yesterday and slammed their arm into the wall. An x-ray was ordered and revealed an acute right humeral (upper arm bone) fracture and the resident was sent to the hospital. The resident was unable to report what had happened with clarity but did verbalize hitting their elbow while on the toilet. The facility 'Investigative Summary' dated as completed on 10/28/21 and signed by Registered Nurse Manager #1, included that staff had transferred Resident #608 to the toilet with an Apex lift (sit to stand lift) (vs using a bedpan or a full mechanical lift) and that the updated Resident Care Summary had not been posted in the resident's room following the changes. During an interview on 9/22/22 at 9:15 a.m., the Clinical Manager for rehab stated that Resident #608's care card had been updated by the rehab department on 10/21/21 but that the updated care card had not been replaced in the residents' room. The Clinical Manager stated that it is the responsibility of the person that modifies the care card to ensure that the new card is printed, the changes highlighted and placed in the resident's room. 2. Resident #121 had diagnoses including [CONDITION(S)] (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), [CONDITION(S)] disorder, and a recent fracture of the arm. Review of Resident #121's MDS Assessment, dated 12/6/21 revealed that the resident was unable to complete a Brief Interview of Mental Status (BIMS) but that staff had identified the resident as having independent and reasonable decision making skills. The MDS Assessment documented that the resident required extensive assist of two staff for transfers, ambulation, and toileting. Review of Resident #121's CCP revealed the resident was at risk for injury related [CONDITION(S)], memory impairment, seizures, a history of falls with injury, and exit seeking behavior and required assist with all activities of daily living. The Resident Care Summary, found in the EMR and dated 11/30/21 at 10:25 a.m., documented that Resident #121 required limited assist of one staff with a gait belt and a hemi-walker (half a walker that allows the resident to lean on one side for support) for transfers. The Resident Care Summaries found in the EMR and dated as updated on 11/30/22 at 4:38 p.m., 12/5/21 at 3:05 p.m. and again on 12/6/21 at 11:17 a.m., all included that transfer instructions had changed to use a mechanical sit to stand lift with one assist. In a nursing progress note dated 12/6/21 at 4:54 p.m., Registered Nurse (RN) #1 documented that Resident #121, with the help of CNA #1 and a hemi-walker, was transferring to a wheelchair when the resident lost balance and fell backwards. CNA#1 was unable to break the fall. Resident #121 hit their head and suffered an abrasion to the head. The facility 'Investigation Summary', dated as completed on 12/14/21 and signed by the Assistant Director of Nursing (ADON), included that at the time of the fall Resident #121 care card (Resident Care Summary) listed the resident's transfer needs as a limited assist of one staff with a gait belt and hemi walker. The 'Investigation Summary' documented that the updated care card had not been posted in the resident's room. Additionally, CNA#1 had not used a gait belt according to the outdated care card that was posted in the resident's room During an interview on 9/22/22 at 9:00 a.m., the Clinical Manager for rehab stated that Resident #121's care card had been updated by the rehab department on 11/30/21 and the care card had not been replaced in the residents' room. The Clinical Manager stated that it is the responsibility of the person that modifies the care card to ensure that the new card is printed, the changes highlighted, and the new care card placed in the resident's room. During an interview on 9/22/22 at 10:20 a.m., the Assistant Director of Nursing (ADON) stated that the person that updates the care card should print it and swap it out in the resident's room. During an interview on 9/22/22 at 11:00 a.m., the RN educator stated that the CNAs are trained that the care card is behind the resident's room door and that it should be reviewed before providing care. NYCRR 415.12 (h)(2)

Based on observations, interview, and record review conducted during the Recertification Survey completed on 9/22/22, it was determined that the facility did not ensure compliance with all applicable State codes. Specifically, the facility was not in compliance with section 915 of the 2015 edition of the International Fire Code as adopted by New York State, which requires the use of carbon monoxide detection in a building that has fuel-burning appliances. The findings are: During the initial tour of the ground floor kitchen on 9/15/22 between 8:53 a.m. and 9:40 a.m. it was observed that a natural gas range was present and in use, and there were no carbon monoxide detectors within the kitchen. Additionally, on 9/16/22 from 8:30 a.m. to 10:00 a.m. it was observed that there were no carbon monoxide detectors present in the basement, ground floor, and lobby level of the 9-story St. Ann's Home. The basement was observed to include a potential carbon monoxide source in the boiler room. A summary of carbon monoxide detectors throughout the facility was sent to the surveyor via email by the Director of Facilities and included that there are no carbon monoxide detectors on the 1st and 2nd floors in the St. Ann's Home because there are no natural gas sources on either of these floors. During an interview on 9/20/22 at 10:42 a.m., the Director of Facilities stated that they did not believe that there were carbon monoxide detectors in the basement, ground floor, or lobby. The 2015 edition of the International Fire Code (IFC), requires carbon monoxide detection to be provided in an approved location between the fuel burning appliance and the dwelling unit, sleeping unit, or classroom; or on the ceiling of the room containing the fuel-burning appliance. 10NYCRR: 415.29(a)(2), 711.2(a)(1); 42 CFR: 483.70(b), 2015 IFC: Section 915, 915.1, 915.1.4, Section 1103.9

Based on interviews and record review conducted during an Abbreviated Survey (#NY00273240) completed on 6/30/22, the facility failed to protect a residents' right to be free from abuse for one (Resident #12) of twelve residents reviewed for abuse. Specifically, Resident #12, who had severe cognitive impairment, was photographed by Certified Nursing Assistant (CNA)#1 while in bed wearing only a soiled brief. The photograph was shared via cell phone to CNA#2. The findings are: The facility policy Abuse/Neglect Mistreatment Policy, last revised 4/11/22, documented that the facility does not tolerate abuse, mistreatment, or neglect of residents/patients. Should abuse, mistreatment or neglect of resident's/patient's occur, or be suspected, St. Ann's Community has an investigating process that follow the rules and regulations as established by state and federal regulations, with mandated Internal and External reporting as indicated. The policy did not include guidance on abuse related to photographing of residents. The facility policy Photography, Audio Recording, and Other Smart Device Usage, last revised 2/21/22, indicated that workforce members are not permitted to take or use in any way photographs, audio recording or other images of elders, family members, visitors, or other workforce members at St. Ann's without such person's express written consent. Resident #12 had diagnoses including dementia, cognitive communication deficit, and anxiety disorder. The Minimum Data Set Assessment, dated 2/24/21, documented that the resident had severe impairment of cognitive function. The current Comprehensive Care Plan for cognitive loss/dementia, documented that Resident #12 had impaired cognition due to dementia which affects their short-term memory and orientation. The Incident/Accident Report dated 3/19/21 and signed by the Assistant Director of Nursing (ADON), documented that on 3/11/21, CNA #1 took an unauthorized photograph of Resident #12 while working the night shift. In the photograph the resident was in bed, undressed except for a soiled brief. CNA #1 then sent the photograph of Resident #12 via text message on their personal cell phone to CNA #2's (evening shift staff) personal cell phone. In a written statement received by the facility dated 3/16/21, CNA #2 stated that they had received a photograph of a naked resident (from CNA #1) on their phone which they first saw on 3/12/21 day shift of a resident that CNA #2 had cared for on the previous evening shift. CNA #2 stated they showed it to the Licensed Practical Nurse (LPN) #1 because they knew it was a violation of HIPAA (Health Insurance Portability and Accountability Act or Privacy Act) and also showed it to Registered Nurse (RN) Supervisor #1 who told CNA #2 they would find out what steps needed to be taken. In a statement received by the facility via email dated 3/16/21, CNA#1 stated that they had shared the photograph of Resident #12 with CNA#2 and that they were aware that it was breaking the HIPAA law. CNA #1 stated they were sharing concerns over the care of the residents on the unit. CNA#1 stated that they understood and accepted any consequences behind their action for violating the law. During a telephone conversation on 6/27/22 at 2:50 p.m., CNA#1 stated that they understood that taking the photograph and sharing the photograph was wrong and added that the photograph was not taken to humiliate the resident but to show CNA #1 the resident's soiled condition. During an interview on 6/28/22 at 2:59 p.m., RN Supervisor #1 stated that the incident was clearly negligent and that they told CNA #2 they needed to report it right away. RN Supervisor #1 stated that they educate staff (regarding abuse/photographing) on orientation and with yearly mandatories. During an interview on 6/30/22 at 1:23 p.m., the ADON stated that they were not made aware of the photograph until March 16, 2021. The ADON added that once they had seen the photograph, they contacted Human Resources to determine the next step. The ADON stated that CNA #1 had been suspended on 3/16/21 and that the DON and Administrator were made aware the same day. During an interview on 6/30/22 at 3:30 p.m., the Administrator stated that they do everything they can to prevent this from occurring including ongoing education and that CNA #1 was terminated as soon as Administration became aware of the incident. Review of staffing logs revealed CNA #1 worked at the facility on 3/14/21 (2 days after the incident occurred) and was suspended on 3/16/21. 415.4 (b)(1)(i)

