Every finding on record at The Grand Rehabilitation and NRSG at Chittenango

Based on observation, record review, and interview during the recertification survey conducted 9/22/2025-9/25/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards in one (1) out of one (1) main kitchen and for two staff (Dietary Aide #5 and Dietary Aide #6). Specifically, in the main kitchen staff did not wash their hands before preparing food; food was not labelled and dated; and food contact surfaces were not sanitized appropriately. Additionally, Dietary Aide #11 and [NAME] #9 did not wear beard restraints during food preparation.Findings include:The undated facility policy Sanitization documented all equipment, food contact surfaces and utensils would be sanitized using chemical sanitizing solutions per manufacturer's instructions.The facility policy Hair Net Use, revised 1/2025, documented all foodservice staff would wear hair restraints when handling food or working in food related areas, and the hair net would fully cover all hair. In addition, all staff with facial hair would wear a beard net in the kitchen. The undated facility policy Hand Washing documented foodservice staff would wash their hands when entering the kitchen at the start of their shift.The product label for the three-bay sink sanitizer documented dishes were immersed completely in a 150-400 parts per million active quaternary solution for at least 60 seconds. The chlorine test strips for the dish machine stated the test strip would be immersed in the sample and immediately removed. The test would be read after 5-10 seconds. Handwashing:During an observation on 9/22/2025 at 6:25 AM, there were no paper towels at both main kitchen handwashing sinks, and both sinks were dry. Dietary Aide #5 and Dietary Aide #6 had just arrived and started work on food preparation for the day. Staff were not observed washing their hands before starting food preparation. When asked about the paper towels they looked at each other wide eyed and stated the director would arrive soon then left the area.During an observation on 9/23/2025 at 11:45 AM, [NAME] #9 changed their gloves and touched the garbage can, then went back to meal preparation without washing their hands. When questioned about this, they went and washed their hands. Food Service Director #10 stated they should have washed their hands after touching garbage and staff sometimes forgot the garbage lid was dirty.Undated and unlabeled items:During an observation of the 2-door reach-in cooler on 9/22/2025 at 6:25 AM, there were three unlabeled and undated sandwiches in a metal pan. Dietary Aide #5 stated they must have been from the previous evening dinner. During an observation of the walk-in cooler on 9/22/2025 at 6:40 AM, there were two unlabeled pans of sliced meat in a metal pan. During an observation of the walk-in cooler on 9/23/2025 11:10 AM, there was one unlabeled pan of sliced meat in a metal pan.Hair Restraints:During an observation on 9/23/2025 at 11:40 AM, Dietary Aide #11 and [NAME] #9 were observed with uncovered beards, working with food. Sanitization:During an observation on 9/23/2025 at 10:30 AM, the following sanitization issues were observed:-the 3-bay sinks were all empty. [NAME] #8 brought a metal pan over and ran some detergent mix from the far right sink into the pan and scrubbed it clean. They rinsed it under the sanitizer mix in the first sink for fifteen seconds. They stated the pan needed a quick dip in the sanitizer and utensils and pans needed to be submerged for 30 seconds to sanitize. They demonstrated testing the sanitizer strength by dipping the strip in the sanitizer quickly and pulling it out. They were not sure how to read it and stated they didn't usually do this task. -Dietary Aide #7 stated they tested the sanitizer of the low temperature dish machine most days. They demonstrated how they did this every day and placed the test strip in the water at the end of the machine cycle and read the result immediately. No sanitizer registered on the test strip. They tried to test it again with the same results. The label of the test strips stated the reading would take place after waiting 10 seconds. After 10 seconds, the sanitizer read 300 parts per million.