Every finding on record at The Commons on St Anthony, A S N F & Short T R C

Based on record review and interviews, the facility failed to ensure the services arranged or provided by the facility meet professional standards of quality for one of six residents reviewed. Specifically, Resident #2 had increased confusion, urinary frequency and a strong urine odor, a physician order was obtained for a urinalysis, culture and sensitivity and Resident #2's urine sample was not collected to rule out a urinary tract infection. Findings include:The 04/01/2024 facility policy, Change in a Resident's Condition or Status documented a significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without interventions by staff or by implementing standard disease-related clinical interventions.The undated facility policy, Laboratory Specimens Collection of Routine Urine Specimen documented explain procedure to resident, bring equipment to the bedside and provide privacy. Require resident to urinate, place urine in specimen cup and immediately label with resident's name and room number, complete lab request form and place it in a biohazard bag and send it to the laboratory. Chart procedure in nursing record, indicate color, odor and quantity and include pertinent observations. Resident #2 had diagnoses of syncope (fainting due to low heart rate), right femoral neck fracture status post right hemiarthroplasty of hip (hip fracture repair) and unspecified non-Alzheimer's dementia. The 09/26/2024 Minimum Data Set assessment documented Resident #2 had severely impaired cognition, was dependent on staff for toileting hygiene and toileting transfers, was frequently incontinent of bladder and bowels, and required nutrition/hydration interventions to manage skin conditions. The 09/23/2024 lack of capacity form signed by their health care proxy and Nurse Practitioner #18 documented Resident #2 had dementia and their medical decision-making capacity was poor.The 10/10/2024 at 1:27 PM nursing progress note by Registered Nurse Unit Manager #14 documented Resident #2 had been lethargic for the past few days, had a decreased appetite, had increased confusion, urinary frequency with odor, required more physical assistance from staff and developed a dry, intermittent cough. The resident agreed they did not feel well. Nurse Practitioner #18 was notified, and an order was obtained for a urinalysis with culture and sensitivity and cough syrup three times a day for seven days.The 10/10/2024 untimed physician order by Nurse Practitioner #18 documented obtain urinalysis with culture and sensitivity to rule out urinary tract infection for increased confusion, urinary frequency and malodor (strong urine odor) 10/10 one time only to obtain urinalysis with culture and sensitivity for three days.There was no documented evidence the medical order for a urinalysis was transcribed to the treatment administration records, a laboratory requisition form was created, or a urine sample was collected from Resident #2. The 10/12/2024 at 10:48 AM nursing progress note by Registered Nurse #19 documented the resident's family was insistent the resident be sent to the emergency department for evaluation due to increased confusion, a urinalysis was ordered, and the family did not want to wait until Monday. Registered Nurse #19 documented the resident seemed stable and did not want to go to the emergency department. The family representative was coming to the facility to evaluate and speak with the resident.The 10/12/2024 at 11:29 AM nursing progress note by Licensed Practical Nurse #16 documented Resident #2's family member had phoned the unit five times and had requested the resident's urinalysis results. Licensed Practical Nurse #16 stated they did not have the results, the resident had refused to go to the emergency department and a visitor from their assisted living facility arrived to evaluate them. Resident #2 changed their mind, Emergency Medical Services was phoned, and the resident went to the Emergency Department at 11:25 AM.Fluid intakes for Resident #2 documented:-On 10/10/2024 at 9:32 PM- resident refused-On 10/11/2024 at 10:07 AM and 2:37 PM- resident refused-On 10/12/2024 at 11:48 AM- resident refused.There was no documented evidence that a provider was notified regarding the resident's decreased fluid intake or change in condition.There was no documented evidence the 10/10/2024 urine sample was collected from Resident #2 prior to leaving for the hospital on [DATE].During an interview on 06/23/2026 at 10:20 AM, Licensed Practical Nurse #15 stated if a resident had symptoms of a urinary tract infection, the registered nurse supervisor would obtain a physician order to collect a urine sample and fill out a lab form. The order would show on the resident's treatment record. They would know how to collect a urine sample when the order appeared on the treatment record. Licensed Practical Nurse #15 stated they were unsure where a urine specimen went once it was collected and if the order was finished, the registered nurse supervisor would remove the order from the computer. During an interview on 06/23/2026 at 10:44 AM, Registered Nurse Unit Manager #14 stated if a resident showed signs and symptoms of a urinary tract infection, which may be increased confusion, having to urinate all the time or a strong odor, an infection screening questionnaire was required to be completed. If the screening indicated a possible infection, the physician would be notified, and either the physician would enter an order for a urine sample, or they would give a verbal order to the registered nurse to enter. The licensed practical nurse working on the unit would need to confirm the order before collecting the urine sample and place a laboratory slip into the lab binder on the unit. The facility utilized the local hospital for labs and specimens. If a urine sample was collected for Resident #2, it would have been documented on the 24-hour report sheet, and the lab slip would have been missing out of the lab book. Urine samples were collected and brought to the Supervisor's office and placed into the refrigerator for pick up. Results for a urinalysis should be available either the same day or the next day. There was no documented evidence Resident #2 was placed on the 24-hour report sheet for 10/10/2024-10/12/2024. During an interview on 06/23/2026 at 3:30 PM, Medical Technologist #17 stated they worked in the laboratory of the local hospital. There was evidence of a urine sample collected for Resident #2 on 10/12/2024 at 1:20 PM and resulted at 1:39 PM. Medical Technologist #17 stated the urine was collected while the resident was an inpatient in the Emergency Department and not the facility. During an interview on 06/24/2026 at 12:30 PM, the Director of Nursing stated if a resident exhibited signs of a urinary tract infection, they would expect nursing to obtain the resident's vital signs and an order from a provider for a urine sample. Orders are typically collected within three days, but they would expect it to be collected immediately if a resident was showing symptoms. The facility did not keep the laboratory requisitions. The Director of Nursing stated if a resident was not drinking well and exhibited symptoms of a urinary tract infection, they would expect nursing to push fluids and notify a provider to see if they would want nursing to obtain a urine sample via a straight catheter. If family was insistent on the resident going to the hospital and the resident had poor medical decision making, they would expect nursing to send the resident to the hospital. It was not appropriate for nursing to wait two to three days after the resident was exhibiting symptoms of a urinary tract infection. The resident's Health Care Proxy should be notified and included in the decision making. Urine sample results were usually ready in a day. 10 NYCRR 483.21 Comprehensive Resident Centered Care Plan

Based on observations, record review, and interviews during the recertification survey conducted 10/28/2024-11/1/2024, the facility did not ensure residents had the right to a dignified existence in a manner and an environment that promoted the maintenance or enhancement of quality of life for 1 of 2 residents (Resident #196) and for 3 of 8 resident units (Units 3, 5, and 6) reviewed. Specifically, Resident #196's room had personal care information posted in an area visible to other residents and visitors; and Units 3, 5, and 6 had signs on the elevators documenting they were out of order to keep cognitively impaired residents from using the elevators. Findings include: The facility policy, Quality of Life-Dignity, dated 1/10/2023, documented residents were to be treated with dignity and respect at all times. Each resident should be cared for in a manner that promotes and enhances their sense of wellbeing, level of satisfaction with life, and feeling of self-worth and self-esteem. Signs indicating the resident's clinical status or care needs would not be openly posted in the resident's room unless specifically requested by the resident or their family. Discreet posting of important clinical information for safety reasons was permissible if it was taped to the inside of their closet door. Residents would be allowed unrestricted access to common areas open to the public unless it posed a safety risk to the resident. Staff were expected to treat cognitively impaired residents with dignity and sensitivity by addressing the underlying motives or root causes for behavior and not challenging or contradicting the resident's beliefs or statements. 1) Resident #196 had diagnoses including dementia and chronic obstructive pulmonary disease (lung disease). The 8/15/2024 Minimum Data Set assessment documented the resident had severe cognitive impairment, required partial/moderate assistance with personal hygiene, toileting hygiene, lower body dressing, and was occasionally incontinent of urine. The Comprehensive Care Plan initiated 4/17/2024, documented the resident had occasional bladder incontinence related to activity intolerance. Interventions included clean peri area after each incontinence episode, the resident was not to use briefs, utilize underwear with a pad due to rashes and change with each incontinence episode. The active Kardex (care instructions) documented the resident did not use briefs and was to utilize underwear with a pad due to rashes. Change after each incontinence episode and as needed. During observations on 10/28/2024 at 1:52 PM, 10/29/2024 at 9:33 AM, and 10/31/2024 at 10:19 AM, Resident #196's room had a white sign with black bolded letters on the outside of the closet door that documented, no pullups or briefs per Nurse Manager, only a pad with underwear. During an interview on 11/1/2024 at 9:26 AM, Certified Nurse Aide #34 stated they were assigned to care for Resident #196. They looked at the Kardex to know how to properly care for the resident. The Kardex included no briefs for Resident #196. They thought the sign on the resident's closet door was hung up by the Nurse Manager as a reminder because staff were still putting briefs on the resident even though they had a rash from wearing them. They stated having private information posted in the resident's room could affect the resident and it was not dignified. During an interview on 11/1/2024 at 9:53 AM, Certified Nurse Aide #35 stated they looked at the Kardex daily when caring for residents to know how to properly care for them. They were unsure why the sign was put up in Resident #196's room because all the information was in the Kardex, and staff should look there before caring for residents. They stated the sign was a privacy issue and was not dignified. During an interview on 11/1/2024 at 10:13 AM, Licensed Practical Nurse #36 stated they had seen the sign on the closet in Resident #196's room and it was put up as a reminder, so staff did not use briefs because the resident had a reaction to them and developed a rash. All care information was listed in the residents Kardex. They thought the sign could have been a dignity issue and it should have been put inside Resident #196's closet door or they could put up a sign that reminded staff to review the Kardex before performing care. During an interview on 11/1/2024 at 10:36 AM, Registered Nurse Unit Manager #24 stated all nursing staff had access to the resident's Kardex. The Kardex contained all care information including brief size, transfer status, toileting, safety, and all activities of daily living and was found in the computer and was not posted in resident rooms. They put the sign up in Resident #196's room to remind staff not to use briefs or stock them in their room because they kept getting a rash when they wore them. They stated having a sign that contained private resident information that was visible to visitors and residents was not dignified. 2) During the following observations signs documenting, Stop, Elevator Out of Order covered the elevator buttons outside the elevators: - on 10/28/2024 at 10:36 AM on Unit 3. - on 10/28/2024 at 2:30 PM on Unit 6. - on 10/29/2024 at 9:15 AM on Unit 3. - on 10/29/2024 at 10:06 AM on Unit 5. - on 10/29/2024 at 10:15 AM on Unit 6. - on 10/30/2024 at 8:21 AM on Unit 5. - on 10/30/2024 at 8:55 AM on Unit 6. - on 10/30/2024 at 1:13 PM on Unit 3. - on 10/31/2024 at 8:10 AM on Unit 5. - on 10/31/2024 at 2:30 PM on Unit 6. - on 11/1/2024 at 9:03 AM on Unit 5. - on 11/1/2024 at 9:18 AM on Unit 3. The elevators functioned when the buttons were pushed. During an interview on 10/29/2024 at 11:00 AM, the Director of Nursing stated the out of order signs were put on the unit elevators to deter the residents from using the elevators. They did not notify visitors about the signs, and if visitors asked, they would explain the elevators were not out of order. During an interview on 11/1/2024 at 12:17 PM, the Administrator stated they hung the out of order signs over the elevator buttons to deter confused residents from using the elevators. They did not think the signs confused visitors or residents and if the elevators were broken, they would hang the sign on the elevator doors. If alert and oriented residents wanted to leave the units and they had off unit privileges they would just lift the sign, push the button, and use the elevator. During an interview on 11/1/2024 at 11:00 AM, Registered Nurse Unit Manager #60 stated out of order signs were hung on unit elevators to deter residents from using them. Unit 4 did not have a sign because they were able to deter the confused residents on their unit and they thought the sign would confuse alert and oriented residents. They understood why the signs could be considered undignified, but they also understood why some units were using the signs and thought it was for resident safety so confused residents would not try to constantly get on the elevators. During an interview on 11/1/2024 at 9:04 AM, Unit Secretary #61 stated they used the out of order sign to prevent exit seeking residents from getting into the elevators. Occasionally visitors would ask them what they should do if the elevators were out of order, and they would explain why the sign was up and routine visitors would know the elevators were not broken. They had several residents who would try to exit seek but they had wander alert bracelets and if they asked how to get off the unit, they would explain they needed a friend to go with them. During an interview on 11/1/2024 at 10:05 AM, Licensed Practical Nurse #26 stated the out of orders signs were on every unit and they were used to deter dementia residents from trying to leave the unit. Most of the confused residents had wander alert bracelets so the alarm would sound if they got onto the elevator, and they would not be able to leave the unit unless staff entered a code. Visitors would frequently ask the staff if they needed to use the stairs to leave the unit, but once they explained why the sign was there, they were usually understanding. They thought the signs were confusing to some of the residents and visitors. During an interview on 11/1/2024 at 10:33 AM, Registered Nurse Manager #24 stated the out of orders signs were supposed to be on every unit and they had been up since they had started working there. Visitors frequently asked staff if the elevators were out of order or ask where the stairs were located. They stated staff would explain they were used to deter confused residents from trying to leave the unit. 415.3(d)(1)(i)

Based on record review and interviews during recertification and abbreviated (NY00318491) surveys conducted 10/28/2024-11/1/2024, the facility did not ensure residents had the right to receive visitors of their choosing at the time of their choosing, subject to the resident's right to deny visitation when applicable, and in a manner that did not impose on the rights of another resident for 1 of 1 residents (Resident #243) reviewed. Specifically, the facility restricted Resident #243's family member's visitation based on the resident's healthcare proxy's wishes. Findings include: The facility policy, Visitation Policy, dated 5/23/2023, documented unless visitation was suspended to comply with applicable laws or regulations, the residents were permitted to receive visitors 24/7 subject to the resident's wishes and the protection of the rights of other residents in the facility. The facility recognized the resident's needed to maintain contact with the community they lived and/or were familiar with and they could have visitors as they wished. The facility provided 24-hour access to all individual visiting with the consent of the resident. Visitation would be subjected to reasonable restrictions that protected the security of the facility's residents which included: limiting or supervising visits from person who were known or suspected to be abusive of exploitative to a resident, denying access to individuals who are found to have been committing criminal acts, and denying access to visitors who were inebriated, disruptive, physically, or verbally abusive to the staff. The facility policy, Resident Rights & Notice of Resident Rights and Responsibilities, dated 4/30/2024, documented residents of the facility had the right to visit and be visited by others from outside the facility. Resident #243 had diagnoses including unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The 10/1/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, was usually understood, was usually able to understand others, and felt it was important to be able to choose their own bedtime and have family involved in their care planning. The 1/13/2024 Comprehensive Care Plan documented the resident was dependent on staff and family for meeting emotional, intellectual, physical, and social needs related to cognitive deficits and physical limitations. Interventions included to encourage ongoing family involvement and to invite family to attend special events, activities and meals, and the resident's preferred activities were visiting with family and other alert people. The 2/15/2024 revised plan of care documented the resident had a very supportive family and was not to leave the unit with their adult child. Interventions included to praise family involvement and visits, be available to provide support and discuss concerns, and to invite them to share knowledge and history of the resident. The 2/12/2024 Social Worker #16 progress note documented they called the resident's healthcare proxy to notify them one of the resident's adult children was visiting late at night. The resident's roommate had expressed being uncomfortable about having a visitor in the room at night. The healthcare proxy was informed that the facility did not permit visits late at night and the healthcare proxy agreed the resident's adult child should not visit late at night. The adult child was contacted and informed late night visits were not permitted at the facility. The 4/2/2024 Social Worker #16 progress note documented the resident's adult child called and inquired if the resident was on full comfort measures as their adult sibling stated the resident was. They wanted to be able to come and visit the resident at any time since the resident was dying. Social Worker #16 stated they could not release details as the adult child was not the healthcare proxy and directed them to contact their adult siblings. The adult child stated they wanted to spend as much time with the resident as they were able if the resident was dying and inquired about coming whenever they wanted, especially at night when they were off work. Social Worker #16 stated they would ask but it likely would not change. The 4/8/2024 Social Worker #16 progress documented the resident was full comfort care due to not taking medications or eating. There was no documented follow up with the resident's adult child about the request to visit when they wanted. The 10/11/2024 Social Worker #16 progress note documented the resident was able to make their basic needs known. During an interview on 10/31/2024 at 8:47 AM, Social Worker #16 stated they had problems with Resident #243's adult child sleeping next to the resident in bed, changing the resident, and being in the common area until 11:00 PM at night. They stated they discussed with the resident's adult child they were not able to change the resident or lie in bed with the resident and the facility put limitations on the resident's visiting hours. The adult child was told they could not visit after 8:00 PM. During an interview on 11/1/2024 at 12:17 PM, the Administrator stated their doors lock at 9:00 PM or 10:00 PM at night and they opened at 6:00 AM. Visitors could visit late at night for special reasons like a resident being at the end of life. They stated for Resident #243's situation, there were a lot of family dynamics and the resident's healthcare proxy felt it was inappropriate for the adult child to visit the resident late at night. They stated the resident's adult child would lie next to the resident in bed and the healthcare proxy thought it was inappropriate and so did the facility staff. The facility was not concerned the resident's adult child would abuse or hurt the resident. They stated the facility tried to accommodate residents' visitors, but the resident's adult child was waking the resident up and turning on the lights to visit. The resident's adult child stated they visited later at night due to their work schedule. There were never any concerns voiced by the resident or adverse behaviors noted to the resident's adult child's late visits. They stated they would restrict resident visitors based on the healthcare proxy's wishes if the resident was not able to make their needs known. During an interview on 11/01/24 at 2:16 PM, the Social Services Director stated the facility did not have visiting hours. They stated the doors were locked at 8:00 PM or 9:00 PM but visitors could push the button to be let in. They stated as a rule, the social workers should not tell resident families they were not allowed to visit late at night or after 8:00 PM. They stated they did not specify time frames for visits and if they did, all cases were discussed with administration prior to a decision. If a family member wanted to visit late at night and the roommate of their family member did not like having visitors at that time, there were other spots for the resident and family to visit. They stated they had no indication that Resident #243's adult child was being hurtful in anyway or that the adult child's late-night visits bothered or upset the resident. They stated they did not normally restrict visitors based on a healthcare proxy's wishes but there were special circumstances. 10 NYCRR 483.10(f)(4)