Based on observations, interviews, and record reviews conducted during an Abbreviated Survey (#NY00273240) completed on 6/30/22, it was determined that for one (Resident's #12) of twelve residents reviewed for abuse, neglect, mistreatment, the facility did not ensure that all alleged violations of abuse, neglect or mistreatment were immediately reported to the state survey agency, in accordance with the regulations. Specifically, the facility did not report an alleged violation of resident abuse within 24 hours to the facility Administrator or to the New_York State Department of Health (DOH) following reasonable suspicion of abuse. The findings are: The facility policy Resident Abuse/Neglect/Mistreatment dated 4/11/22, included incidents of witnessed or suspected resident/patient abuse, mistreatment or neglect or unexplained injuries (i.e., origin or etiology unknown or failure to follow the care plan) are to be reported immediately to the supervisor/manager and the Director of Nursing (DON) or Chief Nursing Executive. In addition, the supervisor (or directors/managers) are to report suspected abuse or neglect incidents immediately to the on-call Associate Director of Nursing (ADON) and/or the DON or Chief Nursing Executive. The policy included reports must be made to the Department of Health immediately upon achieving a reasonable cause threshold, revealing that misappropriation of property, abuse, mistreatment, or neglect occurred. Immediate is defined as as soon as possible, not to exceed 24 hours. The facility has five working days to complete the investigation after the DOH notification. Resident #12 had diagnoses that included, dementia, history of falls and heart failure. The Minimum Data Set assessment dated [DATE], documented the resident had severe impairment of cognitive function. A facility Incident/Accident (I/A) Report dated 3/19/21, signed by the ADON, documented that an incident had occurred on 3/11/21 at 11:42 p.m., in which Certified Nurse Assistant (CNA) #1 took a picture of Resident #12 on a cell phone and sent it to CNA #2 via text. The Investigation Conclusion documented that Resident #12, who was unable to authorize due to cognitive impairment was in bed, undressed except for a soiled brief and uncovered and that this constituted mental abuse. CNA #1 was terminated. The Investigation Summary documented that CNA #2 stated they had reported the incident to Licensed Practical Nurse (LPN) #1 and Registered Nurse (RN) Supervisor #1 on 3/12/21. A statement by LPN #1 included that they had not been notified until 3/13/21 and a statement by RN Supervisor #1 included they were made aware of the photo on 3/15/21 and instructed CNA #2 to inform the ADON. In a statement dated 3/19/21, the ADON stated they were made aware on 3/16/21 by CNA #2. The incident was reported to the State Survey Agency on 3/18/21. During an interview on 6/28/22 at 2:44 p.m., LPN #1 stated that when CNA #2 informed them of the picture they had told CNA #2 that the incident was state reportable. LPN #1 stated they called the nursing supervisor right away but was unable to remember when that was. During an interview on 6/28/22 at 2:59 p.m., RN Supervisor #1 stated that they were informed by CNA #2 at approximately 10:00 p.m. but was unable to remember the day. RN Supervisor #1 stated that they told CNA #2 to report but that they should have called someone themself immediately. During an interview on 6/30/22 at 1:23 p.m., the ADON stated that it is their expectation that staff report concerns regarding resident abuse, neglect or mistreatment immediately to a higher licensing level and that the staff member who took an unauthorized picture of Resident #12 was asked to leave as soon as they (Administration) were aware. The ADON stated that once the facility has an understanding of an event, it is reported to the Department of Health, which the facility tries to do immediately or within 24 hours. During an interview on 6/30/22 at 3:45 p.m., the DON stated that leadership was not notified until 3/16/22 but did not report it until 3/18/22. The DON stated that the expectation is for nursing staff to report suspected incidences of abuse, neglect, or mistreatment to nursing leadership immediately. 10NYCRR 415.4 (b)(2)

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one resident (Resident #187) of three residents reviewed for abuse, the facility did not investigate a concern of rough handling during care that was reported to the nurse. This is evidenced by the following: Resident #187 has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 11/18/19, revealed that the resident's cognitive skills for daily decision making were severely impaired, and the resident required the extensive assistance of two staff members for personal hygiene, bed mobility, bathing, and transfers. When interviewed on 1/2/20 at 8:52 a.m., Licensed Practical Nurse (LPN) #1 said she works the day shift. She said the resident's family member had reported to her that there are some evening Certified Nursing Assistants (CNAs) that are rough with the resident during cares. LPN #1 said she did not report the concerns to a supervisor because she had not observed rough cares on her shift. During an interview on 1/6/20 at 3:10 p.m., the Director of Nursing said the nurse should have immediately reported the family member's concerns to a supervisor and an investigation should have been started. When interviewed on 1/6/20 at 11:49 a.m., the Director of Social Work said any staff member who receives a report of alleged abuse or neglect should report that concern to a supervisor for investigation. (10 NYCRR 415.4(b)(3))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of three residents reviewed for mobility, and one of six residents reviewed for activities of daily living, the facility did not ensure that each resident received appropriate treatment or services to improve or maintain ambulation. Specifically, Resident #187 was not walked consistently on a daily basis with the appropriate equipment, and Resident #254 was not walking independently on a daily basis and staff did not monitor or evaluate for a decline. This is evidenced by the following: 1. Resident #187 has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 11/18/19, revealed that the resident's cognitive skills for daily decision making were severely impaired. The resident required the extensive assist of one staff member to walk on and off the unit and had a functional limitation in range of motion of the upper extremity on one side. An Occupational Therapy (OT) Treatment Plan Summary, dated 11/12/19, revealed that the resident walks daily in their room and 100 feet in the hallway or as resident will allow with the extensive assistance of one staff member. The resident needs assistance to steer the wheeled walker and keep it close to their body. The resident should have a right walker hand splint which should be secured with a strap over the wrist. The resident will need encouragement to keep walking and may need more assistance when they turn to sit in the wheelchair as they try to sit before being aligned. The Certified Nursing Assistant (CNA) Care Card, dated 12/6/19, and the current Comprehensive Care Plan (CCP) revealed the same ambulation instructions as the OT Treatment Plan Summary, dated 11/12/19. Review of the CNA Ambulation Report, from 12/1/19 through 1/2/20, revealed that the resident walked from 1 to 50 feet on 5 of 33 occasions. There was no documentation of the distance the resident walked for 9 days during that time, and 19 days were documented as 8/8 which means ambulation did not occur. There was no documentation for the reason the resident did not walk. During an observation on 12/30/19 at 10:09 a.m., a staff member returned the resident to their room in a wheelchair. The staff member did not offer to walk the resident back to their room. In an observation on 1/2/20 at 9:28 a.m., the resident had a walker in their room without a hand splint. There was no hand splint in the room. At 1:32 p.m., CNA #1 walked the resident from the wheelchair to their recliner in their room, a distance of