- A red bucket of liquid with a cloth in it was observed under the cooks' table. [NAME] #8 stated it was sanitizer used to sanitize the tray line, and they had filled the bucket about an hour prior. They tested the sanitizer strength, and no sanitizer registered. They stated they accidentally filled the bucket with cleanser instead and had used it to sanitize tray line.During an interview on 9/25/2025 at 10:37 AM, Dietary Aide #7 stated they tested the dish machine temperature and sanitizer strength every morning they worked and recorded the information of the dish machine log sheet. They stated they dipped the test strip in the water at the end of the wash and immediately read it. They stated it was always around 50 parts per million. They stated they sanitized dishware to kill germs. They stated they were required to wash their hands anytime they entered the kitchen, when they were dirty, after using the bathroom, and after breaks. They stated all hair needed to be in a hair net, including beards. During an interview on 9/25/2025 at 10:45 AM, [NAME] #8 stated hand washing occurred when staff arrived at work, after touching food, when gloves were changed, and when dirty and they were trained years ago on the 3 bay sink procedure, and all three sinks would be filled when in use. The pans would be washed in the far-right sink, rinsed in the middle sink, then submerged in the left sink for 30 seconds. The sinks were always full when used at the scheduled washing times, four times a day. [NAME] # 8 stated the sinks were empty when they used it because it was not time to fill the sinks yet. They stated dishes were sanitized to kill germs. They stated the sanitizer strength was tested to make sure it worked properly, and staff assigned to the 3-bay sink did the testing. They stated they did not usually test the sanitizer. [NAME] #8 stated all leftover food was put in a new pan, wrapped up, then labelled and dated to be used first. They stated all staff with facial hair needed it covered so facial hair did not fall in the food.During an interview on 9/25/2025 at 10:52 AM, Food Service Director #10 stated all foodservice staff washed their hands before starting work, after breaks, before touching food, after using the bathroom, and as needed. They stated any leftover sandwiches in the cooler would be dated and labelled or thrown away. All staff were trained to fill all three sinks three to four times a day and if the sinks were not filled dishes would not be washed and the 3-bay sink procedure was to fill the far-right sink using the detergent mix from the dispenser, the middle sink with warm water, and the left sink with the sanitizer mix from the dispenser. The sanitizer strength would be tested after the sinks were filled, to make sure the sanitizer was at the correct strength. Staff would scrub the pans in the far-right sink, rinse in the middle sink, then submerge in the left sink for at least 30 seconds to sanitize. They stated this was being done every day and [NAME] #8 was in a hurry and did not follow procedure. They stated facial hair would be covered to prevent hair from falling in the food. 10NYCRR 483.60(i)(1)-(2)

Based on observation, record review, and interview during the recertification survey conducted 9/22/2025-9/25/2025, the facility did not ensure residents had a means of directly contacting staff for assistance for one (1) of one (1) residents (Resident #9) reviewed. Specifically, Resident #9's call bell was out of reach and not accessible. Additionally, Residents #10, 24, 62's call bells were observed to be out of reach one day of survey and Resident #63's call bell was observed to be out of reach two days of survey. Findings include:The facility policy Call Bell System, revised1/2025, documented that each resident would have a call bell within reach and the cord would be clipped to the bed or another appropriate area within the reach of the resident.Resident #9 had a diagnosis of dementia. The 8/24/2025 Minimum Data Set assessment documented impaired cognition, was usually understood, and was dependent for most activities of daily living.The 12/1/2023 Comprehensive Care Plan, revised 8/18/2025, documented the resident required assistance with self-care. Interventions included encourage resident to use call bell for assistance. During an observation on 9/22/2025 at 7:39 AM, Resident #9 was in bed, and their touch pad call bell was on the floor out of their reach.Additionally, the following observations of call bells were made:-on 9/22/2025 at 6:42 AM, Resident #6 was in bed, and their call bell was resting on the lower frame of the bed out of their reach.-on 9/22/2025 at 7:22 AM Resident #62 was in bed, and their call bell was on the floor out of their reach. The resident was calling out help me repeatedly.-on 9/22/2025 at 7:27 AM Resident #10 was in bed, and their call bell was on the floor under their bed out of their reach.-on 9/22/2025 at 8:44 AM Resident #63 was in bed, and their touch pad call bell was on the floor out of their reach.-on 9/23/2025 at 9:27 AM 15B Resident #63 was in bed, and their touch pad call bell was on the floor out of their reach.During an interview on 9/25/2025 at 10:06 AM, Certified Nurse Aide #26 stated every resident should have a call bell within reach regardless of their physical or cognitive status. Resident #9 was able to use their call bell, make some of their needs known, and should have a call bell in reach at all times.During an interview on 9/25/2025 at 10:18 AM, Licensed Practical Nurse #27 stated every resident should have either a touch pad or push button call bell within reach. They have had to get after the aides many times about making sure that happened. Resident #9 was able to make their needs known and should have a call bell within reach.10NYCRR 415.5(e)(1)