Based on record review and interviews during the recertification survey conducted 10/28/2024-11/1/2024, the facility did not ensure the individual financial record was available to the resident through quarterly statements and upon request for 2 of 2 residents (Residents #93 and #198) reviewed. Specifically, Residents #93 and #198 were not provided with personal fund statements within 30 days after the end of the quarter, and upon request. Finding include: The facility policy, Resident Fund Policy and Procedures, dated 10/1/2015, documented the Resident Banker was on duty Monday- Friday from 9:00 AM-12:00 PM and from 1:00-3:00 PM; resident fund statements were delivered to the resident and/or authorized representative quarterly and showed the prior quarter's transactions; and the resident and/or authorized representative could request balance and/or printed statements during banking hours. Resident #93 was admitted with diagnoses including Parkinson's Disease (a progressive neurological disorder). The 10/23/2024 Minimum Data Set assessment documented the resident had intact cognition and required moderate assistance with most activities of daily living. Resident #93's 10/26/2023 Comprehensive Care Plan documented the resident was alert and oriented and able to make decisions regarding their care. Interventions included decision making was encouraged. Resident #198 was admitted with a diagnosis including Sjogren syndrome (an autoimmune disorder). The 10/19/2024 Minimum Data Set assessment documented the resident had intact cognition and required supervision to moderate assistance for most activities of daily living. Resident #198's 10/26/2023 Comprehensive Care Plan documented the resident was alert and oriented and able to make decisions regarding their care. Interventions included decision making was encouraged. During an interview on 10/28/2024 at 4:27 PM, Resident #198 stated they had an account with the facility but had not received a statement since admission (approximately 8-9 months ago). They did not know how to access their money in the facility account and when they asked the social worker, they were only given an account balance. During an interview on 10/28/2024 at 4:28 PM, Resident #93's family member stated they did not get statements and they had to ask for a balance quarterly. During an observation on 10/29/2024 at 2:07 PM, signage outside the bank door documented resident bank hours were Monday-Friday 8:00 AM to 4:00 PM. During an interview on 10/30/2024 at 11:02 AM, Financial Associate #5 stated the resident bank was usually open from 8:00 AM to 4:00 PM and they often stayed until 4:30 PM. They took a lunch break from 12:00-12:30 PM but let security know they could tell the residents to come to the bank at that time as well. Usually when a resident came into the facility, they received a packet and a form to sign if they wanted to open a personal funds account. They provided residents a quarterly savings statement and it went to the resident or the family. Some of the alert residents had their statement sent to their social worker and the social worker dispersed it. If the statements were to go to the family, they were responsible to send them in the mail. They told all families they did not have to wait for a quarterly statement, and they could come in and ask for a statement with their balance at any time. For alert and oriented residents, they entrusted the social workers handed them out when they put a note on the envelope that said, please give to the resident. Resident #93's and Resident #198's statements went to Social Worker #15. They reviewed the electronic record of each resident and knew which residents got a statement and which residents had their statement sent to their power of attorney, or they checked with the social worker. They stated Accounting Manager #4 handed out statements during the last 6 months, and maybe some were missed. During a telephone interview on 10/30/2024 at 11:30 AM, Accounting Manager #4 stated they were not really in charge of the resident funds account but helped Financial Associate #5. During an interview on 10/30/2024 at 11:37 AM, [NAME] Manager #63 stated there was no cap on how much Medicaid residents could have in their account. They stated that Financial Associate #5 oversaw the tracking, the deposits, and the personal funds account. During an interview on 10/30/2024 at 12:08 PM, Social Worker #16 stated they sometimes took the resident's money down to the bank for them and brought the receipt book up and had the resident sign it or brought down their checks. They gave the residents their monthly statement or a balance. They taught residents how to open a personal account and how to deposit into and withdraw money from their account if there was a store they wanted to go to or something they wanted to purchase. If the resident did not remember their account usually the family was on top of the account information. During the off hours, they had a locked box with envelopes they could deposit into. Financial Associate #5 kept track of the money. They had not handed statements to Resident #93 and #198. Resident #198 just recently asked for a balance statement. They stated Accounting Manager #4 sent them quarterly statements via electronic mail, and they handed out the ones that went to the residents. 10NYCRR 415.26(h)(5)(iii)

Based on observation, record review, and interview during the recertification survey conducted 10/28/2024-11/1/2024, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for each resident to meet medical and nursing needs identified in the comprehensive assessment for 1 of 3 residents (Residents #20) reviewed. Specifically, Resident #20 did not have footrests and lateral supports while in their scoot chair (a specialty chair used to improve positioning and mobility) as planned. Findings include: The facility policy, Turning and Repositioning, dated 3/27/2024, documented the resident would receive the required assistance for repositioning based on their assessment from the interdisciplinary team. Repositioning would be provided to prevent the development of secondary conditions that could infringe on the resident's ability to function at the highest practical level attainable. The certified nurse aide would provide turning and repositioning per the care plan and document in the electronic medical record plan of care. Nursing would monitor and adjust the intervention as needed and ensure documentation compliance. Resident #20 had diagnoses including dementia, abnormal posture, and muscle weakness. The 6/25/2024 Minimum Data Set assessment documented the resident had severe cognitive impairment, was dependent for activities of daily living, was non-ambulatory, used a wheelchair, and did not have functional limitation in range of motion in their arms or legs. The Comprehensive Care Plan initiated 9/8/2021 and revised 10/22/2024 documented the resident was at risk for falls related to confusion, gait/balance problems, and incontinence. Interventions included assure resident was in reclined/low position when in their scoot chair, place resident in scoot chair when awake, and keep resident in the lounge area when in the scoot chair, and therapy trigger for resident positioning in scoot chair. The Comprehensive Care Plan initiated 8/22/2021 and revised 10/22/2024, documented the resident required assistance with self-care related to activity intolerance. Interventions included utilizing footrests while in scoot chair, bilateral lateral supports in scoot chair, range of motion for bilateral hips, resident should be kept in lounge area when in scoot chair and out of bed for all meals. The undated care instructions documented assure resident was in reclined/low position when in scoot chair, keep in lounge area when in scoot chair, and utilize footrests while in scoot chair. The 2/2/2024- 2/15/2024 Occupation Therapist #30 assessment documented the resident's discharge recommendation included a scoot wheelchair and use of bilateral supports. Nursing would continue to monitor and notify therapy with any concerns. The 7/5/2024 Registered Nurse Unit Manager #29 documented the resident was discussed during care planning with the daughter present on the phone. There was concern about the resident leaning forward in their scoot chair. the following observations of Resident #20 were made: - on 10/28/2024 at 11:25 AM, sitting in a scoot chair in the lounge area, leaning forward with their head in their lap. - on 10/28//2024 at 12:01 PM, sitting in their scoot chair at the dining room table leaning forward with their feet touching the floor. At 12:56 PM, sitting in their scoot chair, bent forward touching the floor with their hands. At 1:09 PM, leaning to the left side while staff assisted them with their meal. At 1:51 PM, the resident was brought to the lounge area in their scoot chair and staff did not reposition the resident. - on 10/29/2024 at 9:51 AM, sitting in their scoot chair in the lounge area sitting upright. At 10:16 AM, leaning over to the left side of chair with their head hanging off the side of the chair. At 10:20 AM, Certified Nurse Aide #28 moved the resident in their scoot chair closer to the television and did not attempt to reposition the resident to the middle of the chair. The resident leaned forward in the chair. At 2:36 PM, the resident remained in the lounge area, leaning forward (head on their knees) in the scoot chair. - on 10/30/2024 at 8:23 AM, sitting in their scoot chair in the lounge area, asleep with their head leaning on the right arm rest. At 9:20 AM, Licensed Practical Nurse #33 brought the resident into the lounge area and put the resident in front of the television. At 9:40 AM, the resident was bent forward in their scoot chair, and Social Worker #16 was talking to another unidentified resident that was seated close by. At 11:49 AM, the resident remained in the scoot chair bent forward touching their feet with their head on their lap. - on 10/3/12024 at 12:15 PM, and 1:34 PM, sitting in the scoot chair in the dining room leaning forward with their hands on their feet. During an interview on 10/31/2024 at 1:44 PM, Certified Nurse Aide #31 stated the resident required a mechanical lift from the bed and should be repositioned every 2 hours when in bed. They were not sure about repositioning in the chair. The resident was not contracted but liked to lean over and needed to be repositioned so they would not fall. During an interview on 10/31/2024 at 1:47 PM, Certified Nurse Aide #32 stated they routinely cared for Resident #20 and the care instructions said the resident should be repositioned every 2 hours while in the chair and in bed. During a telephone interview on 11/1/2024 at 8:51 AM, the resident's family member stated they talked to the staff about the positioning of the resident, and it was heart breaking to see the resident in those positions. The resident had scoliosis (curvature of the spine) and they were not sure if the resident had pain. The staff tilted the chair back because the resident had fallen forward out of the scoot chair in the past. During an interview on 11/1/2024 at 9:23 AM, Occupational Therapist #30 stated Resident #20 was last seen in February 2024, from February 2 until February 15. The resident flexed forward on their own in the chair. Nursing staff needed to assist the resident with the lateral supports. There were two small black pieces that should have been next to the resident on each side to prevent the resident from leaning. The resident required total assistance from staff with positioning upright. The supports were removable, they had trialed a pillow a long time ago but that ended up on the floor. The resident was screened in 9/2024 and nursing decided they did not need therapy. Nursing was responsible for repositioning the resident as needed. During an observation on 11/1/24 at 9:52 AM, Resident #20 was sitting in their scoot chair in the lounge area with bilateral side support to right side only. There was no left lateral side support. During an interview on 11/1/24 at 9:53 AM, Certified Nurse Aide #27 stated Resident #20 was supposed to be repositioned every 2 hours to make sure they were sitting upright in the chair. The resident was supposed to be checked on and repositioned every 2 hours when in the scoot chair. They did not have to document the regular positioning or checking the resident every 2 hours. During an interview on 11/1/24 at 10:15 AM, Registered Nurse Manager #29 stated the resident should have had two side supports and be reclined back in the scoot chair if they were not eating and the brakes should not be locked. The resident always leaned forward and pulled their knees up in the chair. They stated when the resident was repositioned that was considered range of motion to the hips. There was a 2-hour check and change order while in the bed but there was nothing documented for repositioning while out in the lounge sitting in the scoot chair. They did not have the bilateral support in place, the right one was in the closet, and they were not sure where the left one was placed. Therapy had just brought up a new left side support. They stated they had seen the resident in the forward and leaning position several times during the past few days and did not reposition the resident. The resident was always sitting in a strange position, and they were used to seeing the resident that way. 10NYCRR415.12(e)(2)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00356778) surveys conducted 10/28/2024-11/1/2024, the facility did not ensure residents received treatment and care in accordance with professional standard of practice for 1 of 2 residents (Residents #1 and #232) reviewed. Specifically, Resident #232 had bilateral (both sides) above the knee amputations and the facility did not follow up on a prosthetics (artificial limb) referral timely and Resident #1 experienced an emotionally distressing event that was not addressed timely. Findings include: The facility policy, Request for Consultation and Follow Up, dated 1/22/2024, documented upon return from an appointment, the nursing staff conveyed the results of the consultation to the attending provider and the recommendations for additional interventions or follow-up. The consult form was dated and initialed and indicated it had been reviewed by nursing. The facility policy, Resident Rights and Notice of Resident Rights and Responsibilities. dated 4/30/2024, documented the resident had a right to access services outside the facility. The facility policy, Adverse Incidents and Incident Report, dated 10/21/2024, documented the facility ensured the residents environment remained as free of accident hazards as possible. Staff responded to the immediate needs of the resident involved in the adverse incident and immediately notified the nursing supervisor and/ or registered nurse on the unit. 1) Resident #232 had diagnoses including encounter for orthopedic aftercare following surgical amputation and acquired absence of left and right legs above the knee. The 8/14/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition and had functional limitation of both lower extremities. The Comprehensive Care Plan initiated 8/27/2024 documented the resident had an amputation of the left and right legs above the knee related to venous insufficiency (improper blood flow of the veins). Interventions included position was changed frequently, and periods of rest were alternated with activity out of bed. Dependent edema (fluid buildup in tissues due to gravity), flexion deformity (loss of joint motion), and skin pressure areas were to be prevented. The 8/8/2024 hospital discharge summary documented a right above the knee amputation was done on 7/26/2024 and a left above the knee amputation was done on 8/2/2024. Follow-up appointments with vascular surgery were scheduled for 8/19/2024 and 9/9/2024. The 8/19/2024 Vascular Surgery Consultation Sheet documented the bilateral above the knee amputation sites were healing well. The 9/9/2024 Vascular Surgery Consultation Sheet documented bilateral above the knee amputations were now healed and the staples were removed. Recommendations included to follow up with vascular surgery as needed and a referral was placed to the prosthetics department who would call to schedule. The consultation sheet was signed as reviewed by Registered Nurse Manager #19. The 9/10/2024 Registered Nurse Manager #19 progress note documented the resident was seen at vascular surgery on 9/9/2024. Per the consultation sheet bilateral above the knee amputations were now healed and the staples were removed, and the resident tolerated the procedure well. Follow up was as needed with vascular and a referral was placed to the prosthetics department, they would call to schedule. There was no documented evidence of an appointment or follow-up communication with the prosthetics department. During an interview on 10/29/2024 at 8:52 AM, Resident #232 stated they were waiting for an appointment for prosthetics for their bilateral leg amputations. They had an appointment in September but had not heard anything since. They thought the facility would let them know when the appointment was scheduled. During an interview on 11/1/2024 at 9:57 AM, Unit Secretary #20 stated they did not know anything about an appointment for prosthetics for Resident #232. The unit secretary to do list was on a clipboard used to communicate progress with the two other unit secretaries. The list did not include if any calls were made to follow-up on the prosthetics referral made by the vascular surgery office on 9/9/2024. Referrals were normally followed up on after a couple of weeks. They checked with Unit Secretaries #21 and #22 who confirmed they did not know anything about this referral either. During an interview on 11/1/2024 at 10:15 AM, Registered Nurse Manager #19 stated they signed the consultation sheets after appointments. They signed the 9/9/2024 vascular surgery consultation sheet. Their progress note stated the referral for prosthetics was sent by vascular surgery. This should have been followed up on within a couple of weeks and they were not sure why it was not. The prosthetics appointment was important to Resident #232 for their mobility, dignity, and mental health. During an interview on 11/1/2024 at 11:58 AM, the Director of Therapy stated Resident #232 had worked with therapy and was discharged . They were aware the resident wanted prosthetic legs and had voiced the goal of walking. The goal for the resident was to achieve the highest level of functioning and they deserved the chance to try. 2) Resident #1 had diagnoses including anxiety disorder, mild intellectual disabilities, and cerebral palsy (a neurological disorder that affects movement). The 2/23/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, required substantial/ maximum assistance with bed mobility, and was dependent for transfers. The resident's face sheet documented the resident's representative was the responsible party. The Comprehensive Care Plan initiated 9/9/2021 documented the resident had potential for impairment of skin integrity. Interventions included an alternating pressure air mattress (a specialized mattress with an electronic air pump used for pressure relief). The Comprehensive Care Plan initiated on 8/6/2024 by Social Worker #41 documented the resident had a psychosocial well-being problem (potential) related to an incident (7/21/2024) when their bed made a loud noise, accompanied by a flash which startled the resident who had an intellectual and developmental disorder diagnosis. Interventions included being cautious of loud noises and bright flashes around the resident and family and social work were to be notified of any events in the future as soon as they happened. There were no documented nursing progress notes addressing an incident with the resident's bed on 7/21/2024. There was no documented evidence the resident was assessed after the incident. During an observation on 10/28/2024 at 10:31 AM, Resident #1 was lying in their bed on their right side. There were fall mats on both sides of the bed and an electric powered air mattress was in use. During a telephone interview on 11/1/2024 at 8:04 AM, Resident #1's representative stated they had visited the resident on 7/21/2024. They were outside the resident's room in the hallway when Certified Nurse Aide #42, Certified Nurse Aide #43, and Licensed Practical Nurse #45 were in the resident's room. The fall mats were lodged between the wall and the head of the bed. To pull out the fall mats, the bed was pulled over the air mattress cord connected to the outlet behind the head of the bed. This created a loud noise and a flash of light, and the resident verbalized call the fire truck! call the police!. Certified Nurse Aide #42 explained to them what had happened. They asked Licensed Practical Nurse #45 if they had made an incident report and were told it was not needed because the resident was not hurt. For the next several days, the resident was fearful, jumped with any noise, and verbalized to them whew, me scared. Social Worker #41 was not made aware of the event until a week later when they informed them. Social Worker #41 verbalized they were surprised they were not notified so they could provide emotional support to the resident. The resident should have had the opportunity to talk with the social worker. During an interview on 11/1/2024 at 10:45 AM, Certified Nurse Aide #44 stated Resident #1 became startled when there was a loud noise. They were not aware of any incidents that may have triggered this. During a telephone interview on 11/1/2024 at 1:17 PM, Licensed Practical Nurse #45 stated the resident was scared during the event because Certified Nurse Aide #42 had jumped. The resident would get agitated, nervous, and upset about loud noises. They called their Registered Nurse Supervisor #46 after the event, and they came to see the resident. They thought Registered Nurse Supervisor #46 had completed an incident report. During an interview on 11/1/2024 at 2:05 PM, Social Worker #41 stated they were not immediately notified of the event on 7/21/2024. It happened on a weekend, and they were not notified until the following Monday. There was no documented incident or behavior note that would have alerted them. As soon as the resident's representative informed them of the event, they went to see the resident. They should have written a progress note when they saw the resident, but they verified there was no progress note. They stated they updated the resident's care plan the day they had gone to speak with them (8/6/2024). The resident's representative knew them best but by the time they had seen the resident, they seemed to be at their baseline. During an interview on 11/1/2024 at 2:24 PM, the Director of Nursing stated they were notified by Registered Nurse Supervisor #46 about the event on 7/21/2024. An accident/ incident report was not necessary because the resident was not hurt. Emotional distress should be addressed and would be documented in a progress note and then discussed in morning report. Registered Nurse Supervisor #46 should have entered a progress note about the incident. The Nurse Manager would have seen that and notified the social worker. If emotional distress was not addressed timely, it could negatively affect the resident's mood or appetite. 10NYCRR 415.12 50561