about two to three feet. There was no hand splint on the walker. When interviewed at that time, CNA #1 said there was no hand splint to use. She said the resident seldom walks with the walker anywhere unless she walks with therapy. She said the resident walks with therapy maybe twice a week. When interviewed on 1/3/20 at 9:41 a.m., CNA #1 said that she did not know anything about using a splint. She said that 8/8 means that walking did not occur. She said she uses that code if the resident buckles during an attempt to walk. Interviews conducted on 1/3/20 included the following: a. At 8:08 a.m., OT #1 said the resident was discharged from an active therapy program about a month ago. OT #1 said a right-hand splint should be in place on the walker and used because it helps the resident to grip the walker. She said the resident needs encouragement to walk but if she refuses, the CNAs are to document the refusal in the computer. OT #1 said the goal was to walk the resident 100 feet per day. She said that therapy staff does not walk residents on the unit. OT #1 said she expects the CNAs to report to the Clinical Coordinator if residents are not walking as care planned. b. At 9:08 a.m., LPN #2 said she has never seen any staff walk the resident with her walker. She said if the resident was care planned to walk, then it should be offered, and if the resident refuses, it should be reported to the nurse for follow up. c. At 9:12 a.m., the Clinical Coordinator said that no one has reported to her that the resident was not being walked. She said that she would expect to be notified. 2. Resident #254 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 11/27/19, revealed that the resident was cognitively intact and walked in the corridor on the unit on one or two occasions in the seven day look back period and with the assistance of one staff member. The physical therapy discharge summary, dated 12/6/19, included that the resident was able to ambulate 100 plus feet independently with a rollator walker in the hallways. The resident stated they walk twice daily. Since the resident's goals were attained, the resident was discharged from therapy. The current CCP and CNA Care Card included that the resident was at risk for falls, had an alteration in activities of daily living and skin breakdown due to diabetes, and a history of [MEDICAL CONDITION] and osteo[DIAGNOSES REDACTED]. Interventions included, but were not limited to, encourage out of room daily and to monitor for any decline in positioning, walking, or transfer status and to notify therapy as needed. During observations of the resident throughout the day shift on 12/30/19, 12/31/19, 1/2/20, 1/3/20, and 1/6/20 the resident was observed sitting in her room, including for all meals. The resident was not observed ambulating in the hallway. Review of the CNA Ambulation Report for the past month revealed that the resident walked outside of their room on 13 occasions and 3 occasions in the past two weeks. In an interview on 12/30/19 at 12:50 p.m. and again on 1/3/20 at 1:07 p.m., the resident stated that they can walk on their own but that sometimes the pain in their foot was so bad they cannot even make it to the dining room. The resident stated that very few staff members will walk with them, or offer, so they have to go on their own. The resident said that they cannot walk far and that they do not ask staff because they have so much to do. When interviewed on 1/3/20 at 1:38 p.m. and again on 1/7/20 at 9:03 a.m., the Nurse Manager stated that the resident told her they wanted to be able to walk independently so therapy evaluated the resident and determined that they could walk independently in the hallway. The Nurse Manager stated that she would expect staff to ask the resident daily and encourage them to walk outside of their room. She said if the resident refuses, the nurse should be notified. In an interview on 1/6/20 at 1:13 p.m., the Physical Therapist stated that she had seen a decline in the resident due to shoulder pain but was not aware or notified that the resident was not walking daily. She said she would expect staff to encourage the resident to walk several times a day and ask them if they need help. She said if the resident declines consistently, therapy should be notified. She later said that after she explained to the resident how important it was to walk the resident was willing to walk outside of their room with her. (10 NYCRR 415.12(e)(1-2))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #143) of two residents reviewed for respiratory care and oxygen, the facility did not provide proper care and treatment. Specifically, the resident's oxygen equipment was signed off as cleaned and changed weekly but was observed dirty and dated as last changed approximately a month earlier. This is evidenced by the following: Resident #143 had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 11/6/19, revealed that the resident had moderately impaired cognition and received oxygen therapy. The current medical orders included oxygen at 3 liters via nasal cannula and directed to change, label, and date the oxygen tubing and humidifier bottle every week on the evening shift, check and refill the humidifier bottle every shift, check the concentrator filter and clean with sterile water if needed once a day on the evening shift. Observations conducted on 12/31/19 at 10:24 a.m., 1/2/20 at 11:29 a.m., and 1/6/20 at 10:26 a.m., the resident's oxygen tubing was undated and was dirty with a sticky residue (common with the use of adhesive tape). The concentrator filter was covered with a gray dust, and the humidifier bottle was dated 12/10/19. The (MONTH) 2019 Treatment Administration Record (TAR) revealed that the tubing and humidifier was signed off as changed on the evening shift on 12/10/19, 12/17/19, 12/24/19, and 12/31/19. The humidifier bottle was signed off as checked and refilled three times a day every day. The filter was signed off as checked and cleaned daily on the evening shift. When interviewed on 1/2/20 at 8:35 a.m. and again on 1/6/20 at 10:26 a.m., the Licensed Practical Nurse (LPN) stated that the evening shift was responsible for changing the oxygen equipment, but the equipment was checked every shift. The LPN said the humidifier bottle was dated as last changed on 12/10/19. The LPN stated she checked the humidifier bottle daily as signed off on the TAR. She said that she thought the humidifier bottle had been changed on 12/31/19 but was not sure where she got that date from. In an interview on 1/7/20 at 8:34 a.m., the Nurse Manager and the Clinical Coordinator both stated that the policy was that oxygen equipment should be labeled, dated, and changed weekly to help prevent infection. They both said that it should not be signed off as completed on the TAR if it was not done. (10 NYCRR 415.12 (k) (6))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for four of eight medication carts reviewed for medication storage, the facility did not ensure that all drugs and biologicals were properly labeled and stored in accordance with State and Federal laws. The issues involved a controlled substance that was not double locked, multiple unlabeled pre-poured medications, and multiple loose pills in the bottom of drawers in the medication carts. This is evidenced by the following: Home for the Aged: In an observation on 1/2/20 at 10:10 a.m., a medication cart on the third floor contained multiple loose pills in the bottom of the drawer. On 1/3/20 at 9:07 a.m., a medication cart on the sixth-floor contained several loose pills in the bottom of the drawer. Wegman's Continuing Center: In an observation on 1/3/20 at 10:24 a.m., the medication cart on the third floor contained two medication cups filled with multiple pills and one medication cup was filled with multiple crushed pills. The resident's name or the name of the medications were not on the cups or anywhere in the drawer and the cups were uncovered. When interviewed at that time, Licensed Practical Nurse (LPN ) #1 stated that the cups contained morning medications for three different residents who were busy with showers and eating. She said she should not have pre-poured the medications. In an observation on 1/3/20 at 10:35 a.m., the medication cart on the second floor contained a 25 milliliter bottle of [MEDICATION NAME] that was in an unlocked drawer. LPN #2 attempted to lock the drawer but was unable because the lock was broken. When interviewed at that time, LPN #2 said that she did not know how long the lock on the drawer had been broken. When interviewed on 1/3/20 at 2:44 p.m., the Director of Nursing stated that medications should not to be prepoured. She said the broken lock on the medication cart drawer was fixed immediately. She said that the night shift was responsible for cleaning the carts and making sure there were no loose medications in the drawers. (10 NYCRR 415.18)