Based on observations and interviews during the recertification survey conducted [DATE]-[DATE], the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for one (1) of two (2) medication rooms (Units A and B medication rooms) and one (1) of one (1) medication carts (Unit A South) reviewed. Specifically, the Unit A medication room had medications stored on the floor, discontinued medications were placed on a shelf with a resident's unlabeled personal medications stored in an emesis bag (used to collect vomit), and the medication refrigerator temperatures were out of range and contained frozen insulin pens; the Unit A South medication cart had an unlabeled insulin pen in the top drawer, and a licensed practical nurse handed their medication cart and medication room keys to another licensed practical nurse without completing a narcotic medication reconciliation count.Findings include: The facility policy Storage of Medications, last reviewed 1/2023, documented drugs and biologicals should be stored in the packaging, containers or other dispensing systems in which they are received. The nursing staff was responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. Drug containers with missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. The facility policy Controlled Substance/Narcotic Management Protocol, last reviewed 1/2023, documented all narcotics would be counted and reconciled at the beginning of every shift with the outgoing and oncoming nurse. Both must sign the controlled substance log attesting to the presence of the narcotic as stated from the previous shift. The facility policy Maintenance Policy and Patient Care-Related Electrical Equipment, revised on [DATE], documented medication refrigerators were inspected annually and maintained according to manufacturer's' specification as stated in the user manual for the item by the maintenance department at the facility.The [DATE] A Wing Refrigerator /Freezer Temperature log documented temperatures above 41 degrees and below 32 degrees Fahrenheit should be reported to the Director of Maintenance or designee. The A wing refrigerator temperatures were documented as follows:-On [DATE] at 12:30 AM, 28 degrees Fahrenheit, the temperature was not in compliance, and a text was sent to the Administrator on call.-On [DATE] at 8 PM, 30 degrees Fahrenheit and was documented as a Y for in compliance.-On [DATE] at 11:30 PM, 28 degrees Fahrenheit and the temperature was adjusted as a corrective action.-On [DATE] at 7:00 AM, 28 degrees Fahrenheit, and the temperature was adjusted. N/A (not applicable) was documented each day the refrigerator was out of temperature for corrective action taken.During an observation and interview with Licensed Practical Nurse Unit Manager #1 on [DATE] at 1:07 PM, the Unit A medication room had three 2-gram vials of ceftriaxone (an antibiotic) in a clear bag and a box of 100 count 25-gauge syringes on the floor. Licensed Practical Nurse Unit Manager #1 stated the resident was no longer taking the antibiotic and it should be hung in the bag on the wall and returned to pharmacy. Licensed Practical Nurse Unit Manager #1 stated there should not be anything on the floor in the medication room. There was a green emesis bag with an unlabeled bottle of Tylenol Extra Strength inside. Licensed Practical Nurse Unit Manager #1 stated the Tylenol belonged to a new resident and was supposed to be sent home with the family but should be labeled and stored in a clear bag and not wrapped in an emesis bag. The bottom refrigerator temperature read 28 degrees Fahrenheit and there were two vials of lispro insulin, and three Humalog insulin pens that appeared frozen and frosty in color. The Licensed Practical Nurse Unit Manager #1 stated the refrigerator was for storing surplus insulins and the insulin would need to be thrown out. They were not sure what they needed to do and would call their pharmacy representative and notify maintenance. They stated the refrigerator temperature was out of range that morning and they turned the temperature up. The refrigerator was supposed to be above 32 degrees Fahrenheit and was still out of temperature range. During an observation on [DATE] at 1:16 PM, Licensed Practical Nurse #3 gave their medication cart and narcotic keys to Licensed Practical Nurse Unit Manager #1 so the locked narcotic cabinet in the medication room could be opened. Licensed Practical Nurse Unit Manager #1 stated they realized they should not have taken Licensed Practical Nurse #3's keys and returned them to the nurse. At 1:22 PM, the top refrigerator in the medication room had a buildup of ice in the freezer. There were vaccines, insulin vials and rectal suppositories. Licensed Practical Nurse Unit Manager #1 stated the freezer would need to be defrosted and the