Based on observation, record review, and interview during the recertification and abbreviated (NY00347746) surveys conducted 10/28/2024-11/1/2024, the facility failed to ensure a resident with an indwelling catheter (a tube inserted into the bladder to drain urine) received the appropriate care and services to prevent urinary tract infections for 1 of 1 resident (Resident #238) reviewed. Specifically, Resident #238's urinary drainage collection bag was not positioned below the level of the bladder to promote free urine flow (allows urine to back flow into urinary tract). Findings include: The facility policy, Catheter Care Indwelling Urinary Catheter, revised 12/2023, documented the urinary drainage device drainage bag was positioned below the level of the bladder at all times and tubing was positioned to prevent urine reflux toward the bladder. The facility policy, Urinary Tract Infection Prevention and Catheter Use and Care, dated 12/12/2023, documented leg bags (a small urine collection bag attached to the leg) were only used if the resident walked or was on an ambulation program. A leg bag must be worn below the level of the bladder. Resident #238 had diagnoses including history of urinary tract infections, resistance to multiple antibiotics, and retention of urine. The 10/10/2024 Minimum Data Set assessment documented the resident had intact cognition, used an indwelling urinary drainage device, and had a urinary tract infection in the last 30 days. The Comprehensive Care Plan revised 9/20/2024 documented the resident had an indwelling urinary catheter. Interventions included the catheter bag and tubing were positioned below the level of the bladder and leg bags were used only for residents who were able to ambulate when out of bed. The 10/3/2024 hospital discharge summary documented the resident was admitted to the hospital on 9/28/2024 with a diagnosis of sepsis secondary to complicated urinary tract infection. The 10/8/2024 hospital discharge summary documented the resident was admitted to the hospital on 10/4/2024 with a diagnosis of multifactorial metabolic encephalopathy (a brain disorder) due to urinary tract infection. During an observation on 10/29/2024 at 3:11 PM, the resident was lying flat in bed with a leg bag attached to their upper thigh. The position of the leg bag did not allow gravitational flow of urine from the catheter. During an observation on 10/30/2024 at 9:09 AM, the resident was sitting upright in their standard wheelchair using their feet to self-propel. The outline of the leg bag was seen and was attached to the resident's left upper thigh, parallel with the level of the bladder. The position of the leg bag did not allow gravitational flow of urine from the catheter. During an interview on 11/1/2024 at 9:45 AM, Resident #238 stated no one discussed the risk associated with urine backflowing if the collection bag was not positioned below the level of the bladder. During an interview on 11/1/2024 at 11:52 AM, Infection Preventionist #38 stated urinary drainage bags should be below the waist. If they were not below the waist this could cause the urine to back flow to the bladder and cause a urinary tract infection. During an interview on 11/1/2024 10:04 AM, Certified Nurse aide #47 stated they switched residents' urinary drainage bags to leg bags in the morning for those residents who walked. They always positioned the leg bag up high on whichever leg that had the anchoring device on it. To prevent pulling on the catheter, they never placed the bag low on the leg. Resident #238 had a catheter and switched between the urinary drainage bag and the leg bag daily. The resident went back to bed after breakfast and sometimes after lunch and kept the leg bag on when they laid down in bed. During an interview on 11/1/2024 at 10:41 AM, Licensed Practical Nurse #49 stated leg bags were for residents who walked and regular urinary drainage bags were for those who did not. Drainage bags should always be kept below the level of the bladder. Resident #238 had a catheter and had a urinary tract infection a little while ago. The resident sat in a wheelchair and went back to bed before lunch and sometimes again in the afternoon. They thought the resident used a regular urinary drainage bag placed under their chair with a cover. If the resident went back to bed with a leg bag urine could back up, cause discomfort, and infection. During an interview on 11/1/2024 at 10:58 AM, Registered Nurse Unit Manager #3 stated leg bags could be used for a resident who sat in a wheelchair only if they were positioned lower than the bladder. The position was important because if the leg bag was not below the bladder, urine would not drain and could cause stagnation and a major urinary tract infection. Resident #238 used a leg bag during the day and switched to a urinary drainage bag at night. They walked very little now and went back to bed during the day. They had multiple urinary bladder infections with sepsis that led to hospitalization s. 10 NYCRR 415.12(d)(1)

Based on observations, record review, and interviews during the recertification survey conducted 10/28/2024-11/1/2024, the facility did not ensure that residents who required dialysis services (filtration of blood when the kidneys do not work) received such services consistent with professional standards of practice for 1 of 2 residents (Resident #152) reviewed. Specifically, Resident #152 received hemodialysis treatments at a community-based dialysis center and: - did not have ongoing assessments of their condition and monitoring for complications before and after dialysis treatments; - there was inconsistent communication and collaboration between the dialysis center and the facility; - the resident did not receive a bagged lunch prior to attending dialysis as planned; - the resident frequently did not complete treatments due to discomfort from the mechanical lift pad left under them in their wheelchair, and medical was not notified; - staff documented the resident's permacath (central catheter used for long-term venous access) dressing was dry and intact and the resident did not have a permacath. Findings include: The undated facility policy, Dialysis Care, documented dialysis observation/ assessment and care was documented in the progress notes on each dialysis day, prior to dialysis, and upon return. The vascular access site was examined and assessed for bruit (swooshing sound that indicates the fistula is working) and thrill (a vibration that can be felt when placing fingers over the arteriovenous fistula indicating blood flow). The extremity was examined for adequate circulation, blood pressure obtained, and level of consciousness was assessed. Any dialysis communication in the dialysis book or via telephone conversation was documented in the progress notes. The dialysis book and a bagged meal would be sent with the resident for all treatments. Any correspondence to the dialysis center was documented in the dialysis book. Resident #152 had diagnoses including end stage renal (kidney) disease/dependance on renal dialysis, diabetes, and hemiplegia/ hemiparesis (weakness or paralysis on one side of the body) following cerebral infarction (stroke) affecting the left side. The 9/2/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, had upper and lower extremity impairment on one side, was dependent for mobility and transfers, had end stage renal disease, and required dialysis treatments. The Comprehensive Care Plan initiated 9/30/2021 and revised 4/18/2023 documented the resident needed hemodialysis related to renal failure. Interventions included pain medications were administered prior to the resident leaving for dialysis; any signs/symptoms of infection at access site were monitored, documented, and reported; the resident was to be ready in their wheelchair for dialysis Tuesday, Thursday, Saturday at 9:30 AM; and the dialysis binder and bagged lunch were to be sent. The Comprehensive Care Plan did not include the type of dialysis access site the resident had. The 9/11/2024 Physician Assistant #57 orders documented: - Remove dressing from dialysis site at bedtime every Tuesday, Thursday, and Saturday. - Right upper arm: place fingers over resident's fistula (a surgically created connection between an artery and a vein to provide access for hemodialysis) to confirm thrill (motion of blood flowing through it) every day and evening. The order did not include to assess for a bruit. - Transport to and receive from hemodialysis on Tuesday, Thursday, and Saturday at 11:00 AM. Leave at 10:00 AM with [medical transport company] to dialysis center. Have resident ready by 9:45 AM. - Vital signs prior to leaving and upon returning from dialysis two times a day on Tuesday, Thursday, and Saturday. The October 2024 Treatment Administration Record documented the resident attended dialysis on 10/1/2024, 10/3/2024, 10/5/2024, 10/8/2024, 10/10/2024, 10/12/2024, 10/15/2024, 10/17/2024, 10/19/2024, 10/22/2024, 10/24/2024, 10/26/2024 and 10/29/2024. The dialysis communication book documented the following: - On 10/1/2024 there was no documented assessment of the arteriovenous fistula from the facility. The permacath dressing was dry and intact. There was no signature of the nurse that completed this facility report to the dialysis center. The dialysis treatment was ended early. - On 10/3/2024 the permacath dressing was dry and intact. - On 10/5/2024 there was no documented evidence of any communication to/from the facility to the dialysis center. - On 10/8/2024 the permacath dressing was dry and intact. The dialysis treatment was ended early. - On 10/10/2024 there was no documented evidence of any communication to/from the facility to the dialysis center. - On 10/12/2024 the reports were completed. - On 10/15/2024 there was no facility report documented to the dialysis center. The dialysis treatment ended early. - On 10/17/2024 the facility report did not include the resident's name, vital signs, assessment of the arteriovenous fistula or a signature of the nurse that completed the report. - On 10/19/202 the facility report did not include the resident's name, vital signs were incomplete, no arteriovenous fistula assessment, or a signature of the nurse that completed the report. There was no return report from the dialysis center. - On 10/22/2024 the permacath dressing was dry and intact. - On 10/24/2024 there was no documented evidence of any communication to/from the facility to the dialysis center. - On 10/26/2024 the facility report did not include an assessment of the arteriovenous fistula or a signature of the nurse that completed the report. - On 10/29/2024 there was no documented evidence of any communication to/from the facility to the dialysis center. The October 2024 nursing progress notes did not document any evidence medical was notified of incomplete dialysis treatments on 10/1/2024, 10/8/2024, and 10/15/2024 or why the treatments ended early. During an observation and interview on 10/28/2024 at 10:35 AM, Resident #152 was in their room sitting in their wheelchair with a purple mechanical lift pad underneath them. They stated they attended dialysis three days a week, missed lunch on dialysis days, and was not provided with a bagged lunch. They were diabetic and sometimes had problems with low blood sugars. A dialysis book was supposed to go with them to dialysis but sometimes the dialysis center would tell them the facility did not send it. Staff at the facility did not look at their dialysis access site. They stated they often stopped dialysis treatments early because they were in pain from sitting on the mechanical lift pad. They had a sore on their buttocks, and it was uncomfortable to sit on the pad for four hours. Dialysis was aware they stopped treatments early because of pain from the pad and they thought dialysis staff documented that for the facility. During an interview on 10/30/2024 at 10:35 AM, Certified Nurse Aide #44 stated some residents complained about the mechanical lift pad underneath them. Some residents did not have to keep the pad under them if they had been evaluated by therapy and their care plan indicated it. They had not heard Resident #152 complain about the pad under them. They thought the kitchen provided bagged lunches for dialysis residents and put them in the refrigerator, but they were not sure. Resident #152 was diabetic and should take a lunch with them to dialysis, so their blood sugar did not go low. They were not sure if the resident went with a bagged lunch. During an interview on 10/30/2024 at 10:50 AM, Licensed Practical Nurse #58 they routinely cared for Resident #152 and had never provided them with a bagged lunch before dialysis. Resident #152 should have been provided with a bagged lunch, so their blood sugar did not drop. There was also a communication book the nurse was responsible for completing and it included the residents blood pressure and medications taken that morning. The arteriovenous fistula was monitored for bleeding and the presence of the thrill and bruit. Resident #152 complained frequently about being uncomfortable with the mechanical lift pad under them. Licensed Practical Nurse #58 stated they had not told the Assistant Director of Nursing/Interim Nurse Manager about the discomfort but thought they were aware. During an interview on 10/30/2024 at 11:12 AM, the Assistant Director of Nursing/Interim Nurse Manager stated vital signs were obtained before and after dialysis. There was a communication book that went with the resident, but they had never looked at it and was not sure what information it contained. Resident #152 did not take a lunch with them. They left the facility shortly after breakfast and returned around 4:30 PM. Staff offered a snack when they returned. They did not think the facility sent lunches, but they probably should, so the resident did not have a hypoglycemic (low blood sugar) event. Resident #152 had an arteriovenous fistula, but it was only monitored if there were issues. They reviewed the dialysis communication book and confirmed the communications were not completed and were inconsistent. It was important the communication between the facility and the dialysis center included the resident's blood pressure and mentation so changes could be assessed. The mechanical lift pads were left underneath the residents unless they had been evaluated by therapy. Staff had not told them Resident #152 complained of discomfort with the pad or they would have triggered physical therapy to assess the resident. They were not aware the resident's dialysis treatments were not always completed due to the discomfort. Resident #152 had a healing sore on their buttocks and the pad probably increased their discomfort. If they knew, they would have alerted the provider as completion of the treatments was important for electrolyte balance. During an interview on 10/30/2024 at 11:51 AM, Physician Assistant #57 stated Resident #152 was very brittle with their diabetes and had fluctuating high and low blood sugars. They should have received three meals a day regardless of if it was a dialysis day or not. Communication between the facility and the dialysis center was important especially if there were any medication changes. They were not aware the resident did not always complete dialysis treatments, but they had heard the resident complain about the pad under them. They would have wanted to be notified of incomplete treatments as this was important for electrolyte balance. During an interview on 10/31/2024 at 9:00 AM, the Food Service Director stated bagged lunches used to go with residents to dialysis, but it had been at least a year since that had happened. They were not sure if there were any current dialysis residents in the building. They had heard the dialysis center did not allow the residents to eat there. Everyone should receive three meals a day for nutrition and enjoyment. During an interview on 10/31/2024 at 9:14 AM, the Director of Dietary stated they heard the residents were not permitted to eat in dialysis. Resident #152 had additional needs for nutrition, was on supplements, and they should have been provided with three meals a day. 10NYCRR 415.12(k)