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that the facility did not ensure food was prepared in a form designed to meet each resident's needs. Specifically, the pureed lasagna was prepared without a recipe and the serving size was not equivalent to the regular portion size. This is evidenced by the following: When interviewed on 1/6/20 at 10:13 a.m., the Assistant Cook said that he pureed the lasagna entrée for lunch that day. He said that he needed 34 servings of 4 ounces each. He said that he did not follow a recipe but put the lasagna into the blender and added water to make it liquidy. He said he did not know how much water he added to the lasagna. He said the lasagna was a heat and serve purchased product and he used two half pans. The lasagna was Molly's Kitchen: 15 orders per half pan. The label read serving size one cup; 227 grams, servings per container about 12. When interviewed at that time on 1/6/20 at 10:18 a.m., the Chef said one pan equals 96 ounces divided by 12, so one serving should be 8 ounces. He said the resident's receiving pureed foods were not getting what the menu directs for a regular portion size. He said the production sheet includes 4 ounces when really, they should be receiving twice that amount. When interviewed on 1/6/20 at 10:47 a.m., the Registered Dietician (RD) said that she has a recipe for lasagna that directs to add a half or cup of water per serving. She said the residents on a pureed diet should have received 8 ounces of lasagna. The RD said that she was not aware of that and she would need to check other heat and serve products to verify portions sizes in order to ensure the residents on a pureed diet are getting the same calories, nutrients, and serving size as the regular menu. (10 NYCRR 415.14(d)(3))

Based on interviews and record reviews conducted during the Abbreviated Survey (complaint #NY 655) completed on 4/30/19, it was determined that for one (Resident #1) of three residents reviewed for a significant change in condition, the facility did not ensure that the medical staff was notified of a significant drop in blood pressure during a medical illness. This is evidenced by the following: Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 2/6/19, revealed that the resident was cognitively intact. The Change in Resident Condition Requiring Immediate Notification of Medical Provider forms, dated 8/2/17, included to report the cardiac condition of [MEDICAL CONDITION] (low blood pressure) of a systolic blood pressure of less than 90 unless otherwise specified. The Medical Orders for Life-Sustaining Treatment (MOLST), signed by the resident on 6/17/13, included do not resuscitate, do not intubate, limited medical interventions, and do not send to the hospital unless pain or severe symptoms cannot be otherwise controlled. The current Comprehensive Care Plan included that the resident had hypertension and required blood pressure medication. The goal was for the systolic blood pressure to stay between 100 and 160. The interventions included to monitor the effects and side effects of medication, monitor blood pressure as ordered, and to monitor for [MEDICAL CONDITION] (swelling in legs), chest pains, headaches, dizziness, and vomiting, and report promptly. Review of the Nurse Practitioner (NP) note for the 12:00 p.m. visit on 4/9/19 revealed that the resident and Health Care Proxy (HCP) were informed of the resident's status and discussed hospitalization versus staying in the nursing home. The resident chose to stay in the nursing home for treatment because he did not want to go to the hospital unless his pain got worse, the HCP and another family member were aware. The vital signs from the morning, including the blood pressure of 188/83, was included in the note. The NP note for the 3:30 p.m. visit on 4/9/19 included that the resident continued with abdominal pain but denied nausea or vomiting. The NP documented that she reviewed staying in the nursing home or going to the hospital for more aggressive medical treatment, and the resident continued to opt to stay in the nursing home. There was no documentation of vital signs in that note. Review of the blood pressures on the computer and 24-hour Report for 4/9/19 revealed that at 12:20 a.m. the resident's blood pressure was 185/91, at 1:15 a.m. it was 178/92, at 4:15 a.m. it was 188/83, on the day shift (time undocumented) it was 128/77, and at 4:28 p.m. it was 85/61. There was no documentation in the integrated progress notes that the blood pressure of 85/61 was rechecked, or that a supervisor or medical staff were notified. Interviews conducted on 4/26/19 included the following: a. At 3:40 p.m., evening shift Licensed Practical Nurse (LPN) #1 said the resident's blood pressure was low, and she did not know why she did not report it but said she should have. LPN #1 said she thinks that she is supposed to report a systolic blood pressure of less than 90. She said she did not write a progress note and she did not know why. b. At 4:24 p.m., the RN evening supervisor said that the resident's blood pressure should have been repeated with a manual blood pressure cuff, and if it was still low, it should have been reported to the medical staff. She said the rule is that any systolic blood pressure under 90 is to be reported. The RN evening supervisor said that the resident's low blood pressure was not reported to her. When interviewed by telephone on 4/29/19 at 8:00 a.m., the LPN evening supervisor said that at about 5:15 p.m. she had a face to face talk with LPN #1 as to how the resident was doing. She said LPN #1 did not report the resident's blood pressure. The LPN evening supervisor said that if she had known the blood pressure was 85/61, she would have notified the medical staff immediately. She said she would have asked LPN #1 to recheck the blood pressure manually. She said that any systolic blood pressure under 90 should be reported. Interviews conducted on 4/30/19 included the following: a. At 10:00 a.m., the NP stated that she worked in the facility on 4/9/19 until about 5:15 p.m. or 5:30 p.m. She said she would have expected the nurse to call and notify her of the low blood pressure. The NP said if she had known about it, she would have assessed the resident again and notified the HCP. b. At 10:30 a.m., the Assistant Director of Nursing (ADON) was interviewed via telephone and said that during her investigation, she did not notice that the resident's blood pressure was 85/61 at 4:28 p.m. The ADON said she would have expected LPN #1 to notify the supervisor so the resident could be evaluated and the medical provider notified. She said that the medical provider should have been notified of the resident's low blood pressure. She said there was a list of blood pressure parameters posted on all the medication carts so that staff know when to call the medical provider. The ADON said she believes the provider should be called for a systolic blood pressure under 90. c. At 12:03 p.m., the DON said that a systolic blood pressure under 90 should have been reported to the medical provider. She said she would have expected the nurse to take the blood pressure manually and take it in both arms. She said if the result was still low, she would have expected the nurse to call the supervisor. The DON said the supervisor would have completed a full RN assessment and notified the medical provider. (10 NYCRR 415.3(e)(2)(ii))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of six residents reviewed for non-pressure related skin conditions and one of six residents reviewed for falls, the facility did not ensure a thorough investigation was completed to rule out abuse, neglect, or mistreatment. Specifically, Resident #229 sustained multiple skin tears that were not thoroughly investigated and Resident #282 alleged that she had a fall and there was no documented evidence that an investigation was conducted. This is evidenced by the following: 1. Resident #229 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 5/8/18, revealed that the resident had moderately impaired cognition and required assistance with all care. Review of the current Comprehensive Care Plan revealed the resident is at risk for injury, and interventions included to monitor the environment for safety hazards. When observed on 6/14/18 at 12:31 p.m., the resident had a dressing on his right wrist dated 6/13/18. The resident was not able to state what happened. On 6/15/18 at 2:50 p.m., on 6/18/18 at 2:24 p.m., and on 6/19/18 at 9:46 a.m. the resident was observed with an undated dressing on his right wrist. During these observations, the resident was wearing identification bracelets on both wrists. Review of an integrated Progress Note, dated 6/1/18 and signed by the Licensed Practical Nurse (LPN) Supervisor, included that upon pulling the resident up in bed, a Certified Nursing Assistant (CNA) noted blood on the resident's right wrist. The resident was noted to have a 1.5-centimeter (cm) curved (half circle) skin tear. The area was cleansed, skin edges approximated with 2 Steri-strips, Xeroform (wound dressing) applied, covered with a gauze wrap and the nursing supervisor notified. The note included that the skin tear was caused by the wrist band when the staff repositioned the resident and that there was no evidence of abuse or neglect. The facility was not able to produce an Incident and Accident (I/A) Report with an investigation. Interviews conducted on 6/20/18 included the following: a. At 12:15 p.m. and 12:32 p.m., the Registered Nurse Manager (RNM) stated that she was made aware of the skin tear on 6/3/18. She said there should have been an I/A Report completed, but she is not aware of one being done. When observed with the surveyor at that time, the RNM removed the undated dressing. Bloody