cleanliness and organization of the medication room was the responsibility of all nurses.During an interview on [DATE] at 1:23 PM, Licensed Practical Nurse #3 stated they gave their narcotic cupboard, and medication room keys to the manager because they were passing medication and the manager asked for them. They realized they should not have given the keys to the manager; the keys were their responsibility. During an interview on [DATE] at 1:27 PM, Licensed Practical Nurse #2 stated a nurse should never hand over the keys without a narcotic count.During an observation and interview on [DATE] at 2:26 PM, Licensed Practical Nurse #2 had a Lantus insulin pen that was in the top right drawer of the medication cart, and it did not have a resident name or label. They were not sure who the pen belonged to and stated it should be thrown out. They discarded the insulin pen into the sharp container.During an interview on [DATE] at 12:41 PM, the Director of Nursing stated the medication rooms and cart should be kept clean and medications should be stored properly and with labels. Medications that were not in use or expired should be sent back with the pharmacy the same day and personal medications from home should be sent home with family or stored in a plastic bag with a proper label. The refrigerator temperatures should be checked nightly, and they were made aware of the out-of-range temperatures and Licensed Practical Nurse Unit Manager #1 was directed to reset and recalibrate the temperature. The frozen insulin was thrown out and reordered. The maintenance staff had to reset the refrigerator temperature. They stated a licensed nurse should not hand their medication room/cart keys over to another nurse without a proper narcotic medication reconciliation count. That was the facility policy. Also, insulin pens should always have a pharmacy sticker with a resident name and the date they were opened. 10NYCRR 415.18(d)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00495399) surveys conducted 9/22/2025-9/25/2025, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming, and personal and oral hygiene for one (1) of one (1) resident (Resident #22) reviewed. Specifically, Resident #22 had unclean hands, face, fingernails and clothing; disheveled hair; and an unclean wheelchair. Findings include:The facility policy Showers/Tub Bath, last reviewed 1/2025, documented residents were provided regular showers or tub baths, thoroughly washed, dried, and groomed with attention to hair care. Documentation of the type of bath, assistance, tolerance, was completed and refusals reported to the supervisor.Resident #22 had diagnoses including Huntington's disease (a progressive neurological disease) and dementia. The 8/14/2025 Minimum Data Set assessment documented the resident had severe cognitive impairment and required extensive assistance with showering and tub bathing and moderate assistance with personal hygiene. The Comprehensive Care Plan initiated 9/4/2025 documented the resident was at risk for functional decline. Interventions included substantial/maximal assistance for bathing, lower body dressing, and bed mobility; partial/moderate assistance for upper body dressing; and was dependent with a two-person mechanical lift for tub/shower transfers.The September 2025 Certified Nurse Aide Documentation Report documented the resident frequently refused or did not receive scheduled showers. The resident received bed baths or partial hygiene in place of full shower/tub bathing.The following observations were made of Resident #22:-on 09/22/2025 at 8:23 AM, sitting in their specialized wheelchair. The wheelchair was heavily soiled with dried matter on all sides including the seat cushion. The resident's hair appeared greasy, and their fingernails had brown matter on and underneath the nails. -on 9/23/2025 at 1:44 PM their sweatshirt was covered with food debris; their hair appeared greasy; and their fingernails were jagged and contained a dark matter underneath. -on 9/24/2025 at 9:58 AM and 11:53 AM their hair appeared greasy; their fingernails were jagged and unclean; their shirt was covered with food debris; and their wheelchair had dried matter on the sides and the seat cushion was heavily soiled.During an interview on 9/25/2025 at 9:31 AM Certified Nurse Aide #28 stated Resident #22s hair appeared greasy. The resident was washed up that morning. They stated they were unsure of when the resident's actual shower day was but assumed it was at night. Certified Nurse Aide #28 stated the resident had jagged nails and food matter on their face and hands and their chair was splattered with food.During an interview on 9/25/2025 at 9:35 AM, Licensed Practical Nurse Manager #17 stated the resident was scheduled for a shower every Friday. They stated the resident occasionally resisted care. Licensed Practical Nurse Manager #17 stated the resident had food on their face and the resident's wheelchair was soiled with dried food and matter. They attributed the increased soil to the resident's diagnosis of Huntington's disease, which caused frequent spilling and increased debris on the chair. Wheelchair cleaning was scheduled for Monday evening, but spot cleaning should be done. The resident should receive thorough care after meals and, if needed, more frequent hair and nail care on non-shower days.10NYCRR 415.12(a)(3)