Based on observations and interviews during the recertification survey conducted 10/28/2024-11/1/2024, the facility did not post on a daily basis the current resident census and the total number, and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, in a prominent location readily accessible to residents and visitors for 5 of 5 days. Specifically, the current daily resident census and nurse staffing schedules were located on the nursing supervisor/staffing office door that was down a hallway off the main lobby and not readily accessible to visitors or residents. Findings include: There was no documented facility policy on nurse staffing posting requirements. The daily nurse staffing information was observed posted on the nursing Supervisor/Staffing office door located down a hallway off the main lobby that was not readily accessible to visitors and residents: - on 10/28/2024 at 4:09 PM. - on 10/29/2024 at 8:15 AM. - on 10/30/2024 at 8:50 AM. - on 10/31/2024 at 7:56 AM. - on 11/1/2024 at 7:39 AM and did not include the daily census. During an interview on 11/1/2024 at 11:03 AM, Staffing Supervisor #13 stated their role was to oversee the staffing department and they made the schedules for the certified nurse aides and licensed practical nurses. The overnight nursing supervisor was responsible for updating the daily nurse staffing numbers. Staffing Supervisor #13 stated they double checked them and ensured they were posted in the morning when they arrived at work. They did not have access to check the daily census and they were not aware the census was not listed on the 11/1/2024 nurse staffing information sheet. They stated they were not aware daily staffing had to be posted in a readily accessible location for both residents and visitors. Visitors would not likely go down the hallway where the Supervisor/Staffing office was when they visited the facility so they would not see them. During an interview on 11/1/2024 at 11:12 AM, the Director of Nursing stated the overnight nursing supervisor completed the daily nurse staffing and hung it on the door for the day shift. The staffing department was responsible for ensuring the daily nurse staffing sheet had the correct nurse staffing numbers, census, and was posted. They were not aware the 11/1/2024 nurse staffing information did not include the census. They stated they were aware the daily nurse staffing had to be posted in a readily accessible location. They thought it accessible on the Supervisor/Staffing door because visitors and residents would go down the hallway to use the bathroom or to go to the bank. 10 NYCRR 415.13

Based on observations, record review, and interviews during the recertification and abbreviated (NY00356778) surveys conducted 10/28/2024-11/1/2024, the facility did not ensure routine and emergency drugs and biologicals were provided to 1 of 1 resident (Resident #1) reviewed. Specifically, Resident #1 was not administered the respiratory syncytial virus vaccine (helps protect against a common respiratory virus, RSV) timely after the vaccine was ordered in 2023 and 2024. Findings include: The facility policy, Resident Immunizations, dated 3/27/2024, documented upon admission resident's immunization records were reviewed. If the resident had not received the respiratory syncytial virus vaccine and was [AGE] years of age or older, the vaccine would be offered, and an order was obtained. Prior to administration, the vaccine information sheet was reviewed with the resident or designated health care proxy and consent was obtained. Resident #1 had diagnoses including heart disease, hypertension (high blood pressure), and allergic rhinitis (seasonal allergies). The 8/24/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, had shortness of breath with exertion and lying flat, and was up to date on influenza (flu) and pneumococcal (pneumonia) vaccines. The 4/5/2022 Health Care Declaration and Proxy (a person appointed to make medical decisions) documented the resident's family member was their appointed representative. 2023 respiratory syncytial virus vaccine: The 10/24/2023 Nurse Practitioner #51 medical order documented Arexvy (respiratory syncytial virus vaccine) intramuscular suspension 120 microgram/0.5 milliliter. Inject 0.5 milliliter intramuscularly one time only for the prevention of respiratory syncytial infection. The 10/2023 Medication Administration Record documented Arexy intramuscular suspension 120 microgram/0.5 milliliter, inject 0.5 milliliters intramuscularly one time only for prevention of respiratory syncytial infection with an order date of 10/24/2023. There was no documented evidence Arexvy was administered as ordered. The boxes for 10/24/2023 and 10/25/2023 were blank. The remaining boxes had an x. There was no documented evidence why the vaccine was not administered as ordered. 2024 respiratory syncytial virus vaccine: The 10/2024 Medication Administration Record documented Arexy respiratory syncytial virus vaccine 0.5 milliliters intramuscularly one time only for immunization for 3 days with an order date of 10/2/2024. There was no documented evidence the vaccine was administered. The boxes for 10/2/2024, 10/3/2024, 10/4/2024, and 10/5/2024 were blank. The Medication Administration Record documented Arexy respiratory syncytial virus vaccine 0.5 milliliters intramuscularly one time only for immunization for 3 days with an order date of 10/5/2024. The boxes for 10/7/2024, 10/8/2024, and 10/9/2024 were blank. The vaccine was administered on 10/10/2024 at 3:16 AM by Licensed Practical Nurse #55. During a telephone interview on 11/1/2024 at 8:04 AM, Resident #1's representative stated approximately 3 weeks ago they received a phone call from the Infection Control Nurse who asked if they wanted the resident to receive the respiratory syncytial virus vaccine. They stated they told the Infection Control Nurse the resident received that vaccine a year ago. The Infection Control Nurse told them the resident did not receive the vaccine a year ago and they were not sure what happened. The resident's representative stated they consented for the resident to receive the vaccine. During an interview on 11/1/2024 at 10:36 AM, Licensed Practical Nurse #52 stated vaccines were ordered by the provider and pharmacy delivered them twice a day, at 8:00 PM and 3:00 AM. The vaccines were put in the medication refrigerator in the medication room. If the vaccine was not given, it would fall off the Medication Administration Record and needed to be reordered. It was important vaccines were given to protect the resident against those illnesses. Licensed Practical Nurse #52 did not know why the vaccine was not administered. During an interview on 11/1/2024 at 10:51 AM, Licensed Practical Nurse #53 stated the pharmacy was alerted electronically when a new order was entered. If it was a one-time dose, such as a vaccine, it needed to be given in a certain window or it would drop off the medication administration record. It was the nurse's responsibility to check the medication refrigerator for the vaccine if it showed up on the Medication Administration Record. It was important the resident received ordered vaccines to prevent infection. During an interview on 11/1/2024 at 11:04 AM, Licensed Practical Nurse #54 stated there was a 3-day window to administer a vaccine. If the vaccine was not administered in those 3 days, it fell off the active Medication Administration Record, and they thought the provider was notified if that happened. It was important for residents to receive vaccines because they lived in a communal setting, and it was their right. They did not recall any issues with Resident #1 receiving the respiratory syncytial vaccine. They thought the Assistant Director of Nursing/ interim Nurse Manager obtained the consents. During an interview on 11/1/2024 at 11:11 AM, the Assistant Director of Nursing/ interim Nurse Manager stated vaccines were handled by the Infection Control Nurse who obtained consents and entered the orders. The vaccines were only on the Medication Administration Record for 3 days. If it was not given, the order would fall off the active Medication Administration Record. It was important that all residents receive ordered vaccinations as they were around many other residents, there were many visitors coming and going, and the residents were elderly and compromised. They had noticed Resident #1 had not received the respiratory syncytial virus vaccine as ordered a year ago and they were not sure why. It looked like a consent was never documented in 2023. They called the Infection Control Nurse and consent was obtained, and the vaccine was reordered in the beginning of October 2024. During an interview on 11/1/2024 at 12:13 PM, the Infection Control Nurse stated a resident's vaccination status was checked upon admission. They tracked the vaccine orders and verified they were administered after ordered. They were not tracking the respiratory syncytial virus vaccine in 2023 only the influenza, pneumococcal and COVID-19 vaccines. They now tracked all vaccines including the respiratory syncytial virus. The vaccine was re-ordered in October 2024 because it had fallen off the Medication Administration Record because the resident also received the influenza and COVID-19 vaccines, and the resident's representative wanted them given on different days. It was important the resident received the vaccines because they lived in a close community, there were many visitors, and they were more prone to diseases due to comorbidities. The vaccine was not given in 2023 because it fell through the cracks. During an interview on 11/1/2024 at 12:43 PM, Nurse Practitioner #51 stated the Infection Control Nurse entered the consents and the orders, and then they would sign them off electronically. They did not follow-up if residents had received the ordered vaccinations. Residents should receive ordered vaccines to protect themselves and their peers. It was important for herd immunity. If a vaccine could not be given for any reason, they expected to be notified. They did not recall being notified that Resident #1 did not receive the respiratory syncytial virus vaccine as ordered in 2023. 10NYCRR 415.18(e)(2)

Based on record review and interviews during the recertification survey conducted 10/28/2024-11/1/2024, the facility did not ensure residents were free of any significant medication errors for 1 of 1 resident (Resident #152) reviewed. Specifically, Resident #152 did not receive 24 of 26 doses of physician ordered levetiracetam (brand name Keppra, used to treat seizures). Findings include: The facility policy, Medication Administration Pour-Pass-Sign, dated 8/2021, documented registered nurses and licensed practical nurses appropriately and safely administered and documented medications administered to residents. Refusals were documented in the electronic medical record and included a refusal reason and progress note. The policy did not include details of required documentation if a resident was out of the building during the scheduled medication administration time. Resident #152 had diagnoses including epilepsy (seizure disorder), end stage renal (kidney) disease, and dependence on renal dialysis (removal of waste products from the body when the kidneys don't work properly). The 9/2/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, had a seizure disorder or epilepsy, and required dialysis treatments. The Comprehensive Care Plan initiated 4/11/2022 documented the resident had a seizure disorder. Interventions included medications were given as ordered, labs were monitored, and any sub therapeutic or toxic results were reported. The 8/27/2024 Hospital Discharge Summary documented an admission diagnoses of recurrent seizure disorder, questionable up to date on seizure medications. Seizure medication doses were increased and there was a new order for an additional dose of levetiracetam 500 milligrams to be given on dialysis days after dialysis. The 8/28/2024 Physician Assistant #57 medical order documented the resident was to receive levetiracetam 500 milligrams, one tablet by mouth once daily every Tuesday, Thursday, and Saturday for seizures, to be given after dialysis. The August 2024-October 2024 Medication Administration Record documented levetiracetam 500 milligram dose to be given after dialysis on Tuesdays, Thursdays, and Saturdays scheduled for 2:00 PM. The medication administration record documented the following: - on 8/29/2024 the medication was documented as a 1 absent from home without medications. - on 8/31/2024 the medication was documented as 3 absent from home with medications. - on 9/3/2024, 9/5/2024 and 9/7/2024 the medication was documented as 1 absent from home without medications. - on 9/10/2024 there was no documentation (the box was blank) - on 9/12/2024 9/14/2024, 9/17/2024, 9/19/2024, 9/21/2024, 9/24/2024, 9/26/2024 and 9/28/2024 the medication was documented as a 1 absent from home without medications. - On 10/1/2024 the medication was documented as a 1 absent from home without medications. - There was no documentation on 10/3/2024. - On 10/5/2024, 10/10/2024, 10/12/2024, 10/15/2024, 10/17/2024, 10/19/2024,10/22/2024,10/24/2024 and 10/26/2024 the medication was documented as a 1 absent from home without medications. All the days marked as a 1 absent from home without medications were the resident's designated dialysis days of Tuesday, Thursday, and Saturday. There was no documented evidence that medical was notified of the missed doses of levetiracetam 500 milligrams after dialysis from 8/28/2024-10/30/2024. There was no documented evidence of why the resident did not receive the ordered levetiracetam after dialysis treatments. During an interview on 10/30/2024 at 10:14 AM, Resident #152 stated they were not sure if they had any recent seizures. They were not given any medications when they got back from dialysis. During an interview on 10/30/2024 at 10:50 AM, Licensed Practical Nurse #58 stated they were frequently assigned Resident #152. They did not initially think the resident had seizure disorder but then decided the levetiracetam was for absence seizures (a type of seizure that can cause brief episodes of disconnection from the surrounding environment) or tremors. It was an important medication and if the resident did not receive it as ordered, they could have tremors or absence seizures. They stated if a resident was not in the building for a scheduled medication it was signed off that they were absent without medications. The resident did have an afternoon dose of levetiracetam. They thought the Medication Administration Record sent a notification to the next shift if this medication was not given. They did not relay this information to the next shift. During an interview on 10/30/2024 at 11:12 AM, the Assistant Director of Nursing/ interim Nurse Manager stated if a resident did not receive 3 doses of a medication in a row, the provider should be notified. Levetiracetam was a critical medication used to treat a seizure disorder. If the medication was not consistently given, the resident could have a seizure. Resident #152 did have a seizure disorder and was ordered to receive an extra dose of levetiracetam on dialysis days. There was an hour before and after a scheduled administration time to give the medication. They were not aware this extra dose was ordered for 2:00 PM and confirmed the resident was not receiving the dose and usually did not get home from dialysis usually until 4:30 PM. They felt the licensed practical nurses should have informed them the resident was not getting this dose because they were not in the building during the scheduled administration time. It was easy to change the time. During an interview on 10/30/2024 at 11:51 AM, Physician Assistant #57 stated they took care of Resident #152, and the resident was recently hospitalized with seizures. The resident received levetiracetam twice daily and an extra dose on dialysis days after dialysis. The extra dose after dialysis was ordered after the hospitalization for seizures. They were not notified the resident had not received those doses after dialysis. They expected medications to be given as ordered. They were surprised the documentation on the Medication Administration Record for the extra dose on dialysis days showed it had only been given a couple of times since it was ordered and that was not good. The resident had not had another seizure since they returned from the hospital. 10NYCRR 415.12(m)(2)