drainage, approximately 1 cm round, was noted and ecchymosis (bruising), but no open areas or Steri-strips. The resident's identification bracelet that allegedly caused the skin tear was still on the right wrist and the resident had a hospital identification bracelet from an emergency room visit on 6/6/18 on his left wrist. The RNM said the bracelets should have been removed. b. At 12:19 p.m., the LPN Clinical Leader said she had not seen the skin tear. Review of an I/A Report, dated 4/4/18, revealed that staff noted a skin tear on the resident's back. There was no documentation of interviews conducted with the resident or any staff. The 4/21/18 entry by the RNM concluded she ruled out abuse or neglect because the skin tear was possibly caused by an x-ray plate on 4/3/18. When interviewed on 6/20/18 at 11:55 a.m., the Director of Nursing (DON) stated that all incidents are reviewed in morning meeting to ensure an I/A Report was generated, investigations were being conducted, and the care plan was followed. She stated that she cannot find an I/A Report for the 6/1/18 skin tear, but there should have been one. The DON said she did not consider the 4/4/18 I/A Report a complete investigation. She said there should have been interviews done to better determine the cause of the skin tear. 2. Resident #282 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 5/21/18, revealed that the resident was cognitively intact and required assistance for transfers, ambulation, and toilet use. Review of an Integrated Progress Note, dated 12/26/17, revealed the RN Supervisor was requested to see the resident for complaints of left knee pain. The resident had stated that she fell out of her chair two days prior. The chair had tilted and threw her out and that she needed staff to assist her up from the floor. The facility was not able to produce documentation that any investigation and/or an I/A Report was completed for this incident. When interviewed on 6/19/18 at 10:20 a.m., the LPN Clinical Leader said she remembers a fall around 12/25/17, and that there should be an I/A Report. Interviews conducted on 6/20/18 included the following: a. At 8:26 a.m., the RNM said she would expect the staff to complete an I/A Report, but she does not have it on her desk. b. At 11:51 a.m., the DON said she is not able to find an I/A Report, and that there is no documentation that an investigation was done. She said the facility always investigates incidents like falls and it is a problem that the paperwork was either not done or cannot be found. (10 NYCRR 415.4(b)(3))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #329) of two residents reviewed for implementation of the care plan for [MEDICAL CONDITION] (swelling), the facility did not ensure that care was provided in accordance with the resident's written plan of care. The issue involved the lack of consistent application of compression socks and Velcro leg wraps. This is evidenced by the following: Resident #329 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 6/1/18, revealed that the resident was cognitively intact, required assistance with dressing and had no rejection of care. Physician orders, dated 2/2/17, included to apply compression stockings and Velcro leg wraps in the morning on the night shift and remove at bedtime. The Certified Nursing Assistant (CNA) Closet Care Plan, dated 6/11/18, included to provide extensive assistance with lower body dressing and for evening shift to wash stockings every evening. The current Comprehensive Care Plan does not include the use of compression stockings or Velcro leg/ankle wraps but includes to complete activities of daily living per care card (CNA Closet Care Plan). When observed on 6/14/18 at 10:12 a.m., on 6/18/18 at 10:40 a.m., and on 6/19/18 at 12:15 p.m., the resident was out of bed and dressed for the day with his legs in a dependent (hanging down) position without the compression stockings or Velcro leg wraps applied. Review of the (MONTH) (YEAR) Treatment Administration Record revealed the stockings were signed off as applied on all three days. When interviewed on 6/14/18 at 10:12 a.m. and on 6/19/18 at 12:15 p.m., the resident said he had swelling in his feet and ankles and the night staff were supposed to put his stockings and wraps on him. He said he frequently had to remind the day staff that they were not applied but sometimes they just do not get around to doing it. Interviews conducted on 6/19/18 included the following: a. At 12:20 p.m., the CNA stated that the nurses should put the stockings and wraps on the resident, not the aides. She said the night nurse is responsible. The CNA said that on Thursdays when the resident gets a shower, the stockings and wraps should be applied right after the shower. b. At 12:22 p.m., the Licensed Practical Nurse (LPN) stated that night shift should have put the stockings on the resident but they were wet. When observed at that time, two pairs of stockings were in the closet that were not wet. The stockings hanging in the bathroom were dry and the Velcro leg wraps were in the resident's chair. c. At 12:35 p.m., the LPN Clinical Leader said that night shift is supposed to apply the stockings and leg wraps but if they do not do it, the day nurse should do it. She said that on 6/14/18 the resident had a shower and it was her responsibility to put on the stockings and wraps. She said she did not get around to it until 4:00 p.m. She said that they should be applied while the resident is still in bed because it is easier but was unaware of any other reason. When interviewed on 6/20/18 at 8:17 a.m., the Registered Nurse Manager (RNM) said the resident needs the stockings and leg wraps because his legs are very [MEDICAL CONDITION] (swollen with fluid) and at one time, they were weeping. She said it is the responsibility of the night nurse to apply them. The RNM said the stockings and wraps are applied while the resident is in bed because it is easier and was not aware of any benefit of applying them before the legs are dependent. (10 NYCRR 415.11(c)(i))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #229) of four residents observed for incontinence care, the facility did not ensure that proper infection control procedures were followed. Specifically, there was lack of glove changes and handwashing following incontinence care. This is evidenced by the following: Resident #229 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 5/8/18, revealed that the resident had moderately impaired cognition and required assistance with toileting. The current Comprehensive Care Plan included to assist the resident with incontinence care as needed. The Certified Nursing Assistant (CNA) Closet Care Plan, dated 6/11/18, included total assistance with incontinence care. When observed on 6/18/18 at 12:18 p.m., the resident was lying in bed and was incontinent of a large amount of liquid feces that had overflowed his incontinence brief and was pooled between his legs. During a continuous observation until 2:24 p.m., staff had come in and out of his room but did not do incontinence care. At 2:24 p.m., the surveyor approached the CNA and questioned her about cares. She said she was finished work and was going home at 2:30 p.m. At first, she said she did incontinence care at 6:00 a.m. and 12:00 p.m., and had checked his [MEDICAL CONDITION] and incontinence brief just a few minutes ago. Upon entering the room together, the CNA saw the pool of feces and admitted she had not checked on the resident. The CNA donned gloves and did incontinence care. Without removing gloves or washing hands, the CNA applied the clean incontinence brief, then turned on the water faucet and rinsed the wash basin. As the CNA approached the resident's [MEDICAL CONDITION] with a wet washcloth, the surveyor intervened and asked her what she was going to do. The CNA said she had to clean the area around the [MEDICAL CONDITION]. The surveyor asked the CNA to remove her gloves before touching the [MEDICAL CONDITION] area, which she then did. When interviewed at that time, the CNA stated that she should have removed her gloves after cleaning the feces but she was rushing to finish so she could go home. Interviews conducted on 6/20/18 included the following: a. At 8:29 a.m., the Registered Nurse (RN) Manager stated that the resident can put his call bell on when he needs to be checked and changed but that she expects staff to check him every two hours. She said gloves should be changed after working on a dirty part and before touching anything else. b. At 10:31 a.m., the RN Infection Control Nurse said she has not done any observations of care or audits. She stated that she expects gloves to be changed and hand hygiene performed after care is given and before touching anything else. (10 NYCRR 415.19(a)(1-3))