Based on observations, record review, and interviews during the recertification survey conducted 9/22/2025-9/25/2025, the facility did not ensure residents maintained acceptable parameters of nutritional status for two (2) of three (3) residents (Residents #2 and #8) reviewed. Specifically, Resident #2 had weight loss not addressed by the registered dietitian and there was no documented intervention implemented to prevent further weight loss, and Resident #8 was not supervised during self-administration of their tube feeding and was observed to be administering the incorrect amount. Additionally, Resident #8 did not have a physician order or a care plan to self-administer.Findings include: The 10/1997 facility policy Administering Medications, revised 1/2023, documented medications must be administered in accordance with the orders; residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, had determined that they had the decision-making capacity to do so safely; and the individual administering the medication would record the dosage in the resident's medical record.The 10/1997 facility policy Maintaining Patency of a Feeding Tube (Flushing), revised 1/2023, documented feeding tubes would be flushed after each feeding and medication administration. Additionally, the total amount used to flush the tube and how the resident tolerated the procedure would be documented.The 10/1997 facility policy Nutritional Assessment, revised 1/2023, documented the nutritional care plan would indicate the route of administration, the resident's requirements for nutrient intake, and would be consistent with the resident's wishes and goals. In addition, the dietitian would conduct a nutritional assessment which included estimated nutritional needs and interventions for residents with a change in condition that placed them at risk for impaired nutrition. The nutritional assessment included the resident interview, observations, and if the resident's current intake was adequate to meet their nutritional needs.The 10/ 1997 facility policy Weight Assessment and Intervention, revised 1/2025, documented nursing would have notified the dietitian of any significant weight losses, and the dietitian would have responded within seven days. The dietitian would have estimated nutritional needs and the interdisciplinary team (dietitian, nursing, medical, pharmacist) would have planned the appropriate interventions. 1) Resident #2 had diagnoses of urinary tract infection, pneumonia and depression. The 6/7/2025 Minimum Data Set assessment documented the resident had a Brief Interview for Mental Status score of eight, had daily symptoms of depression, weighed 149 pounds, and did not have weight loss. Their daily intake was 25% or less, and their fluid intake was 501 milliliters or less. The Comprehensive Care Plan initiated 4/4/25 and updated 9/23/25 documented the resident had depression, pneumonia, urinary tract infection, and a risk for malnutrition. Interventions included encourage and monitor meal intake, identify and honor preferences, double portions with meals, monitor weights, and monitor meal consumption. The resident's record documented the following weights:-on 5/1/2025 142 pounds;-on 6/3/25 149 pounds;-on 7/3/2025 147.2 pounds;-on 7/9/2025 142.6 pounds;-on 7/16/2025 142.3 pounds-on 7/24/2025 138.8 pounds-on 8/1/2025: 127.6 pounds with reweight 128.6 pounds (12.6 percent weight loss in one month and 9.5% loss in five months). There was no documented evidence the family, physician, or dietitian were notified timely of the significant change in weight. The 5/8/2025 Registered Dietitian #13 progress note documented the weight of 144.4 pounds and noted weights were stable with intake greater than 75 percent of meals. The 5/19/2025 Registered Dietitian #13 progress note documented Resident #2 requested double portions at meals, which was implemented. Meal Consumption Records for May of 2025 documented their intake ranged from fifty to one hundred percent of meals at that time. The 7/16/2025 Nurse Practitioner #18 progress note stated Resident #2 developed pneumonia, antibiotics were initiated, and recommended staff encouraged sips of liquid supplements and fluids at that time. There was no documentation that staff encouraged sips of liquid supplements or fluids. The 7/20/2025 Physician #19 progress note documented abnormal labs with altered mental status. They initiated one liter of hydration given by given subcutaneously for hydration. The treatment was on the Treatment Administration Record