Based on observation, record review, and interview during the recertification survey conducted 10/28/2024-11/1/2024, the facility did not ensure they established and maintained 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 diseases and infections for 2 of 3 residents (Residents #238 and #52) and for 1 of 1 staff (Cycle Cleaner #1) reviewed. Specifically, Cycle Cleaner #1 did not practice appropriate use of personal protective equipment or hand hygiene during the cleaning of Resident #644's room who was on precautions for COVID-19; Resident #238's urinary drainage collection bag was not stored in a manner to prevent contamination; and Resident #52's urinary collection bag was observed lying directly on the floor. Findings include: The facility policy, Guideline for Type and Duration for Selected Infections and Condition, dated 5/30/2023, documented in addition to standard precautions, special droplet contact precautions would be put in place for COVID-19 infections. Those precautions included wearing a gown, clean gloves, and protective eyewear when entering the resident room and removing gloves and gown and washing hands before leaving the room. The facility policy, Urinary Tract Infection Prevention and Catheter Use and Care, dated 12/12/2023, documented when a gravity drainage bag or leg bag was removed, it would be rinsed with 1 part vinegar and 3 parts water, soaked for 20 minutes, rinsed with warm water, then hung up to dry; a leg bag/drainage bag cap must be put in place on the end that attached to the urinary drainage device tubing and stored covered in the resident's bedside stand; and the collection bag must be covered at all times for dignity and to prevent it from touching the floor and wheels of wheelchairs. 1) Resident #644 had diagnoses including COVID-19.The admission Minimum Data Set assessment had not yet been completed. The Comprehensive Care Plan did not include COVID-19 or related precautionary measures. On 10/28//2024 Resident #644's COVID-19 test was positive. The 10/28/2024 Nurse Practitioner #59 medical order documented contact/droplet precautions for COVID-19. During an observation on 10/28/2024 at 1:29 PM, Resident #644 had a Droplet Contact Precautions sign hanging outside their room. The sign documented all healthcare personnel must clean hands before entering and when leaving the room; wear a gown when entering the room and remove before leaving; wear an N95 or higher-level respirator before entering the room and remove after exiting; wear protective eyewear (face shield or goggles); and precautions should be followed during room cleaning. During an observation on 10/29/2024 at 10:27 AM, Cycle Cleaner #1 was cleaning Resident #644's room wearing a gown and a N95 mask. They were not wearing gloves or eye protection. They exited the room, obtained a wash rag from their cart, dipped it in the cleaning solution located on their cleaning cart, reentered the room, wiped down flat surfaces and the doorknob, exited the room, disposed of the cleaning rag in a bag located on their cart, took a trash can liner from the cleaning cart and brought it into the resident's room, exited the room wearing the same gown, no gloves or eye protection, and without performing hand hygiene. They removed their gown in the hallway, placed it in the garbage receptacle located on their cleaning cart, removed the bag from their cart with bare hands, took it down the hall to the soiled utility room, exited the soiled utility, and applied clean gloves without performing hand hygiene. They entered the room adjacent to Resident #644's, brought the garbage out, placed a new wash rag in the same tub of cleaning solution, reentered the same room, wiped down the bedside table, exited the room, and discarded the cloth in a bag located on the cleaning cart. They reentered the room, dried the bedside table, moved to the other half of the room, brought the garbage out to the hall, and delivered both garbage cans back to the room. Cycle Cleaner #1 exited the room, removed their gloves, and did not perform hand hygiene. During an interview on 10/29/2024 at 10:47 AM Cycle Cleaner #1 stated they received training about infection prevention and precautions about a year ago when they were hired. The cleaning buckets were filled with cleaning solution every morning and disposed of at the end of the day.They changed the solution in between those times the cleaning cloths touched something dirty. When they entered a precaution room they wore a gown and gloves and knew what precautions to take by looking at the precaution sign outside the door. Wearing gloves was important because they could contract germs while in the room and then spread it to the next room. Gowns were important for extra protection and could be removed after they left the room. They stated they should have washed their hands with soap and water after cleaning the room and after removing their gloves. They forgot a step when cleaning, so they went back into the room and did not put gloves on. They did not need to wear protective eye wear, but after reading the precaution signage, stated eye wear should have been worn. During an interview on 10/29/2024 at 2:15 PM, Housekeeping Supervisor #2 stated their staff received infection prevention training during the annual mandatory trainings and inservices throughout the year. They expected their staff to be fully gowned and gloved when entering a COVID-19 positive room. They should know what each isolation sign was, what it stood for, and follow its directives. They should wear eye protection if called for, put a bag at the door threshold so they could remove their gown and gloves before leaving the room, and perform hand hygiene after glove removal and before leaving the room. Staff should not go into a COVID-19 positive room without gloves, leave that room without washing their hands, and then go into another room. They could spread COVID-19 all around the building. It was possible that if a contaminated gown was worn into the hallway, it could cause germs to spread into the hallway. During an interview on 10/29/2024 at 2:28 PM, Registered Nurse Unit Manager #3 stated precaution sign directives should be followed by any employee who entered a COVID-19 positive room and included gloves, gowns, a N95 mask, and goggles if any splashing was anticipated, or if the resident was symptomatic. Protective equipment should be removed before leaving the room.Hand hygiene should be performed before entering the room and after removing protective equipment. Gowns and gloves were important to avoid cross contamination and if the same gown and gloves that were worn in a COVID-19 room were worn into the hall the organisms could be brought into the hall and expose others. If an employee did not wash their hands after leaving a COVID-19 room and then entered another room, COVID-19 could spread very quickly. During an interview on 11/01/2024 at 11:52 AM, the Registered Nurse Infection Preventionist stated they expected all staff, including housekeepers, to wear a N95 mask, gown, gloves, and goggles before entering a COVID-19 positive room and should have removed that equipment and performed hand hygiene before leaving the room. Housekeeping staff should have all the necessary equipment when they entered the room. If a housekeeper left a COVID-19 positive room and went into another room, COVID-19 could spread. Following precautions was important to decrease the spread of infectious diseases and for the protection of the employee, residents, and their loved ones. 2) Resident #238 had diagnoses including history of urinary tract infections, resistance to multiple antibiotics, and retention of urine. The 10/10/2024 Minimum Data Set assessment documented the resident had intact cognition, an indwelling urinary drainage device, and had a urinary tract infection in the last 30 days. The Comprehensive Care Plan revised 9/20/2024 documented the resident had a urinary drainage device. Interventions included when collection bags were removed rinse them out with one part vinegar and 3 parts water, soak the bag for 20 minutes, rinse with warm water, then hang up to dry; and a leg bag/drainage bag cap must be put in place on the end that attaches to the urinary drainage device when not in use. During an observation on 10/30/2024 at 9:09 AM, Resident #238's gravity drainage bag was hanging on a grab bar in the resident's bathroom with 25 milliliters of yellow clear fluid in it. The port that connected to the catheter was not covered. The back of the bag had brown, smeared material on it. No supplies of vinegar were observed. During an observation on 11/1/2024 at 9:45 AM, Resident #238's gravity drainage bag was hanging on the toilet grab bar with approximately 300 milliliters of clear yellow fluid in it. The port that connected to the catheter was not covered. During an interview on 11/1/2024 10:04 AM, Certified Nurse aide #47 stated in the morning when changing from a gravity drainage bag to a leg bag, the gravity drainage bags were disconnected, rinsed out with water and hung on the bathroom bar to dry. There was not a specific cleaning solution used to clean the bags. Some bags had a long, blue cap on the connection port that some staff threw away. The purpose of that blue cap was to prevent contamination. Leg bags also had a protective cover. Resident #238 had a catheter and switched between a gravity drainage bag and a leg bag daily. They observed the resident's gravity drainage bag that was hanging in the bathroom and said there should have been a blue cap on the end and there was nothing protecting it from things getting into it. During an interview on 11/1/2024 at 10:26 AM, Certified Nurse Aide #48 stated there were leg bags and regular gravity drainage bags and when disconnecting a bag, it was emptied and hung on the bar on the side of the bathroom toilet. They did not do anything else to the bag. New gravity drainage bags had a blue cap on the connection port that connected to the catheter that was usually thrown away once opened. They had never seen the cap used after it was opened and no one had told them that it should have been covered. Resident #238's leg bag was hung in their bathroom that morning without a cap on it. After disconnecting the gravity drainage bag, they hung it on the bar next to the toilet. They did not have a chance to empty the urine out of it yet. They did not put a cap on the connection port but did try to anchor it to the bar so that it would not fall or touch something. During an interview on 11/1/2024 at 10:41 AM, Licensed Practical Nurse #49 stated when gravity drainage bags where not in use they should be capped and hung in the bathroom on the bar around the toilet. They were unsure what the rinsing or cleaning process was. The cap should have been put in place for infection control reasons. If not capped, and someone used the bathroom and had a bowel movement, particles could spray up when they flushed, and it could contaminate the tubing. They believed bags were dated, changed weekly, and it would come up on the treatment administration record when it was due. If there was a bag in the bathroom that was not capped, they would not use that bag because they did not know if it was contaminated. Resident #238 had a catheter and they recently had a urinary tract infection. During an interview on 11/1/2024 at 10:58 AM, Registered Nurse Unit Manager #3 stated the policy regarding the cleaning of urinary collection bags stated something about vinegar, but the facility used warm soapy water. They expected when the bags were changed, they were cleaned with warm soapy water, capped, and hung to dry. They were unsure how often bags were changed, if they should have been dated, and there was nothing in the administration record that prompted when a bag needed to be changed. The bag should have been replaced if it was hanging without a cap to maintain the integrity of the tubing. Without that barrier, contamination and infection could occur. Resident #238 used a leg bag during the day and switched to a gravity drainage bag at night. The resident had a history of multiple urinary bladder infections with sepsis that required hospitalization . During an interview on 11/1/2024 at 11:52 AM, the Registered Nurse Infection Preventionist stated they were unsure what the policy was regarding bag storage, but they should be stored in clean areas, not in an area that had potential to contaminate the bag and lead to an infection. The drain spout should not have been left open to the air because there was a potential for bacteria to enter. 3) Resident #52 had diagnoses including acute cystitis (inflamed bladder) and neuromuscular dysfunction of the bladder (nerves and muscles that control the bladder do not work properly). The 10/4/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, was dependent on staff for toileting hygiene, and had an indwelling urinary catheter. The Comprehensive Care Plan initiated 12/22/2021 documented the resident had a suprapubic catheter (a tube that drains urine from the ballder through a small incision in the lower abdomen) related to neurogenic bladder. Interventions included catheter care every AM and PM, change catheter every 4 weeks, and as needed, position the catheter bag and tubing below the level of the bladder, place a dignity bag on the catheter bag, and monitor for signs and symptoms of a urinary tract infection. The 1/24/2024 physician order documented indwelling suprapubic catheter 24 French (size of tube) 10 milliliter balloon (used to anchor the device in the bladder), monitor patency, output, and urine clarity every shift. The following observations of Resident #52 were made: - on 10/28/2024 at 11:30 AM, lying in bed with their urinary drainage bag resting directly on the bare floor on the window side of the bed. There was no barrier between the drainage bag and the floor. - on 10/29/2024 at 9:22 AM, lying in bed with their urinary drainage bag hanging from the window side bed frame, the bed was in the lowest position and the bottom of the bag was resting directly on the bare floor. There was no barrier between the bottom of the drainage bag and the floor. - on 10/31/2024 at 8:53 AM, lying in bed with their urinary drainage bag hanging from the window side bed frame, the bed was in the lowest position and the bottom of the bag was resting directly on the bare floor. There was no barrier between the bottom of the drainage bag and the floor. During an interview on 11/1/2024 at 9:26 AM, Certified Nurse Aide #34 stated they cared for Resident #52 during the day shift on 10/31/20204. They received catheter training upon hire and during yearly in-services. They were responsible for completing catheter care every shift and as needed, emptying the urinary catheter drainage bag, and documenting the output. The drainage bag should always be kept off the floor for infection control reasons and could cause the resident to get a urinary tract infection. They were not aware the drainage bag was touching the floor and if they saw it on the floor, they would have notified the nurse so they could have replaced it with a new drainage bag. During an interview on 11/1/2024 at 9:48 AM, Certified Nurse Aide #35 stated they cared for Resident #52 a few times that week during the day shift. They received catheter training upon hire, yearly, and as needed. They completed catheter care, emptied the urinary drainage bag, and made sure the bag did not overflow. They stated it was important to keep drainage bags off the floor for infection control reasons, the floor was dirty, and Resident #52 could have developed a urinary tract infection. During an interview on 11/1/2024 at 10:08 AM, Licensed Practical Nurse #36 stated the certified nurse aides and nurses received catheter training upon hire, annually, and as needed. The drainage bag should never touch the floor. If the drainage bag was on the floor, it should have been sanitized, switched out for a new one, or some kind of barrier should have been put down between the bag and the floor. They stated floors were dirty with bacteria, which could have caused Resident #52 to develop a urinary tract infection. During an interview on 11/1/2024 at 10:27 AM, Registered Nurse Unit Manager #24 stated nursing staff received training on catheters upon hire, annually, and as needed. Urinary drainage bags were to be hung on the wheelchair or bedframe, so they did not touch the floor. If the drainage bag was on the floor, they would expect nursing staff to pick it up off the floor immediately and clean the bag or change it out for a new one. They stated it was important for Resident #52's drainage bags to be kept off the floor because floors were dirty, and it could put the resident at risk for an infection. During an interview on 11/1/2024 at 11:52 AM, the Registered Nurse Infection Preventionist stated urinary drainage bags should be kept below the resident's waist, in a blue privacy bag, and should not rest on the floor. The floor was dirty, the bag could have been contaminated, and lead to a urinary tract infection. 10 NYCRR 415.19

Based on record review and interviews during the recertification survey conducted 10/28/2024 -11/1/2024, the facility did not ensure that a surety bond (an agreement between the facility, the insurance company, and the resident wherein the facility and the insurance company agree to compensate the resident for any loss of residents' funds the facility holds, safeguards, manages, and accounts for) was purchased in the amount equal to or greater than the total resident funds to assure the security of all personal funds of residents deposited with the facility for 239 of 296 residents with personal funds accounts. Specifically, the facility's surety bond was for an amount less than the total of all resident personal fund accounts being held by the facility. Findings include: The facility policy, Resident Fund Policy and Procedures, dated 10/1/2015, documented the facility shall hold, safeguard, manage and account for resident personal funds placed in its care. The facility would ensure compliance with Federal, State, and County resident fund requirements. There was no documented facility policy regarding the surety bond for resident funds. The facility resident Personal Funds Account balance for resident accounts held by the facility totaled: - $309,021.74 on 9/16/2024. - $309,980.04 on 10/1/2024. - $303,807.41 on 10/15/2024. - $286,256.24 on 10/30/2024. The Surety Bond dated 8/10/2023 for coverage dates from 11/8/2023 to 11/8/2024 documented the resident Personal Funds Accounts were insured for $250,000.00. There was no documented evidence the facility had a surety bond to cover the Personal Funds Account total managed by the facility. During an interview and record review on 10/30/24 at 11:41 AM with Financial Associate #5 and Accounting Manager #4, Financial Associate #5 stated the Resident Funds Account total was $268,072.82. Accounting Manager #4 stated they had a surety bond for the Resident Funds Account, and they paid an extra $5,000 a month for it. They would have to look up the surety bond to see how much it covered. During an interview and record review on 10/30/24 at 3:06 PM, the Chief Operating Officer stated their coverage for the Resident Personal Funds Account was $250,000. They stated the amount fluctuated and the question was the timing with when social security money was deposited into resident accounts. They were unaware of what the balance consistently was. The Accounting Manager and Comptroller tracked the amount in the resident accounts. During an interview on 11/01/24 at 1:03 PM, the Corporate Treasurer stated they managed the treasury for the company's banking relationships. They oversaw anything that came through for the accounts, the cash flows, fraud, or abuse claims regarding the accounts, and until recently, all insurance aspects for the company accounts. They stated they did not check to make sure the Resident Funds Account total did not exceed the surety bond on a regular basis and was unaware they were required to. 10 NYCRR 415.26(h)(5)(v)

Based on interviews during the recertification survey conducted 10/28/2024-11/1/2024, the facility did not ensure the rights of citizenship, including the right to receive mail, were maintained for 296 of 296 residents residing in the facility. Specifically, mail was not delivered to residents on Saturdays, thereby denying all residents the same rights provided to other citizens of the general community. Additionally, 3 of 6 anonymous residents present at the resident group meeting stated their mail was opened prior to it being delivered to them. Findings include: The facility policy, Resident Mail, dated 2/27/2024, documented residents received their mail promptly and unopened unless requested in writing by the resident or designated representative. Any front desk deliveries were delivered to the resident promptly. On Saturdays, the nursing supervisor delivered mail to the units during rounds. Staff then distributed the mail to residents on the same day. The facility policy, Resident Rights & Notice of Resident Rights and Responsibilities, dated 4/30/2024, documented residents had a right to access mail. The nursing facility ensured residents had a right to exercise their rights without interference from the facility. During a resident group interview on 10/28/2024 at 2:17 PM, 6 of 6 anonymous residents stated mail was not delivered to them on Saturdays because the social workers did not work on Saturdays. Three residents stated they received mail that had been opened prior to it being delivered to them. During an interview on 11/1/2024 at 10:12 AM, Certified Nurse Aide #9 stated they did not know the process of mail delivery and had never seen mail passed out to the residents. During an interview on 11/1/2024 at 11:00 AM, Certified Nurse Aide #10 stated mail was delivered to the front desk and the front desk called the floor and alerted the floor the mail had been delivered. Sometimes the person at the front desk brought the mail to the unit, sometimes a staff member went to get it and the unit secretary, or the certified nurse aides delivered it to the residents. During an interview on 11/1/2024 at 11:31 AM, front desk Security Site Supervisor #12 stated they worked Monday through Friday and sorted the mail by floor and placed it in that floor's folder. Each floor had an assigned social worker that came to get the mail from the folder after it was sorted. They stated Security Officer #11 worked on weekends. During an interview on 11/1/2024 at 11:35 AM, front desk Security Officer #11 stated they worked on Saturday and Sunday. On Saturday when the mail came, they sorted the mail by floor. Anything that looked like an official document went into the folder for the social worker of the floor the resident resided on. If it looked like a card or a personal item that was handwritten, the nursing supervisor was notified and would deliver that piece of mail to the resident. During an interview on 11/1/2024 at 11:47 AM, the Director of Social Work stated the front desk sorted mail by floor and the assigned social worker delivered it. The social workers were the only ones who knew if the facility was the representative payee for the resident. If so, the social worker got the resident's bills. Residents that did not have the facility as their representative payee received their own mail. The social workers did not work on Saturdays, so residents received greeting cards on Saturdays that were distributed by the Nursing Supervisor. All other mail went into folders to be sorted by the social workers on Monday. The residents should receive mail on Saturdays as it was their right. It was not fair the residents had to wait until Monday to receive their mail. This was the residents' home, and they should have the same rights as anyone. 10NYCRR 415.3(d)(2)(i)