Based on interviews and record reviews, it was determined that for one (Resident #431) of one resident reviewed for [MEDICAL TREATMENT], the facility did not provide services in accordance with the resident's written plan of care. Specifically, the facility was not following the plan of care for monitoring the resident's access site for [MEDICAL TREATMENT]. This is evidenced by the following: Resident #431 has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 3/11/17, revealed that the resident is cognitively intact. The Comprehensive Care Plan (CCP), dated 3/21/17 and the [MEDICAL TREATMENT] Communication Sheet, dated 2/27/17 revealed the resident has [MEDICAL CONDITION], attends [MEDICAL TREATMENT], and has a Permacath (external vascular access device) in the right chest. Interventions include notifying the physician/[MEDICAL TREATMENT] center if any of the following signs/symptoms are present: infection at the access site, bleeding, pain, if leg cramps develop, itching, nausea, [MEDICAL CONDITION], changes in blood pressure, temperature or blood glucose. Other interventions include that if an occlusive dressing is present, to document on the integrity of the dressing, to keep the catheter site dry at all times, and instructions of what to do if the catheter falls out. Review of the February and March 2017 Treatment Administration Records (TARs) and the current physician orders, do not include orders for the resident's Permacath. Interviews conducted on 3/28/17 included the following: a. At 9:18 a.m., the resident said the facility staff only check her dressing when she returns from [MEDICAL TREATMENT]. b. At 9:21 a.m., the Licensed Practical Nurse (LPN) said there were no orders regarding the care of the catheter, so they do not touch it. c. At 9:26 a.m., the Registered Nurse Manager (RNM) said she expects the nurses to monitor the resident's Permacath every shift, checking for signs of infection, redness, swelling, bleeding, pain, and ensuring the dressing is intact. The RNM said she was unable to find any documentation that the nurses were monitoring the Permacath every shift. d. At 9:39 a.m., the Health Information Management Coordinator said she reviewed all of the TARs since the resident's admission to the facility, December 2016 to present, and was unable to find any information to direct staff on the care of the Permacath. e. At 12:52 p.m., the RN Associate Director and RN said they would expect the resident's access site to be monitored every shift. They both said that the information was included in the care plan, but not transferred over to the TARs, so the nurses have not been doing it. f. At 3:59 p.m., the evening LPN said she does not do anything with the resident's catheter site or dressing. The facility policy, [MEDICAL TREATMENT] Care, dated 5/29/12, directed that for Permacath devices, the nurse should monitor every shift for bleeding and/or drainage, the integrity of the dressing and catheter, and document on the TAR. (10 NYCRR 415.11(c)(3)(ii))

Based on interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 611) completed on 4/22/15, it was determined that for one (Resident #1) of three residents reviewed for feeding tubes, the facility did not provide services that met professional standards of quality. Specifically, staff failed to follow physician orders [REDACTED]. This resulted in actual harm that is not immediate jeopardy, and is evidenced by the following: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician orders, dated 3/20/15, include to provide Diabetisource tube feeding (via [DEVICE]) at 115 cubic centimeters (ccs) per hour to start daily at 5:00 p.m. and stop at 9:00 a.m. Additional orders include 50 cc water flush after each medication pass, 150 cc water flush every six hours, to check for gastric residual prior to start of each feeding and every shift, and to hold the feeding if residuals are greater than 200 ccs. The Nursing Care Plan Report, dated 3/19/15 to the present, includes to check placement of [DEVICE] prior to flushes, medications, and feeding per protocol. Review of the March 2015 and April 2015 Treatment Administration Records (TARs) revealed that staff are to check gastric residual prior to start of each feeding and every shift. This was signed off as completed once daily at 5:00 p.m., including on 4/1/15 at 5:00 p.m. Additionally, 150 cc of water flush was signed out as given on 4/1/15 at 6:00 p.m. and on 4/2/15 at 12:00 a.m. and 6:00 a.m. Review of the interdisciplinary progress notes included the following: a. A note, dated 4/1/15 and signed by Licensed Practical Nurse (LPN) #7, documented that at 10:00 p.m. the Certified Nursing Assistant (CNA) found that the resident had pulled out his feeding tube and disconnected it from his [DEVICE]. When the tube was reconnected, the [DEVICE] section leaked profusely, and the supervisor was notified. b. A note, dated 4/1/15, signed by the Registered Nurse (RN)/Supervisor included that she received a report about the tube leaking at 10:25 p.m., checked the tube and found two holes, which she covered with tape, resumed the feeding, and notified the Nurse Practitioner (NP). This note did not include that she checked for tube placement prior to resuming the feeding. c. A note, dated 4/2/15 night shift signed by LPN #8, included that the resident had increased anxiety throughout the shift, yelling out, thrashing in bed, and did not sleep. It included that the resident's [DEVICE] was under the abdominal binder and up along the left side of his chest to his left shoulder so that the resident did not have access to it to chew on it and that he tolerated the tube feed and flushes. d. On 4/2/15 day shift, LPN #10 wrote that at 8:10 a.m. the resident was heard making grunting noises, was unable to focus, and was sweating. The LPN was unable to get a blood pressure at that time, medical was notified, and the resident was transferred to the hospital. Review of the hospital emergency record, dated 4/2/15, revealed that the resident was admitted with [DIAGNOSES REDACTED]. The operative report, dated 4/2/15, documented the finding of a dislodged [DEVICE] and 2,200 ccs plus of tube feeds in the peritoneal (abdominal lining) cavity requiring emergency surgery. Interviews on 4/6/15 included the following: a. At 11:05 a.m., LPN #2 stated that when they hook up a feeding tube, they are to check for residuals and test any residuals to make sure the tube is in the stomach by testing the acidity (PH) of the stomach contents with paper (litmus). She added that the PH should be less than four. She also said that if there was no residual at all, then it would be ok to proceed. b. At 2:00 p.m., the RN/director of staff development stated their policy is that staff should check placement of the [DEVICE] prior to feeding, water flushes, medications, and every shift by testing the stomach contents for PH with litmus paper. She added that the acceptable range should be one through four (orange to yellow color). She also said if no residual is able to be obtained, staff should notify medical especially if the resident is at high risk for tube displacement, such as pulling on the tube. c. At 4:10 p.m, LPN #7 stated that on 4/1/15 she hooked the resident up to the tube feeding at 5:00 p.m. At that time, she checked placement of the tube with the litmus paper and it indicated the tube was in the stomach. At approximately 10:00 p.m., the CNA told her that the resident's tube feeding was leaking from the tube. LPN #7 stated the tube was leaking from multiple little holes. She was not able to flush it or to get any residuals. She then shut it off and notified her supervisor. The supervisor taped the holes and told her to resume the feeding. LPN #7 said she did not check for tube feeding placement again because she could not get anything out the first time. LPN #7 did not know if the supervisor had checked for residuals before instructing her to restart the feeding. Interviews on 4/7/15 included the following: a. At 8:10 a.m., the NP stated that when the RN/supervisor called to say the tube was leaking, she asked her if it had to be held and was told it was fixed temporarily with tape. The NP said when she saw the resident the next morning she did not assess the resident's abdomen. The resident was in an emergency situation, and she was attempting to place an intravenous line. b. At 8:40 a.m., the RN/supervisor stated that the LPN told her there was a leak in the tube. She asked if the tube was in place and was told yes, but added that she did not ask her when it was checked. She stated she taped the tube back together again and flushed it with water to see if it was leaking but did not check for correct placement after she taped it, assuming the LPN had done this. She said that she notified the NP who told her it was ok to resume the feeding and they would have it assessed in the morning. She said that the length of the tube from abdomen to cap was approximately the length of her forearm. She said that she did not assess the resident's abdomen, as she was there to trouble shoot the leak in the tube and not check the tube placement. c. At 9:25 a.m., LPN #8 stated that he got a report from the evening nurse that the resident had chewed through his tube, and the supervisor told him that they checked for positioning and taped the tube up and everything was ok. He added that the resident was agitated, moving around a lot throughout the night, and did not sleep. He went on to say that he hung a new bag of feeding and gave the resident two flushes, but at no time did he check for residuals or for tube placement. When asked why not, the LPN stated that the tube feeding was already running when he came on, and he only checks for placement when starting the feeding, not with flushes. The LPN also stated that the [DEVICE] was long, approximately a foot or more, and the connection port was draped over the resident's shoulder. d. At 1:50 p.m., the Director of Nursing stated that the supervisor should have checked for placement of the tube and not assumed the LPN had. She added that all the nurses should check for placement prior to feeding, flushes, and medications. She also said that if the physician order [REDACTED]. Review of the facility's policy, Enteral Feeding Tubes: Care, Maintenance, Feeding and Medication Administration, dated 1/29/13, includes that verification of tube placement will be performed by the RN/LPN prior to accessing tube for administration of feeds, flushes, and/or medications. Nursing is expected to document verification of tube placement prior to the feeding, flushes, or medication administration on the electronic Medication Administration Record. (10 NYCRR 415.11(c)(3)(i))