on 7/18/2025, however was not signed by staff as provided. The 7/29/2025 Nurse Practitioner #20 readmission note documented Resident #2 was treated for influenza and dehydration and was at risk for malnutrition and stated nutritional intervention was mandatory at that point. The 7/31/2025 Physician's Assistant #22, 8/8/2025 Nurse Practitioner #21, and 8/10/2025 Physician's Assistant #23 progress notes all documented Resident #2 was not having regular bowel movements and recommended increased movement and increased fluid intake. There was no evidence of increased fluid intake documentation. The 8/25/25 Physician #19 note documented the resident had unintended weight loss during the last four weeks and recommended a dietitian consult. There was no documentation that a dietitian consultation was completed. The 9/18/2025 Registered Dietitian #14's progress note documented the resident hospitalized (from 8/27/2025 through 9/17/2025) and was readmitted on a regular, pureed diet with honey thick liquids. They noted no change was made to current nutrition plan, no weights would be obtained due to new comfort care orders, and that a full nutrition assessment to follow. The 9/22/2025 Registered Dietitian #14 progress note documented Resident #2 triggered for significant weight loss in one month and intake of food and fluid was minimal. Comfort measures were in place. Their nutritional needs were estimated but no new nutritional interventions were implemented. During an interview on 9/25/2025 at 9:40 AM, Certified Nurse Aide #24 stated they notified their unit manager if they noticed a resident was not eating well, because it meant something might be wrong. They worked with Resident #2 and they were eating very well until a couple months ago. They needed more help with meals but would only allow a few staff to help. They stopped feeding themselves and the unit manager was notified. When they came back from the hospital last week, they ate very little if anything. During an interview on 9/25/2025 at 9:50 AM, Licensed Practical Nurse/Unit Manager #1 stated if a resident was not eating well, they increased supervision at meals, offered increased encouragement, and provided increased assistance. Weights were obtained monthly in the first week of each month. If there was a five-pound weight change a reweight was obtained. If weight loss was confirmed they would have investigated the cause. They monitored weights themselves because they had no dietitians for a couple months, however the dietitian usually monitored for weight changes and entered them into the medical record. They worked closely with Resident #2 and when they had a change in intake of food and fluid, they started feeding them if the resident allowed. The physicians followed Resident #2 closely. Physicians entered their own orders in the medical record, and if an order for a liquid supplement had been entered the nurses would have seen it and initiated the plan. Nurses did not go through the medical record daily to read all the notes that were written. During an interview on 9/24/2025, Dietitian #14 stated they started at the facility a few weeks prior. If a resident was not eating well, they met with them, obtained food preferences and added a supplement if needed. Nursing obtained the weights and typically the dietitian monitored the weights, but the unit manager had been doing it. If a resident was losing weight, they were weighed weekly and they were discussed in morning meeting with nursing and the physician. The dietitian made a list of who needed weekly weights and sent this to the unit manager, as well as any reweights needed. Once everything was finalized the dietitian entered the weights in the medical record. On 9/22/2025 Resident #2 triggered for significant weight loss in one month when the nutrition assessment was completed, and comfort measures were in place with very little intake. They followed up to see if Resident #2 wanted any changes in meal plan, but they declined. They stated any intervention initiated would have been on the care plan. The Comprehensive Care Plan had no new documented interventions. During a telephone interview on 9/25/2025 at 11:49 AM, Dietitian #13 stated they left the facility in the beginning of July 2025. They did not recall Resident #2 but stated nursing obtained the weights and obtained a reweight if a weight changed five pounds or more from the last weight. Nursing then handed the list of weights and reweights to them, and they entered them into the computer. This process often did not happen, and they often had to seek out weights and reweights themselves from nursing. If a resident lost weight, they asked for a reweight, then investigated the cause. Nursing staff was responsible for audit and monitor of weights, which did not always happen. During a telephone interview on 9/25/2025 at 11:56 AM, Nurse Practitioner #16 stated if a resident was losing weight they were discussed in