Based on record review and interview during the abbreviated survey (NY00333847), the facility failed to ensure residents were free from neglect for 1 of 5 residents reviewed (Resident #1). Specifically, Resident #1 was care planned for transfers with a mechanical lift and certified nurse aides #1 and #2 did not utilize a mechanical lift when transferring the resident out of bed; certified nurse aides #14 and 15 did not use a mechanical lift when transferring the resident back into bed, and the resident was not assessed timely after complaints of extreme pain. Subsequently, Resident #1 was found with a fractured arm. This result in actual harm to Resident #1 that was not immediate jeopardy. Findings include: The 6/7/2019 Transferring Residents with Assistive Devices facility policy documented a mechanical lift was used for residents who were unable to, or inconsistently bear weight on one or both legs and participated less than 50% during the transfers; all total lifts (mechanical lifts) were to utilize 2 staff. Transferring a resident that required maximal assistance without a mechanical lift was prohibited for nursing staff, unless pre-approved by the Director of Nursing or Administrator and included in the resident's care plan. The 8/1/2023 Resident Abuse Reported facility policy documented the definition of neglect included failure of the facility, its employees or service providers, to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish, or emotional distress. Neglect also means the failure to provide timely, consistent, safe, adequate, and appropriate services, treatment and/or care to a resident . The 10/2018 Certified Nurse Aide Job Description documented principal duties included the aide would perform resident care according to policy/procedure and standards as delegated by the Nurse Manager, registered nurse, or Charge Nurse; recognize and respond to emergent situations effectively and efficiently, and report changes in the resident's behavior or condition to the team leader. There was no documented evidence the facility had a written policy regarding leaving the mechanical lift pad under a resident after a transfer or removing the mechanical lift pad after the transfer was completed. During an interview with the interim Director of Nursing on 3/5/2024 at 2:19 PM, they stated the facility did not have a protocol to remove mechanical lift pads from under residents once a transfer was completed. The expectation was that staff would leave the mechanical lift pads in place to be used for the next transfer. Resident #1 had diagnoses including rheumatoid arthritis (a chronic inflammatory disorder) and hypothyroidism (under active thyroid). The 2/21/2024 Minimum Data Set assessment documented the resident had moderate cognitive impairment, exhibited no behavioral symptoms, and was dependent for activities of daily living including transfers. The 2/14/2024 Admission Assessment documented the resident was alert to person, place, time, and situation, and had upper and lower body impairment on both sides. The comprehensive care plan, initiated 2/14/2024, did not document the type of assistance the resident needed with transferring. The 2/17/2024 Kardex Report (care instructions) documented the resident was at risk for falls ; was non-ambulatory and was dependent for chair/bed-to-chair transfers with a mechanical lift and 2 persons. On 2/17/2024 at 8:15 PM, registered nurse #18 documented the resident complained of severe pain in their right arm. Upon assessment, there was a very obvious deformity on the upper right arm. The resident stated when certified nurse aides #1 and #2 were getting the resident up, the resident heard a crack in their arm, and it hurt very badly. No other injuries or deformities were noted. The resident's relative was notified of the deformity and that the resident was going to the hospital to be evaluated. On 2/17/2024 at 8:25 PM, licensed practical nurse #16 documented the resident complained of right arm pain and stated they felt a crack after transferring (out of bed) before dinner. Registered nurse #18 was notified. The 2/18/2024 hospital Patient Education Summary documented the resident had a humerus (upper arm bone) fracture treated with a shoulder immobilizer. The shoulder immobilizer was to be used for comfort with pain medication as needed and the resident was to follow up with the orthopedic surgeon. The 2/19/2024 nursing progress note, entered by registered nurse #31 documented the resident went to an orthopedic appointment. Recommendations included ice and the shoulder immobilizer for 6 weeks. The 2/22/2024 facility investigation completed by the Interim Director of Nursing documented the incident occurred on 2/17/2024 and was classified as neglect/failure to follow the plan of care. A summary written by the Interim Director of Nursing of certified nurse aides #14 and #15 statements noted at 7:15 PM, a nurse (unnamed) asked them to put the resident back to bed. The resident told the aides that the 2 people who got them up before dinner (certified nurse aides #1 and #2), pulled their arms and the resident heard a snap followed by immense pain. The resident was transferred back to bed without the lift as there was no lift pad underneath (the resident) and given the pain the resident was describing the (certified nurse aides) were unable to get the lift pad under the resident while in the wheelchair. Certified nurse aides #14 and #15 completed a 2-assist transfer of the resident back to bed without touching the resident's arm. The investigation documented Registered Nurse Supervisor #18 spoke to certified nurse aides #1 and #2 and they reported they used the mechanical lift to transfer the resident out of bed, although a mechanical lift pad was not located in the room and was not under the resident in the wheelchair at the time of the transfer back to bed. The investigation documented Resident #1 was sent to the hospital and found to have a non-displaced midshaft humerus fracture (broken upper arm bone). The Interim Director of Nursing documented the resident's care plan was not followed and the findings were verified through the investigation. The 2/22/2024 Facility Investigation included statements regarding 2/17/2024, from certified nurse aides #1 and #2 who reported they used a mechanical lift when getting the resident out of bed before dinner. The facility investigation included a follow up interview of certified nurse aide #14 by the Chief Nursing Officer and Interim Director of Nursing completed on 2/19/2024 which documented certified nurse aide #14 reported the nurse asked them to put the resident back to bed due to the resident complaining of pain. The resident was crying and said staff hurt their arm when they got them out of bed. Certified nurse aides #14 and #15 cradled the resident to put them back into bed due to the pain in their arm. A follow-up interview of certified nurse aide #15 by the Chief Nursing Officer and interim Director of Nursing completed on 2/19/2024 documented certified nurse aide #15 reported they were told to put the resident back to bed. The resident was complaining of pain and stated the 2 staff who got them up (certified nurse aides #1 and #2) grabbed their arms and the resident heard a snap. Certified nurse aides #14 and #15 cradled the resident back to bed by lifting under their legs and holding their back. After they transferred the resident to bed, certified nurse aide #14 reported the resident's pain to licensed practical nurse #16. The 2/22/2024 Facility Investigation included a statement from licensed practical nurse #16 that documented on 2/17/2024, they saw the resident at 6:00 PM eating in the dining room. When obtaining the resident's blood pressure, the resident said the licensed practical nurse had to use their left arm, as the aides who got them up before dinner (certified nurse aides #1 and 2) hurt their right arm. There were no visible deformities at that time. The resident stated they heard a crack when they were assisted out of bed. When licensed practical nurse #16 was giving the resident their nighttime medications, a very visible deformity was noted and Registered Nurse Supervisor #18 was notified. The resident stated they were picked up by the 2 staff (certified nurse aides #1 and #2) before dinner without the use of the mechanical lift. (The Vitals Report documented on 2/17/2024 at 5:14 PM, the resident's blood pressure was taken and was 148/87, with a warning that the systolic (top) number was over 139). The facility investigation included statements from Registered Nurse Supervisor #18 which reported, on 2/17/2024 at 8:15 PM, they were made aware the resident complained of right arm pain. The resident reported they were assisted out of bed by 2 aides (certified nurse aides #1 and #2) without using the mechanical lift. Licensed practical nurse #17 transcribed the resident's 2/17/2024 statement, which documented the resident reported 2 staff (certified nurse aides #1 and #2) entered their room and lifted them out of bed by their arms without a machine. The resident heard a crack when they were getting up and one of the staff asked, what's that? The resident ate with their left hand due to the pain and cried when it happened. Licensed practical nurse #17 documented they went to the room with licensed practical nurse #16 to look at the resident's arm when the deformity was reported, and the resident's right upper arm was the size of a grapefruit. During an interview on 2/29/2024 at 10:23 AM certified nurse aide #15 stated on 2/17/2024 they went on break with certified nurse aide #14 from approximately 4:00 PM to 4:30 PM and when they returned, the resident had been transferred out of bed and was in the dining room for dinner. After dinner, certified nurse aide #14 stated they had to put the resident back to bed. The resident was very upset and said the other 2 aides (certified nurse aides #1 and #2) yanked them out of bed and their arm was very sore. Certified nurse aides #14 and #15 lifted the resident back to bed. Due to their pain and the fact there was no lift pad under them, certified nurse aides #14 and #15 could not use the mechanical lift. They did not notify the nurse prior to lifting the resident and placing them in bed and certified nurse aide #15 was aware the resident required a mechanical lift. The resident was back in bed at approximately 7:15 PM and they accompanied certified nurse aide #14 as they reported the resident's pain to licensed practical nurse #16. They continued with their rounds. It was an unknown amount of time later when the licensed practical nurse #16 called certified nurse aide #15 to the resident's room to show them their arm, as the nurse was astonished at the amount of the swelling. During an interview on 2/29/2024 at 11:10 AM, licensed practical nurse #16 stated on 2/17/2024, while obtaining the resident's blood pressure at approximately 5:15 PM, the resident reported pain in their right arm. The resident did not appear to be in distress and was moving their arm and they did not recall the resident stating the aides hurt them while getting them out of bed or requesting the nurse use the left arm for the blood pressure. Licensed practical nurse #16 stated they took the resident's complaint as a general complaint as they had observed the resident in prior days with similar complaints of overall aches and pains. The nurse may have instructed the aides to put the resident back to bed based on the resident's general discomfort. No staff reported to the licensed practical nurse about the resident's pain, allegations staff hurt their arm, the missing lift pad, or that they had to lift the resident back to bed without a mechanical lift. Licensed practical nurse #16 provided evening medications to the resident at approximately 8:00 PM and noticed the arm swelling through the resident's clothing. Upon inquiry, the resident reported their arm was hurt when they got out of bed earlier that day before dinner. The nurse immediately notified Registered Nurse Supervisor #18, who assessed the resident, and the resident was sent to the hospital. During an interview on 2/29/2024 at 11:36 AM, certified nurse aide #14 stated on 2/17/2024 at approximately 6:30 PM, they were asked by the nurse (they did not recall which nurse) to put Resident #1 back to bed. Once in their room, the resident said they were in a great deal of pain. There was no mechanical lift pad under the resident, and certified nurse aides #14 and #15 lifted the resident back to bed by cradling them in their arms. The resident told certified nurse aides #14 and #15 the 2 aides (certified nurse aides #1 and #2) who got the resident out of bed before dinner pulled the resident by their arms, they heard a crack and then had pain. They were unaware of the resident's care plan, did not know they were to be transferred with a mechanical lift, and did not look at the care plan prior to transferring the resident. There was no mechanical lift pad under the resident and certified nurse aide #14 thought the resident did not require a mechanical lift for this reason. Certified nurse aide #14 did not go to a nurse or Supervisor prior to lifting the resident back to bed and should have, due to the resident stating they were in so much pain. They placed the resident back into bed at approximately 7:15 PM and reported the resident's complaint of pain and what they said about the other staff pulling them by their arms to licensed practical nurse #16. They continued to do their rounds and was unaware of when the nurse or Supervisor saw the resident. During an interview on 3/1/2024 at 9:23 AM, certified nurse aide #2 stated they followed Resident #1's care plan when transferring them on 2/17/2024. They declined to answer further questions and stated they had no additional information to provide other than what they already provided to the facility. Following unsuccessful attempts to contact certified nurse aide #1, the surveyor received an email on 3/5/2024 from certified nurse aide #1 which documented they maintained their version of events as reported to the facility. They had no further information to add and were unable to be reached by phone. During an interview on 3/5/2024 at 2:19 PM the interim Director of Nursing stated they questioned licensed practical nurse #16 about their statement that the resident reported their hurt arm before dinner and licensed practical nurse #16 explained they thought the resident meant they may have hurt their own arm when getting up and was complaining of general aches and pains due to arthritis. The Interim Director of Nursing stated they did not notice that licensed practical nurse #16 wrote in their statement the resident reported the aides hurt their arm when getting them up. The Interim Director of Nursing was not aware of the discrepancy in the staff statements that included certified nurse aides #14 and #15 documented they reported the resident's pain to licensed practical nurse #16 after putting them into bed at 7:15 PM and licensed practical nurse #16 reported discovering the injury when providing evening medication after 8:00 PM. The Interim Director of Nursing stated certified nurse aides #14 and #15 should have reported the resident's pain prior to transferring the resident back to bed. Transferring the resident by lifting them was not an approved method of transfer and was a care plan violation. The Interim Director of Nursing determined certified nurse aides #1 and #2 did not use the mechanical lift based on the investigation and staff statements including that no lift pad was found on the unit or taken to laundry. During an interview on 3/6/2024 at 9:28 AM the Medical Director stated they were not made aware of the resident's injury until after they saw the resident on 2/26/2024. Their understanding was the resident reported rough handling by staff and sustained a fracture to their arm. The resident was competent without dementia and their report of the incident should be taken at their word. The Medical Director stated if the resident was pulled up by their arms, that could have caused the fracture. The expectation was to follow the care plan to prevent injury and provide appropriate care. The injury could have been prevented had the staff followed the care plan. The Medical Director was not made aware the care plan was not followed when staff placed the resident back to bed. This could have caused additional injury to the resident. When the resident expressed pain before going back to bed, the staff should have notified a nurse immediately. The Medical Director stated their concern was the multiple areas where procedure was not followed and lack of communication. 10 NYCRR 415.4(b)(1)(i)

Based on observation, record review, and interview during the abbreviated (NY00330077) survey, the facility did not ensure residents received adequate supervision to prevent accidents for 1 of 4 residents (Resident #4) reviewed. Specifically, Resident #4 exhibited exit seeking behaviors and had a wanderguard (device to detect wandering) and eloped from the facility (left the facility undetected) during a fire drill when staff did not monitor the exit doors per facility policy. Findings include: The facility's Elopement Evaluation (Wandering/Elopement Risk) policy revised 1/16/2024, documented an elopement was defined as the ability of a resident to leave the facility unsupervised or unnoticed by staff and enter into harm's way. The facility provided a safe environment for residents by evaluating, identifying, and responding to residents who presented a risk based on wandering or elopement behaviors. New admissions would be assessed by licensed nursing staff to determine elopement or wandering risk. A reassessment would be conducted quarterly, annually, and with changes in resident status. The facility policy Accutech Resident Guard System & RCARE (Wanderguard & Nurse Call System) Policy, revised 8/2020, documented in addition to staff regularly checking on and being aware of residents' whereabouts, the wandering alert system would be utilized to alert staff to resident movement off the unit unescorted or unobserved. The wander alert systems would be placed on resident care units, elevators, and facility exits to facilitate safety for residents at risk for wandering. The wander alert devices are tested weekly to ensure function. When the fire doors closed during a fire, the wandering alert system would deactivate. All hallways with exit doors would be monitored by staff to ensure the safety of the residents. The facility policy Fire: General Procedures, updated 1/21/2020, documented all staff on the unit or immediate area were to respond during a fire alarm. Two employees had to be stationed on each nursing unit to observe the stairwell exit doors as all exit doors unlocked when the fire alarm was active. Resident #4 had diagnoses including Alzheimer's disease and dementia with other behavioral disturbance. The 12/19/2023 Minimum Data Set assessment documented the resident had moderately impaired cognition and wandered 3 days or less during the assessment period to potentially dangerous places as well as intruded on other residents' privacy. The resident needed moderate to maximum assist for most activities of daily living except with ambulation where they were independent. The 12/13/2023 elopement risk assessment documented the resident had a history of attempted elopement while at home, the resident's wandering behavior was a pattern, was goal-directed, and the resident's wandering behavior was likely to affect the privacy of others. The resident was deemed at risk for wandering and elopement. The 12/13/2023 physician's order documented the licensed nurse was to check for activation of the resident's wanderguard every week on Thursday. The 12/13/2023 physician's order documented the resident had a wandering alert device that was to be checked for placement every shift. The comprehensive care plan, initiated 12/13/2023, documented the resident had impaired cognition and was at risk for wandering. The resident had a wanderguard on the left ankle. On 12/14/2023, nurse practitioner #23's progress note documented the resident had dementia with disruptive behaviors and was admitted from an assisted living facility on 12/13/2023 after developing increased behaviors and required higher level of care. Nursing progress notes documented the resident had wandering and exit seeking behavior: - on 12/15/2023 at 8:29 PM, licensed practical nurse #24 noted the resident was exit seeking. - On 12/17/2023 at 2:59 PM, licensed practical nurse #25 noted the resident had one-to-one supervision due to exit seeking and attempting to remove their wandering device at lunchtime. - On 12/17/2023 at 7:49 PM, licensed practical nurse #24 noted the resident had increased wandering, cut off their wandering device, and threw it at the nurse. The resident was aggressive and combative with staff. The 12/18/2023 at 4:29 PM, Acting Administrator's incident note documented a fire drill was conducted at 4:10 PM by the Maintenance Director and after the alarm was cleared, the Maintenance Director left the facility and located the resident in the back parking lot in a winter jacket. The Maintenance Director brought the resident back into the building without issue. The investigation summary completed by the Acting Administrator documented on 12/18/2023: - the resident accessed the west stairwell during a fire drill at 4:10 PM and exited the loading dock door. - The resident was observed outside by the Director of Maintenance when the Director was leaving their shift at 4:35 PM and they brought the resident back into the building. - The resident was assessed without physical injuries or psychosocial effects. - The resident's wanderguard was intact and functioning as it set off the alarm when the resident was escorted back into the building. - The summary of employee interviews documented certified nurse aides #19, 20, 21, and 30 and licensed practical nurse #24, who were assigned to the unit, were in resident rooms providing care during the fire drill. - There was no staff member stationed at the stairwell door where the resident exited and no one had the stairwell door within sight during the fire drill. - Licensed practical nurse #24's statement documented the resident attempted to exit through the fire door prior to the alarm going off but was unsuccessful due to the door being locked. The resident was redirected toward the dining room at that time. During an interview on 2/28/2024 at 12:21 PM, the Maintenance Director stated: - On 12/18/2023 prior to the fire drill, they put the system in bypass mode (would enable the doors to remain locked during a fire alarm and would keep wanderguards activated) and had the front desk staff announce that the fire alarm system was in test mode. They should not have had it announced that the system was in test mode because when test mode was announced, the staff did not monitor the doors as they thought someone was testing the alarms. - Staff were to monitor the exit doors during fire drills. - They proceeded with the fire drill, had someone pull the fire alarm station, and then reset the fire alarm panel when they were done. - Later on, they went to leave the facility for the day and found the resident in the parking lot. The resident stated they could not get into their car. The resident followed the Director back into the building and the wanderguard sounded at the elevator when they returned to then unit. - There was no wanderguard alert system at the loading dock door where the resident exited and none at the stairwell door that the resident used. During an interview on 2/28/2024 at 1:00 PM, certified nurse aide #19 stated on 12/18/2023, they last saw the resident at 3:30 PM when the resident was listening to music in their room. They did not see the resident during the fire drill as they were in another resident's room and during the fire drill, they were watching the east stairwell door from the room that they were in. They had not witnessed the resident attempting to exit the unit through the stairwell earlier that day but had seen the resident do it in the past. During a telephone interview on 2/28/2024 at 1:20 PM, certified nurse aide #20 stated when the fire drill occurred on 12/18/2023, they were aware it was a fire drill. Their shift started at 3:00 PM that day and they saw the resident before the fire drill but did not recall what time. During the fire drill they were in another resident's room and did not see the resident exit the floor. They stated they were aware that during a fire drill the staff were supposed to cover the stairwell exit doors, but they were not sure if anyone did. They stated they did not know the resident left the unit until the resident was brought back. During a telephone interview on 2/28/2024 at 1:49 PM, certified nurse aide #21 stated on 12/18/2023, they were in another resident's room providing care during the fire drill but did not remember what room they were in. They stated they were not aware they were supposed to cover the stairwell exit doors during a fire alarm and was not aware the stairwell doors unlocked during a fire alarm. They were unaware the resident left the unit until the resident was brought back by the nurse Supervisor. They stated the resident wandered a lot so it was not unusual that they did not see the resident right away after the fire drill. During an interview on 2/28/2024 at 2:14 PM, the Acting Administration stated on 12/18/2023, they were informed a fire drill was going to occur and heard the announcement that the fire system was being placed in test mode. They stated that as not the procedure for a fire drill. They stated the fire drill occurred and they were under the impression everything was okay until they witnessed the Maintenance Director coming up to the first floor with the resident. They were informed the resident was found outside and the resident stated they had to go because it was time for dinner. They were unable to determine how the resident got into the stairwell during the fire drill. The policy of the facility was that staff were to go to the stairwells when the fire alarm went off as during a real emergency, those doors unlocked, and the wandering alert system would deactivate. If a staff member was providing care to a resident when the fire alarm went off, they should ensure the resident was in the safest possible position and report to the stairwell exit doors. 10NYCRR 415.12 (h)