Based on interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 611) completed on [DATE], it was determined that for one (Resident #1) of three residents reviewed for feeding tubes, the facility did not provide the appropriate treatment and services to prevent metabolic abnormalities. Specifically, nursing staff failed to assess a resident's feeding tube for proper placement prior to administering a tube feeding and water flushes. This resulted in actual harm that is not immediate jeopardy, and is evidenced by the following: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Assessment, dated [DATE], revealed that the resident's cognitive skills for daily decision making were severely impaired and that the resident had not exhibited any unusual behaviors. Physician orders, dated [DATE], include nothing by mouth and Diabetisource tube feeding (via [DEVICE]) to be given at 115 cubic centimeters (ccs) per hour, to start daily at 5:00 p.m. and stop at 9:00 a.m. Additional orders include 50 ccs water flush after each medication pass, 150 cc water flush every six hours, to check gastric residual (amount of feeding in the stomach) prior to start of each feeding and every shift, and to hold the feeding if residuals are greater than 200 ccs. The Nursing Care Plan Report, dated [DATE] to the present, includes to check placement of [DEVICE] prior to flushes, medications, and feeding per protocol. Review of the [DATE] and [DATE] Treatment Administration Records (TARS) revealed staff are to check gastric residual prior to start of each feeding and every shift. This was signed off as completed once daily at 5:00 p.m. including on [DATE] at 5:00 p.m. Additionally, a 150 ccs water flush was signed out as given on [DATE] at 6:00 p.m. and on [DATE] at 12:00 a.m. and 6:00 a.m. According to the hospital emergency record, dated [DATE], the resident was admitted to the hospital with [REDACTED]. The operative report, dated [DATE], documented finding a dislodged [DEVICE] and 2,200 ccs plus of tube feeding in the peritoneal (abdominal lining) cavity requiring emergency surgery. An intensive care note, dated [DATE], included that the resident's condition was critical and prognosis poor. The resident expired on [DATE]. Review of the interdisciplinary progress notes included the following: a. A note, dated [DATE] and signed by Licensed Practical Nurse (LPN) #7, documented that at 10:00 p.m. the Certified Nursing Assistant (CNA) found that the resident had disconnected his feeding tube from his [DEVICE] and parts of it were in the bed. When the tube was reconnected, the [DEVICE] section leaked profusely, and the supervisor was notified. LPN #7 documented that the resident had been biting on his call bell cord. b. A note, dated [DATE], signed by the Registered Nurse (RN)/Supervisor included that she received a report about the tube leaking at 10:25 p.m., checked the tube and found two holes which she covered with tape, resumed the feeding, and notified the Nurse Practitioner (NP). This note did not include that the feeding tube was assesed for proper placement prior to resuming the feeding. c. In a note, dated [DATE], night shift LPN #8 documented that the resident was increasingly anxious during the shift. The resident was yelling out, thrashing in bed, and did not sleep. Also, the resident's [DEVICE] was located under the abdominal binder and up along the left side of his chest to his left shoulder, which prevented the resident's access to the tube (to chew on it) and that he tolerated the tube feed and flushes. d. On [DATE], day shift LPN #10 wrote that at 8:10 a.m., the resident was heard making grunting noises, was unable to focus, and was sweating. LPN #10 was unable to get a blood pressure at that time, medical was notified, and the resident was transferred to the hospital. Interviews on [DATE] included the following: a. At 10:45 a.m., CNA #1 stated that the resident wore an abdominal binder to protect his [DEVICE]. CNA #1 reported that the resident was often agitated and anxious and played with his tube. He said that on [DATE] day shift, the resident was out of bed, alert, and calling him by name. b. At 11:05 a.m., LPN #2 stated that when they hook up a feeding tube, they are to check for residuals. Any residuals are checked to make sure the tube is in the stomach by testing the acidity (PH) of the stomach contents with litmus paper (chemical treated to detect acid base levels). She added that the PH should be less than four. LPN #2 also said that if there was no residual, then it would be ok to proceed with feedings. c. At 2:00 p.m., the RN/Director of Staff Development stated that based upon facility policy, staff should check placement of the [DEVICE] prior to feeding, water flushes, medications, and every shift by testing the stomach contents for PH with litmus paper. She added that the acceptable range should be 1 through 4 (orange to yellow color). She said if no residual is obtained, staff should notify medical. This is especially important if the resident is at high risk for tube displacement, such as pulling on the tube. d. At approximately 3:30 p.m., the Physical Therapy Assistant stated that they saw the resident on [DATE] day shift for therapy in his room. The resident was alert and did very well with therapy that day. e. At 4:00 p.m., CNA #2 stated that he took care of the resident on the evening shift on [DATE], and at approximately 10:30 p.m., during last rounds, he noticed tube feeding on the resident's clothes. CNA #2 said he called the nurse who attempted to flush the tube, but it squirted everywhere. Also, the supervisor came up to see the resident. When he left, the resident was wearing an abdominal binder, the tubing came up out of the top of the binder, and was hooked to the bag. f. At 4:10 p.m., LPN #7 stated that on [DATE] she hooked the resident up to the tube feeding at 5:00 p.m. At that time, she checked placement of the tube with the litmus paper, and it indicated the tube was in the stomach. At approximately 10:00 p.m., the CNA told LPN #7 that the resident's tube feeding was leaking from the tube. LPN #7 explained that she thought the resident had chewed on the tube because it was leaking from multiple little holes and looked like a sprinkling system. She was unable to flush it or get any residuals. She shut the tube feeding off and notified her supervisor. The supervisor came up to see the resident, taped the holes, and told her to resume the feeding. LPN #7 stated that she checked the residual the first time she tried to flush it and could not get anything out. She told the supervisor the resident needed to go to the hospital. (She did not check again nor did she check for placement with a stethoscope.) LPN #7 said that she did not see if the supervisor checked for placement of the tube when she taped it, but she was not in the room with the resident and supervisor the whole time. Interviews on [DATE] included the following: a. At 8:10 a.m., the NP stated that the RN/Supervisor called her on [DATE] on the evening shift to say the tube was leaking. The NP asked the RN/Supervisor if the feeding needed to be held. The RN/Supervisor told her she had fixed it with tape. The NP stated that when she was called to the resident's room the next morning, the resident's condition was bad. She did not do an assessment of his abdomen but had tried to get an intravenous line going, as it was an emergency situation. b. At 8:40 a.m., the RN/Supervisor stated that the LPN told her there was a leak in the tube on the evening shift on [DATE]. She asked if the tube was in place and was told yes, but added that she did not ask the LPN when it was checked. The RN/Supervisor stated that she taped the tube back together again and flushed it with water to see if it was leaking. The RN/Supervisor reported that she notified the NP, who told her it was ok to resume the feeding, and they would have it assessed in the morning. The RN/Supervisor said that the length of the tube from abdomen to cap was approximately the length of her forearm. Also, she did not assess the resident's abdomen, as she was there to trouble shoot the leak in the tube and not check the tube placement. c. At 9:25 a.m., LPN #8 stated he got a report from the evening nurse on [DATE] reporting that the resident had chewed through his tube, and the supervisor told him that they checked for positioning and taped the tube up and everything was ok. He added that the resident was agitated and moving around a lot throughout the night ([DATE]) and did not