the morning meeting, attended by medical staff, unit nursing managers, Director of Nursing, Administrator, and the dietitian. If there was no facility dietitian, the electronic medical record would have notified providers of a clinical issue for weight loss, however they had not received a weight loss notification since starting at the facility last month. During an interview on 9/25/2025 at 12:20 PM, Director of Nursing #4 stated nursing obtained weights monthly and recorded them in the medical record. The unit manager reviewed weights for any needed reweights then the dietitian reviewed the weights and reweights. Any significant changes were initiated by the dietitian or unit manager the next day and discussed with the physician. If a dietitian was not on staff, the physician filled in. The nursing staff alerted the physician if a weight loss triggered in the absence of a dietitian, and triggers occurred with a three percent weight change. Resident #2 lost significant weight on 8/1/2025 and it was not reported to the physician timely while a dietitian was not on staff at the facility. Timely interventions were important for good outcomes. The nursing team should have followed up on the poor intake and read provider notes that recommended starting a liquid supplement. They did not know if nursing followed up with the physician regarding the weight lost, however there was no documented evidence in the chart that they had. The weight loss was not on the 24-hour reports and should have been. They were not sure if Resident #2 was harmed by the lack of follow up regarding the weight loss. During a telephone interview on 9/25/2025 at 12:58 PM, Nurse Practitioner #18 stated they were notified of weight loss by the nursing team or dietitian and would have met with the dietitian to investigate why the weight loss occurred. When they assessed weight loss, they ordered a supplement, but they were not often in the facility to cover clinical issues. They evaluated Resident #2, who was acutely sick, and requested staff tried a liquid supplement with them. If they liked the supplement, then an order would have been written. They were not sure if the staff followed up on the recommended supplement, and they had not been back in the facility since. During a telephone interview on 9/25/2025 at 1:39 PM, Physician #19 stated they were usually notified of weight losses by electronic mail. They checked medications and diagnoses for causes. It is important to find the cause of unplanned weight loss. They were usually the one who notified the facility they had found weight loss when they reviewed weights for a resident assessment. They found Resident #2's weight loss when they reviewed the medical record and immediately wrote a note about it. They evaluated a change in condition with the resident and ordered some testing and consulted a specialist. When the results came back, the resident was sent out to the hospital for gallbladder concerns. If a dietitian was not on staff at the facility, there was nobody that covered the position. They did not know if an intervention was implemented when the weight loss occurred. They stated a lack of intervention when the weight loss occurred could have been harmful. The weight loss evaluation was delayed and should have been caught earlier. 2) Resident #8 had a diagnosis of intracerebral hemorrhage (a type of stroke), hemiplegia (limited use of one side of body), dysphagia (difficulty swallowing), and gastrostomy status (a tube placed in the stomach for the purpose of feeding). The 7/28/2025 Minimum Data Set assessment documented intact cognition; set up for eating; had a gastrostomy tube; and received 51% or more of total calories and 501 milliliters or more of fluids via their feeding tube.The 6/4/2024 Comprehensive Care Plan documented the resident required a tube feeding. Interventions included administer tube feeding and water flushes per the registered dietitian's recommendation and physician orders. It did not document the resident was able to self-administer flushes or feedings.The 6/2/2024 Licensed Practical Unit Manager #1's Care Plan Meeting note documented the resident's medications, tube feeding and trach were managed by nursing, however the resident had been taught and was able to administer their own medications and tube feeding with nursing supervision.The nursing progress notes did not document the dates of the teaching or that the resident was able to perform return demonstration.The physician orders documented the following:-2/3/2023 the resident was to receive 75 milliliters of water after each tube feeding and 100 milliliters before, with, and after each medication administration.-11/30/2023 the resident was to receive Jevity 1.5 (a tube feeding formula) 320 milliliters four times a day.