Based on record review and interview during the abbreviated survey (NY00334306), the facility did not comply with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility for 1 of 5 residents reviewed (Resident #5). Specifically, Resident #5 was found deceased on the floor in another resident's room. The resident had a laceration to their head with bleeding. The facility called the County Coroner (referred to as the Medical Examiner by the facility), who instructed them to notify the police. The facility did not comply with the directives to immediately notify the police, moved the resident's body, and performed post-mortem care prior to the coroner's and police department's arrival. Findings include: The [DATE] Deaths Reportable to the Medical Examiner policy documented New York State County Law mandates the Medical Examiner make an inquiry regarding all unnatural deaths within the county. As required by law, all unnatural deaths, or deaths which appear to be unnatural suspicious, as well as any sudden unexplained death must be reported to the Medical Examiner's office. Examples of reportable deaths include deaths from conditions directly related to trauma (fall or being struck on the head). The facility was to notify the Medical Examiner's office and report relevant information about the resident and circumstances of their death. If all information was not yet available, notification should not be delayed. A decision will be made if the case falls under the jurisdiction of the Medical Examiner. Resident #5 had diagnoses including congestive heart failure, a cardiac pacemaker (device that regulated heart rate), and dementia. The [DATE] Minimum Data Set assessment documented the resident had moderate cognitive impairment and had no falls since admission. The comprehensive care plan, initiated on [DATE], documented the resident was at risk for falls. Interventions included to anticipate needs, keep the call light within reach, urinal within reach, and ensure appropriate footwear. The undated Kardex (care instructions) documented the resident was at risk for falls, did not wear shoes, wore slippers or slipper socks, and had a wheelchair with elevated leg rests. The [DATE] facility investigation completed by the interim Director of Nursing documented: - Certified nurse aide #10 found the resident unresponsive on the floor in another resident's room and notified licensed practical nurse #7 at approximately 4:50 PM. - Licensed practical nurses #7 and 8 responded and immediately called registered nurse Supervisor #9. - Resident #5 was pronounced deceased at 5:02 PM. - Registered nurse Supervisor #9 notified the interim Director of Nursing at 5:13 PM that it appeared the resident fell , had a laceration above their left eyebrow, their pants were down, and they were lying in urine. The resident's wheelchair was in the room behind their body. - The Interim Director of Nursing notified the Chief Nursing Officer at 5:19 PM who instructed them to call the Medical Examiner and leave the body where it was. - At 5:22 PM, the interim Director of Nursing called registered nurse Supervisor #9 and advised the Medical Examiner was to be notified and to leave the body where it was. Registered nurse Supervisor #9 stated they already moved the body back the resident's room. - At 5:30 PM, the interim Director of Nursing called the County Medical Examiner's office and left a message. They then called the emergency telephone number listed on the Medical Examiner's website, the call connected the Sheriff's office, and the interim Director of Nursing hung up. - At 5:36 PM, the Medical Examiner called the interim Director of Nursing back and told the interim Director of Nursing they needed to notify the police to investigate because the County Medical Examiner's physician would not sign off without an investigation. - At 5:42 PM, the interim Director of Nursing reported to the Chief Nursing Officer what the Medical Examiner stated. The interim Director of Nursing and Chief Nursing Officer reviewed the incident and determined it was not suspicious. The interim Director of Nursing was advised to call registered nurse Supervisor #9 and tell them to call the funeral home. - At 5:48 PM, the interim Director of Nursing notified registered nurse Supervisor #9 to call the funeral home. - At 5:53 PM, the Medical Examiner called the interim Director of Nursing to ask why 911 had not yet been notified for a medical investigator to be dispatched. The interim Director of Nursing stated the facility determined it was not a suspicious death. The Medical Examiner questioned if the facility physician would be signing off on the death certificate and the interim Director of Nursing stated yes. - At 6:21 PM, the Medical Examiner called the interim Director of Nursing back stating they were not comfortable with the situation, it needed to be investigated, and advised the interim Director of Nursing to call 911. The Medical Examiner stated they would send their medical investigator to the facility. - At 6:28 PM, the interim Director of Nursing called registered nurse Supervisor #9 to verify the resident's body was still at the facility and advised the police and medical investigator would be arriving to investigate. - At 6:31 PM, the interim Director of Nursing called 911. The Interim Director of Nursing was interviewed on [DATE] and stated: - on [DATE], they were notified by registered nurse Supervisor #9 that Resident #5 was found deceased on the floor on their left side of another resident's room and the resident had a 1-centimeter laceration above the left eyebrow. - The body had been moved prior to the interim Director of Nursing being called and post-mortem care was done. - They called the Chief Nursing Officer who directed them to call the Medical Examiner due to the fall. - They called the Medical Examiner who advised them to call the police and they called the Chief Nursing Officer and explained the phone call they had with the Medical Examiner. - The Chief Nursing Officer told them to call the funeral home as the death was not suspicious. - The interim Director of Nursing told registered nurse Supervisor #9 to call the funeral home. - They were then called by the Medical Examiner who asked why the police had not been called and they stated they informed the Medical Examiner that the Chief Nursing Officer did not feel the death was suspicious, they did not call the police, and called the funeral home instead. - The Medical Examiner stated their recommendation stood and the death should be investigated due to the trauma. - The interim Director of Nursing called the Chief Nursing Officer to inform them the Medical Examiner was coming to the facility, and they had to make sure the facility had not released the body per the physician's order. -The interim Director of Nursing called the police per the Medical Examiner's direction. They body of the resident was released to the county coroner's office. The police Detective was interviewed on [DATE] at 4:15 PM and stated there were concerns related to the manner in which the facility handled the incident. There was a significant delay between the time the facility notified the County Coroner (Medical Examiner) of the death and when they notified the police. In the meantime, the staff moved and cleaned the resident's body, which left no evidence and raised suspicion to the Detective. When the Medical Examiner was notified, the facility was to follow what they were directed to do. It appeared as if the facility was making calls to management before proceeding. The situation looked suspicious because the typical manner was to contact the police first if there was a question about the cause of death, then the police would reach out to the Medical Examiner, who would go to the scene. The Detective thought the Medical Examiner was being cautious, since they were notified first, and the police should have been contacted. The County Coroner (Medical Examiner) was interviewed on [DATE] at 9:33 AM and stated: - they were initially informed on [DATE] the resident had an unwitnessed fall and was deceased . At that time, they asked the interim Director of Nursing to stop providing information and informed them an unwitnessed fall needed to be investigated and the police needed to be called. - Fifteen minutes after the initial phone call, they had not been called to dispatch an investigator to the facility and they called dispatch to inquire if they received a call; they had not. They called the interim Director of Nursing back and inquired why the police had not been called. The interim Director of Nursing reported the Chief Nursing Officer stated they did not need to call the police and that the funeral home had been called. The Medical Examiner inquired exactly what happened to the resident and was told the resident had an unwitnessed fall with head trauma and was found deceased in another resident's room with their pants down. They were also informed the resident had been moved back to their room and the body cleaned up. The Medical Examiner informed the facility the police and an investigator were going to come onsite. - The Medical Examiner stated they felt the facility wanted to inform them of the death and get them to approve it but the Medical Examiner was not going to sign off, as it required an investigation. Once the Medical Examiner's office was involved, it is their decision only on whether an investigation needed to take place. It was not up to the facility to determine if a death was suspicious or not, that is the County Coroner's role. - Given the information as presented, it raised suspicion due to the initial contact, the failure to follow protocol and call the police, the delay in calling the police, moving the body, and providing postmortem care prior to medical examiner approval. The Chief Nursing Officer was interviewed on [DATE] at 10:38 AM and stated there were certain situations in which a death had to be reported to the Medical Examiner, such as a fall within 30 days of death and when that happened, they called the Medical Examiner, reviewed the circumstances, and the Medical Examiner would state if they needed to take the case or if they authorized the facility to call the funeral home. When the Medical Examiner was notified, the facility was to follow their directives. There was no facility protocol related to moving a resident if they were found deceased in an area other than their room. The Chief Nursing Officer expected the body would be left where it was until further direction, and they advised the interim Director of Nursing to leave the body where it was until the Medical Examiner was notified. It was their understanding when the Medical Examiner spoke to the interim Director of Nursing, they stated 911 had to be called. It was then discussed if the facility physician was going to sign off on the death certificate. The interim Director of Nursing stated they told the Medical Examiner the physician was agreeable to sign the death certificate. The Chief Nursing Officer was told by the interim Director of Nursing, the Medical Examiner then stated it was all right to call the funeral home. The Chief Nursing Officer did not provide the directive to notify the funeral home, they thought the Medical Examiner approved. The Chief Nursing Officer stated they thought the Medical Examiner had second thoughts and that was when they notified the facility to have the police involved. During an interview with registered nurse Supervisor #9 on [DATE] at 3:19 PM, they stated they pronounced the resident deceased at 5:02 PM on [DATE]. They noted it appeared the resident had attempted to stand and walk to the bathroom in the room next to theirs, fell , and sustained a head injury. The resident's wheelchair was in the room behind the resident. When they called the Interim Director of Nursing, they reported they had already moved the resident. They were concerned the resident's family might arrive when the resident was lying on the floor in another resident's room. The interim Director of Nursing called them back and stated the Medical Examiner would not be arriving and it was okay to contact the funeral home and complete post-mortem care. Several minutes later, the interim Director of Nursing called back and stated the resident's body could not be released to the funeral home and the Medical Examiner and police were going to be there. 10NYCRR 400.2

Based on observation, record review, and interview during the recertification survey conducted 12/12/22-12/20/22, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 of 7 residents (Residents #44, 82, and 209) reviewed. Specifically, Residents #44, 82, and 209 were observed with unclean wheelchairs. Findings include: The facility did not have a wheelchair cleaning policy in place prior to 12/14/22. The 7/2022-11/2022 facility Wheelchair Cleaning Schedule by day and teams documented unit and rooms (team) scheduled for wheelchair cleaning on a specific day of each month. The schedule documented the following; - Resident #44's wheelchair was last scheduled for cleaning on 12/1/22; - Resident #82's wheelchair was last scheduled for cleaning on 12/9/22; and - Resident #209's wheelchair was last scheduled for cleaning on 11/25/22. The schedule did not document if the cleanings were completed. The following observations were made of Resident #82's wheelchair: - on 12/12/22 at 11:50 AM the resident was sitting in a scoot chair (an adjustable height reclining chair that allows mobility using the feet) in the lounge area with both arm rests soiled with food particles. - on 12/13/22 at 4:10 PM, the resident was sitting in a maroon scoot chair in their room. The chair's right arm rest was soiled with food particles. Registered nurse (RN) Unit Manager #1 stated Resident #82's wheelchair would often get dirty and would be cleaned. RN Unit Manager #1 stated wheelchair cleaning was not documented, and housekeeping was primarily responsible for monthly cleaning of the chairs. Staff were expected to clean wheelchairs if they observed them soiled and the wheelchairs would often get cleaned by housekeeping on the evening shift. The following observations were made of Resident #209's wheelchair: - on 12/12/22 at 4:41 PM and 12/13/22 at 8:51 AM the resident was sitting in a scoot chair and both arm rests were soiled with whitish colored smears. - on 12/14/22 at 8:59 AM, the resident was sitting in a scoot chair in the unit common area and both arm rests were soiled. The following observation was made of Resident #44's wheelchair: - on 12/13/22 at 4:15 PM, the wheelchair had loose debris within the chair padding and the seat cover had a tear in it. - on 12/14/22 at 9:45 AM, the resident was sitting in a scoot chair and the right arm rest had food particles on it. When interviewed on 12/20/22 at 11:50 AM, certified nurse aide (CNA) #6 stated unit staff were responsible for ensuring the residents' wheelchairs were cleaned. The CNA believed the night shift regularly cleaned the wheelchairs, but any unit staff member could clean a soiled wheelchair. When interviewed on 12/20/22 at 11:59 AM, licensed practical nurse (LPN) #7 stated housekeeping was responsible for cleaning resident wheelchairs. Wheelchair cleaning usually occurred when a resident was first admitted and on the 1st day of the month. Housekeeping cleaned all the wheelchairs on a rotating schedule. Unit staff should clean a wheelchair if they noticed a dirty area which could be cleaned on the spot. When interviewed on 12/20/22 at 12:03 PM, RN Unit Manager #1 stated there was a schedule for housekeeping to perform a monthly deep cleaning of each resident's wheelchair and nursing had a copy of the unit's schedule. The RN Unit Manager stated unit staff were expected to wipe down any spills. When interviewed on 12/20/22 at 12:17 PM, RN Unit Manager #3 stated wheelchair cleaning was a team effort. The RN Unit Manager was not sure what the specific cleaning schedule was and stated unit staff should wipe wheelchairs clean as best they could. When interviewed on 12/20/22 at 12:13 PM, housekeeper #8 stated evening shift housekeepers were supposed to clean wheelchairs daily and unit staff were to bring them to the service elevator area on the 1st floor. There was a rotating schedule for wheelchair cleaning in the housekeeping office. Once a wheelchair was cleaned, it was brought by housekeeping staff to the physical therapy room. If a resident needed the wheelchair immediately, it was brought up to the resident. When interviewed on 12/20/22 at 12:25 PM, licensed practical nurse (LPN) #4 stated evening shift housekeeping was responsible for cleaning dirty wheelchairs and the unit schedule was supposed to be in each unit's medication room. Unit staff were responsible for cleaning wheelchairs if they noticed they were dirty between deep cleanings. When interviewed on 12/20/22 at 12:44 PM, Operations Manager for Housekeeping and Laundry stated 2nd shift housekeeping staff were responsible for cleaning all the wheelchairs on the units and the schedule consisted of a rotating basis for each unit. Unit staff were to put any unscheduled wheelchairs that needed cleaning by the service elevator to go down for cleaning on the 2nd shift. Unit staff also had cleaning supplies and were able to clean the chairs. Housekeepers documented the cleaning of wheelchairs on a paper submitted to the Operations Manager or on the wheelchair cleaning checklist. 10 NYCRR 415.5(h)(1)