sleep. LPN #8 also said that he hung a new bag of feeding between 1:00 a.m. and 2:00 a.m. (routine) and gave the resident two flushes. He did not check for residuals or for tube placement. When asked why not, the LPN stated that the tube feeding was already running when he came on, and he only checks for placement when starting the feeding, not with flushes. The LPN also stated that the [DEVICE] was long, approximately a foot or more, and the connection port was draped over the resident's shoulder. d. At 1:50 p.m., the Director of Nursing (DON) stated that the supervisor should have checked for placement of the tube and not assumed the LPN had. She added that all the nurses should check for placement prior to feeding, flushes, and medications. The DON also said that if the physician order [REDACTED]. The DON was not sure why it was only signed off for evening shift. Review of the facility's policy, Enteral Feeding Tubes: Care, Maintenance, Feeding and Medication Administration, dated [DATE], revealed that verification of tube placement will be performed by the RN/LPN prior to accessing tube for administration of feeds, flushes, and/or medications. Gastric contents will be tested using a PH (acidity) dipping strip. Gastric fluid from a patient who has fasted for at least four hours usualy has a PH of 1 to 4. Fluid from the small intestine of a fasting patient usually has a PH of greater than 6. Nursing is expected to document verification of tube placement prior to feeding, flushes, or medication administration on the electronic MAR. (10 NYCRR 415.12(g)(2))

Based on staff interviews and record reviews conducted during the Recertification Survey and complaint investigation (#NY 905), it was determined that for one (Resident #52) of three residents reviewed for quality of care, facility staff failed to provide the necessary care and services to attain and maintain the resident's highest level of physical functioning. Issues involved delays in treatment caused by failure to obtain prescribed laboratory testing and failure to contact a physician in a timely manner when the resident was presenting symptoms of significant changes in medical condition. This resulted in actual harm that is not immediate jeopardy, and is evidenced by the following: Resident #52 was admitted to the facility on [DATE] with mild renal (kidney) impairment and a history of [MEDICAL CONDITION] (stroke). Review of the Minimum Data Set Assessment, dated 4/19/12, revealed that the resident requires supervision with eating and walking and is severely cognitively impaired. Review of the Nutritional Assessment, dated 4/23/12, revealed that the resident's estimated fluid needs were 1,480 cubic centimeters (ccs) per day, nutrient needs were 1,480 calories per day and that the meals served provided 2,000 ccs and 2,000 calories daily. Record reviews revealed the following: a. A physician's note, dated 5/21/12, documented the increased indicators depression and confusion since 4/18/12. These indicators included perseveration, tearfulness, inability to name children and grandchildren when shown pictures, and expressing that she is loosing her mind. b. physician's orders [REDACTED]. c. physician's orders [REDACTED]. Documented results of these laboratory tests, dated 6/10/12, showed that the resident's blood urea nitrogen (measure of kidney function) was 118 (normal is 9-23), a critically high value. d. Nursing documentation in Integrated Progress Notes included that the resident had one loose stool and an episode of emesis on 5/22/12, two diarrheal stools on 5/23/12, a large diarrheal stool on 5/29/12, minimal intake of food and fluids and upset stomach on 6/2/12. e. A Registered Dietitian (RD) requested a reweigh on 6/8/12 due to a 14-pound weight loss and implemented a high calorie supplement three times daily with medication pass, and a mighty shake at lunch and dinner. f. The 24-hour reports, dated from 5/21/12 through 6/9/12, lacked any entries regarding the resident until 6/10/12. g. There were no documented medical visits from 5/22/12 through 6/10/12. h. The daily intake/output chart for 5/27/12 through 6/10/12 showed the resident's average daily intake ranged from 0 to 58 percent for 30 of 45 meals. The average daily fluid from meals was 498 ccs daily. i. The weight log showed the resident weighted 110.7 pounds (lbs) on 5/2/12, 97.9 lbs on 6/1/12, and 105 lbs on 6/11/12. j. On 6/11/12 the Nurse Practitioner (NP) documented that the resident had multiple symptoms of dehydration, i.e., oral membranes were dry, her eyes were sunken in, and the skin tented on the chest wall. k. The abdominal x-ray report, dated 6/21/12, documented the presence of an ileus pattern (no bowel activity) with no evidence of a bowel obstruction. Interviews conducted on 6/19/12 are as follows: a. At 8:20 a.m., the physician stated that she was not notified of the resident's poor food and fluid intake until 6/10/12 and by that time the resident was dehydrated as evidenced by a decrease in blood pressure and a significant increase in blood urea nitrogen. The physician stated the resident was now in acute [MEDICAL CONDITION] due to volume depletion. The physician also reported that she was not notified of the weight loss until 6/11/12 and believes the 6/1/12 weight was erroneous. She said she would expect to be notified of changes in resident condition. For example, when a resident has diarrhea for more than one day, or if the resident is only eating small amounts for days. She also expects that when an order is written for laboratory testing, that the blood is drawn within one day and results are reported to medical staff. b. At 9:15 a.m., the Registered Dietitian (RD) and Chief Clinical (CC) RD both stated that they were not notified of the resident's 14-lb weight loss. They discovered this when they reviewed all weights on 6/8/12. They requested a reweigh that day, which they expected would be done within 24 hours, and did not know that the reweigh was not done until 6/11/12. The RD and CCRD both reported that they expect to be notified if a resident is refusing to eat or has a change in the ability to feed themselves. They were not notified of this resident's change in condition. The RD said that she does have access to resident computerized intake records. c. At 9:45 a.m., the Registered Nurse/Nurse Manager (RN/NM) stated that she was not aware of any changes in resident condition until 6/11/12 and does expect staff to report changes to her or the Clinical Coordinator. Staff should also note changes on the 24-hour report. The RN/NM said she did not know why the laboratory samples and testing were not completed in a timely manner. d. At 10:50 a.m., the Chief Nursing Executive (CNE) stated that she was not aware of any changes in the resident's condition until 6/12/12. The CNE explained that when a resident has a 5 lb weight loss, staff is expected to notify the nurse team leader and to reweigh the resident that same day. Changes in condition like weight changes, decreased food and fluid intake over a few days, change in mental status, and new behaviors should be documented on the 24-hour report and on the physician/Nurse Practitioner round sheets. The CNE said that by 6/2/11, the resident's change in condition should have been reported to the medical staff and noted on the 24-hour report. The CNE said that the orders for laboratory testing were missed. Interviews on 6/20/12 included the following: a. At 2:30 p.m., the Licensed Practical Nurse/Clinical Coordinator (LPN/CC) stated that she checks to see that weights have been done but does not check to see if reweighs are needed. She would expect nursing staff to report changes in condition like mental status changes, poor appetite, loose stools, or emesis. Additionally, she would expect that vital signs were done and other data collected to give to the Nurse Practitioner. The LPNCC said that she was not informed of the resident's poor food and fluid intake until 6/4/12, at which time she placed the resident's name on the Nurse Practitioner's schedule to see the resident on 6/6/12. When the resident ate better at dinner on 6/4/12, she removed the resident's name from the NP's schedule. The LPNCC reported that she did not add this issue to the 24-hour report or document it in the record. She also does not read the progress notes unless there is a pending NP visit. b. At 3:45 p.m., the evening Supervisor stated that she recalled being told about a resident who was not eating and did not know what to do with that information. She said she did not take any further action. During an interview on 6/27/12 at 12:45 p.m., the NP stated that the resident developed a fever, abdominal tenderness, and had emesis on 6/20/12. An x-ray showed ileus of the bowel. The NP explained that after several days of receiving intravenous fluids, the resident's level of alertness improved. The [MEDICATION NAME] was discontinued because it may have contributed to the original acute [MEDICAL CONDITION] and to emesis and loose stools. The NP said the ileus and the acute [MEDICAL CONDITION] was likely caused by the resident's decreased food and fluid intake. Review of the facility's policy, "24-hour Report/Resident Condition Report," revealed that pertinent information regarding specific changes in physical health conditions should be reported. (10 NYCRR 415.12)