Based on observation, record review and interview during the recertification survey conducted 12/12/22-12/20/22, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 9 (Resident #204) reviewed. Specifically, Resident #204 was observed unshaven and with soiled clothing. The facility policy Activities of Daily Living - ADLs dated 1/21/2020 documented the resident who was unable to carry out activities of daily living would receive all the necessary services to maintain good nutrition, grooming, personal and oral hygiene. Resident #204 had diagnoses including chronic obstructive pulmonary disease (COPD, lung disease), tremor, and need for assistance with personal care. The 9/9/22 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition and required limited to extensive assistance with personal hygiene and dressing. The comprehensive care plan (CCP) initiated 11/1/21 and revised 6/28/22 documented the resident had ADL self-care deficit related to impaired balance. Interventions included extensive assistance of 1 with dressing their upper body, extensive assistance of 1 with dressing their lower body at bed level, limited to extensive assistance with personal hygiene and oral care, and supervision with eating. The resident Kardex (care instructions) active 12/15/22 documented the resident required extensive assistance of 2 with personal hygiene and dressing and was independent with eating after set-up assistance. The bath schedule was not completed. The following observations of Resident #204 were made: - on 12/12/22 at 11:06 AM sitting in a high back wheelchair in their room with facial hair approximately 1/4 inch to 1/2 inch long. - on 12/13/22 at 9:47 AM sitting in their room dressed in a maroon shirt and blue sweatpants. Their clothing was soiled with food particles and their facial hair was approximately 1/4 inch to 1/2 inch long. At 10:42 AM, sitting in the TV lounge area with their clothing soiled with food particles. - on 12/14/22 at 10:30 AM sitting in their room with their shirt and pants visibly soiled with food crumbs. At 12:58 PM they were feeding themselves lunch in the TV room and spilling food on their shirt. - on 12/19/22 at 11:43 AM sitting in their wheelchair in the TV room wearing a gray shirt and gray sweatpants. The shirt had eggs spilled on the front and they had approximately a 1/2 inch of facial hair present. During an interview on 12/12/22 at 2:52 PM with Resident #204's representative, they stated there were many times they would visit, and the resident's clothing was soiled. They stated they wished the staff would change the resident's shirt when it became soiled. During an interview on 12/19/22 at 11:43AM with Resident #204, they stated if their clothing was soiled, they preferred to be changed and they preferred to be clean shaven. During an interview on 12/19/22 at 11:48 AM with certified nurse aide (CNA) #2, they stated they were assigned to Resident #204 that morning. The CNA stated they did not shave the resident and the resident needed to be shaved. If a resident had food on their clothing before they were assisted out of bed they should be cleaned up and changed before coming out to the main sitting area. It was not dignified for the resident to be in soiled clothing. During an interview on 12/19/22 at 12:04 PM with registered nurse (RN) Unit Manager #1, they stated direct care staff was responsible for a resident's personal hygiene, transfers, and any other tasks the resident was care planned for. If a resident had soiled clothing and it was their preference to be changed, then staff should assist the resident with changing their soiled clothing. If the resident preferred to be shaved, it was not dignified to have facial hair. They expected staff to shave a resident who had facial hair. 10NYCRR 415.12(a)(3)

Based on observation, record review, and interview during the recertification survey conducted 12/12/22-12/20/22, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, and the comprehensive person centered care plan for 1 of 4 residents (Resident #214) reviewed. Specifically, Resident #214 did not have a physician order for oxygen (O2) and was observed on multiple days receiving O2 via a nasal cannula (NC, a tube delivering oxygen through the nose). Findings included: The facility policy titled Oxygen Therapy dated 10/10/19 documented a nurse may administer oxygen with a physician order. The standing physician order for oxygen therapy was used under the following conditions: Shortness of breath, cyanosis (skin, lips or nails turn blue due to a lack of oxygen in the blood), respiratory distress, and/or oxygen saturation less than 90%. Resident #214 had diagnoses including pneumonia, pulmonary hypertension, and congestive heart failure. The 12/3/22 Minimum Data Set (MDS) assessment documented the resident had intact cognition, required extensive assistance for most activities of daily living (ADLs), and did not receive oxygen therapy. Physician's orders with a date range of 10/26/22-12/20/22 documented to use standing orders (written protocols that authorize designated members of the health care team to complete certain clinical tasks without having to first obtain a physician order) as condition dictates. There was no order for oxygen administration or documented standing orders. The 10/26/22 admission assessment completed by registered nurse (RN) #3 documented a lung assessment was performed, oxygen saturation was 96%, and no oxygen was in use. The comprehensive care plan (CCP) initiated 10/26/22 documented the resident had altered cardiovascular status related to arrhythmia (abnormal heart rate) and infection. Interventions included to monitor for shortness of breath or cyanosis every shift. The CCP did not include the use of oxygen. The 12/5/22 nursing progress note by licensed practical nurse (LPN) #11 documented the resident complained of shortness of breath (SOB), their oxygen saturation (O2 sat, percentage of oxygen in the blood) was 92%, prn (as needed) oxygen was placed on the resident at 2 liters/minute, and the resident was repositioned. The resident's O2 sat went to 98%. The resident continued to complain of shortness of breath, the Nurse Manager and nurse practitioner were made aware and were called to assess. There were no corresponding respiratory assessments or oxygen orders on 12/5/22. Nurse practitioner (NP) #10's progress note dated 12/6/22 at 6:58 AM documented the resident's lung sounds were diminished throughout, right anterior expiratory rhonchi (gurgling sounds in the lungs heard during exhalation), and O2 on via nasal cannula. The resident wore O2 chronically at 2 liters via NC. A nursing progress note by registered nurse (RN) Unit Manager #3 dated 12/8/22 at 8:48 AM documented they were called to the resident's room for complaints of SOB and generalized discomfort. The resident stated it was hard to catch their breath. O2 sats were 98% on 2L O2. Lung sounds with inspiratory (inhale) and expiratory (exhale) wheezes and coarse rales (crackles) bilaterally (both lungs). The resident was observed on 12/12/22 at 11:12 AM, 12/13/22 at 9:21 AM, 12/14/22 at 11:38 AM, and 12/20/22 at 8:59 AM lying in bed receiving oxygen at 3 liters/minute via a nasal cannula. The December 2022 medication/treatment administration records (MAR/TAR) did not include oxygen administration. The resident Kardex (care instructions) active 12/20/22 did not document oxygen use. During an interview on 12/20/22 at 10:27 AM, RN Unit Manager #3 stated that oxygen use in the facility required an order by a medical provider. Standing orders would require an RN assessment and O2 could be administered if needed. A medical provider should be notified if a change requiring O2 use occurred. Oxygen administration should be documented in the MAR/TAR, monitored for correct liter flow, and the method of administration. The resident came in with fluid overload and shortness of breath. The RN Unit Manager stated they were not sure if the resident had O2 orders on admission. During an interview on 12/20/22 at 11:10 AM, NP #10 stated administration of O2 required a medical order. Residents should have standing orders for O2. NP #10 stated they expected to be notified if O2 was administered using standing orders. The need to administer O2 could indicate a significant change with a resident. During an interview on 12/20/22 at 11:18 AM, LPN #4 stated that O2 use required an order and would be on the TAR to check liter flow every shift. They stated there were standing orders available for O2. If standing orders were used, a RN Supervisor and medical staff should be notified. It would show up on the TAR if the standing order was used. Resident #214 had pneumonia and was wearing O2, and they were not sure if there was an O2 order for the resident. During an interview on 12/20/22 at 11:42 AM, LPN #12 stated O2 use required a medical order. O2 use should show on the MAR/TAR as continuous or as needed and would include specific liter flow to be checked every shift. Resident # 214 had been using O2, and it was not documented on the MAR/TAR. During an interview on 12/20/22 at 11:48 AM, certified nurse aide (CNA) #13 stated that O2 use should be on the resident Kardex (care instructions). Their responsibility as a CNA was to make sure the cannula was on correctly, and the O2 concentrator was on. They were to watch all residents for shortness of breath, and report to the nurse. They could ask a nurse or look on the Kardex for the correct flow rate. Resident #214 wore O2, and they thought it was to just be used while the resident was in bed. Oxygen was not listed on the resident's Kardex. 10 NYCRR 415.12(k)(6)

Based on record review and interview during the abbreviated surveys (NY 357 and NY 435) the facility did not ensure residents with pressure ulcers received necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for 1 of 3 (Resident #1) residents reviewed for pressure ulcers. Specifically, Resident #1's pressure ulcer was not monitored and treated as planned, and the resident required hospitalization for treatment. This resulted in actual harm to Resident #1 that was not immediate jeopardy. Findings include: The facility Pressure Injury policy dated 5/2016 documented the following: -Assess the pressure injury initially and re-assess it at least weekly. -With each dressing change, observe for wound deterioration or signs of infection. -All new pressure injuries were to be documented on 24-hour report. Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The 11/14/2018 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired, he required extensive assistance for all activities of daily living (ADLs), did not have any unhealed pressure ulcers and was at risk of developing pressure ulcers. Interventions included pressure reducing device for chair and mattress and application of ointments/medications. The comprehensive care plan (CCP) dated 11/15/2018 documented the resident was at high risk for skin breakdown related to friction/shearing, mobility and moisture. Interventions included a standard pressure relief mattress and to report all skin issues to the nurse. Nurse practitioner (NP) #15's progress note dated 11/26/2018 documented the resident reported an injury to his left heel and it was sore. The NP's [DIAGNOSES REDACTED]. The assessment and plan included Stage 2 Achilles (partial-thickness loss of skin), apply [MEDICATION NAME] Ag (an antimicrobial dressing with silver used for open wounds with drainage) and cover with [MEDICATION NAME] (wound dressing) every 3 days and as needed. A physician order [REDACTED]. The 24-hour nursing report and nursing progress notes did not document the Stage II pressure ulcer on the resident's left Achilles. NP progress notes documented the following: -On 12/17/2018 NP #15 documented the resident was complaining of extreme spasms to his left leg. There was no documented evidence the pressure ulcer on the left Achilles was assessed. -On 12/31/2018 NP #1 documented the resident was having left foot and great toe pain. The dressing was intact to the left Achilles area. The resident was complaining of significant pain in his left toe which was swollen and painful. The plan was to change his pain medication to every 6 hours, obtain an x-ray of the left foot and blood work. -On 1/3/2019 NP #1 documented the x-ray of the left foot showed no acute abnormalities. The dressing was intact to the left Achilles area. The plan was to obtain a computed tomography (CT) scan of the left foot. A physician order [REDACTED]. The physician documented on 1/6/2019 the resident complained of left ankle pain and had a chronic wound on the left ankle. The treatment since 11/26/2018 had been [MEDICATION NAME] Ag every 3 days until healed. The resident's wound appeared to be the source of pain and there was bloody discharge and evidence of slough (moist dead tissue). The area was quite tender and painful. The wound looked infected and the plan was to start Ciproflaxin (antibiotic) 500 milligrams (mg) twice daily for 7 days, increase the dressing changes to daily and have the wound care physician evaluate for possible debridement (removal of dead tissue). The resident was previously scheduled to have a CT scan of the left foot and the ankle would be added to the scan. A physician order [REDACTED]. The handwritten Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. There was no documented evidence on the MAR indicated [REDACTED]. NP #1 documented on 1/8/2019 the resident was evaluated for persistent left foot and ankle pain, was seen by the physician 2 days ago, and antibiotics and a wound culture were ordered and not yet started. The resident had a large venous ulcer of the left posterior (back) calf with exposed Achilles tendon and slight foul drainage. The area was tender to touch with decreased mobility and flexibility of the foot. The plan was to start Ciproflaxin as ordered and change the treatment to Xeroform (petroleum dressing) daily and consult the wound physician. The Wound registered nurse (RN) #2 documented on 1/9/2019 at 2:00 PM she was notified by the Assistant Director of Nursing (ADON) of the resident's wound and a wound assessment was performed. The wound on the left Achilles measured 4 centimeters (cm) x 4 cm x 0.2 cm, tendon was exposed and there was a moderate amount of serosanguinous (blood and serum) drainage. The skin impairment sheet completed by Wound RN #2 on 1/9/2019 documented the wound was a pressure injury and she had not been notified of the wound. A nursing progress note dated 1/9/2019 at 9:05 PM documented the resident was transported via ambulance to the hospital. A hospital discharge summary dated 1/16/2019 documented the resident had [MEDICAL CONDITION] of the left lower extremity with an infected Stage IV (full-thickness tissue loss with exposed muscle, tendon or bone) pressure ulcer on the left calf measuring approximately 6 cm x 4 cm with exposed tendon. The resident was treated in the hospital with intravenous antibiotics and a wound vac (negative pressure wound therapy) was initiated. A facility investigative summary dated 1/18/2019 documented it was concluded there was neglect of the resident as there was no evidence the pressure ulcer was assessed and monitored by the Unit Manager. During an interview with LPN #6 on 3/13/2019 at 1:55 PM she stated she had noted and initialed the physician order [REDACTED].#1. She was not sure what the Cx on the order meant and guessed it was CT. LPN #6 stated she remembered the physician had specifically verbalized that she did not want the antibiotic to be started until after the CT scan on 1/9/2019 because the physician wanted to know how deep the wound was. When LPN #6 wrote the order in the MAR indicated [REDACTED]. She did not know why the culture had not been done until 1/8/2019. During an interview with LPN #3 on 3/13/2019 at 11:45 AM she stated she had changed the Resident #1's dressing on 12/13/2018 and again on 12/28/2018 and did not notice any changes to the pressure ulcer. During an interview with Unit Manager RN #8 on 3/19/2019 at 1:15 PM she stated she no longer worked at the facility. She stated when a resident was found to have skin breakdown or a pressure ulcer she notified the wound nurse and dietary verbally or by email. The resident would be placed on weekly skin rounds and the wound nurse would document on the weekly assessment sheets when the rounds were done. She did not notify the wound nurse or dietary of Resident #1's pressure ulcer on his left Achilles that reopened on 11/26/2018 because it was very small and would heal quickly. She did not document the area on 24-hour report but did notify the NP #15 who ordered a treatment. She did not update the resident's care plan as he had pressure relief measures in place. The LPNs who were doing the resident's treatments should have notified someone the wound was worse. She last saw the resident's pressure ulcer on 12/31/2019 and it had no signs of infection. She did not document her assessments on a weekly wound sheet until after she was suspended pending an investigation on 1/14/2019. After she documented her assessments on the sheet she had another nurse place the assessment sheet in her office, so it would be found by Administration. During an interview with Wound Nurse RN #2 on 3/13/2019 at 10:30 AM she stated she conducted weekly rounds on existing or new wounds reported to her by the Unit Manager or the 24-hour report. She documented assessments on a weekly skin assessment sheet and in a nursing progress note. She had not been notified the pressure ulcer on the Resident #1's left Achilles had reopened on 11/26/2019 and subsequently had not monitored the pressure ulcer. During an interview with NP #1 on 3/13/2019 at 9:48 AM she stated she saw Resident #1 in late (MONTH) of (YEAR) and was aware that he had a wound on the back of his ankle and it was being treated. She evaluated the pressure ulcer on 1/8/2019 after reviewing the physician orders [REDACTED]. The nursing staff reported to her on 1/8/2019 the culture was not done, and the antibiotics had not been started. When she saw the wound on 1/8/2019 there was foul drainage and exposed tendon and the wound culture was taken at that time. She notified the Assistant Director of Nursing (ADON) about the appearance of the wound. She stated she should have been notified about the wound deterioration by the nurses doing the wound treatment. During an interview with physician #13 on 3/22/2019 at 3:30 PM she stated she had evaluated Resident #1 on 1/6/2019 and he had an infected pressure ulcer on the back of his leg. She ordered a wound culture, antibiotic, an evaluation by the wound physician, increased frequency of dressing changes, and added the ankle to a CT scan that was already scheduled. She expected the wound culture to be done immediately and the antibiotic started after the culture was obtained. She had written Cx in the order as it was a standard abbreviation for culture. She was not aware the antibiotic had not been started before he was sent to the hospital. She did not tell the nurse to wait until the CT scan was done to start the antibiotic because that did not make sense and if the nursing staff were confused they should have called her for clarification. It was important to have pressure relief interventions in place for pressure ulcers such as floating the heels or special pressure relief booties, and have dietary involved to ensure the resident had adequate nutrition, hydration and protein intake to promote healing. 10NYCRR 415.12(c)(1)