-12/4/2023 the resident was to receive 100 milliliters of water four times a day prior to tube feeding.The physician orders did not document the resident could self-administer medications or feedings.The 6/27/2025 Dietitian #13's dietary note documented the tube feeding of Jevity 1.5 320 milliliters four times a day and the water flushes of 100 milliliters before each tube feeding, 75 milliliters after each tube feeding and 100 milliliters before, with and after medications provided 94-100% of the estimated kilocalorie needs, and greater than 100% of the estimated protein and fluid needs. During an interview on 9/23/2025 at 10:45 AM Licensed Practical Nurse #12 stated the resident did their tube feeding independently.During an observation and interview on 9/23/2025 at 11:00 AM the surveyor and Licensed Practical Nurse #12 entered the resident's room. The resident poured 200 milliliters of Jevity 1.5 into their feeding bag then added two 60 milliliter syringes of tap water. The resident stated after the feeding was done the amount of water they flushed with would depend on what they felt like. The resident connected the tube feed bag to their tube, unclamped the tubing and the feeding began to flow in. During an observation on 9/23/2025 at 11:49 AM Licensed Practical Nurse #12 brought the resident their crushed medications in a plastic drinking cup. The resident mixed the medications with 60 milliliters of water, poured it in the feeding bag and connected their tube to the bag. Licensed Practical Nurse #12 had to squeeze the bag to get the fluid to infuse and stated they might need to add more flush and asked the resident if they flushed their tube after their last feeding. The resident stated they flushed with 200 milliliters. The resident declined more flush and instead squeezed the tube to prompt the flow. After the bag was empty, they disconnected the tubing. No flush was given.During an interview on 9/23/2025 at 11:14 AM Licensed Practical Nurse #12 stated the nurses were supposed to observe the resident as they may have issues with the bag. After reviewing the order with the surveyor, they stated the resident's order was for 320 milliliters, and that should not include water; it should be 320 milliliters of Jevity 1.5 and then the additional water flushes.The September 2025 Medication Administration Record documented on 9/23/2025 Licensed Practical Nurse #12 signed for the 11:00AM administration of 100 milliliters of water flush prior to tube feed; 75 milliliters of water after tube feeding; and 320 milliliters of Jevity 1.5. Additionally, they signed for 12:00 PM administration of 100 milliliters of water flush before, with, and after medication administration.On 9/25/2025 at 10:30 AM a call was placed to Licensed Practical Nurse #12 and a voice mail left asking they return the surveyor's call. Surveyor did not receive a call back.During an observation and interview on 9/24/2025 at 10:54 AM the resident shook one partially filled carton and one full carton of Jevity 1.5. They emptied the partially filled carton into their feeding bag and then added more from the full carton to fill to the 200-milliliter line on the feeding bag. The resident stated their intent was to fill to the 200-milliliter mark. They then filled a 60-milliliter syringe full of water twice and added that to the bag. They hooked the feeding bag tuning to their gastrostomy tube and released the clamp. They stated they would flush with two more syringes of water once the feeding was done. During an observation on 9/24/2025 at 12:17 PM Licensed Practical Nurse #15 brought a plastic drinking cup of water with crushed medications in it to the resident and left the room. The resident stirred it, poured it into the feeding bag, hooked it up to their tube, and released the clamp allowing the solution to rapidly drip. Once completed the resident used a syringe to put in 60 milliliters of water in the bag. After that flowed in, they disconnected the tube.The September 2025 Medication Administration Record documented that on 9/24/2025 Licensed Practical Nurse #15 signed for the 11:00AM administration of 100 milliliters of water flush prior to tube feed; 75 milliliters of water after tube feeding; and 320 milliliters of Jevity 1.5. Additionally, they signed for 12:00PM administration of 100 milliliters of water flush before, with, and after medication administration.During an interview on 9/24/2025 at 12:57 PM Licensed Practical Nurse #15 stated if a resident was able to self-administer their medications and feedings it required a physician order and would be noted on the medication administration record. Self-administrations still had to be supervised. When they signed the medication administration record it indicated that the right formula and the right amounts were given. They did not believe Resident #8 had to be directly supervised because being supervised upset them. They thought the resident was supposed to get a total of 300 milliliters of water with their medications and 75 milliliters before and after their feeding. That day they crushed the medications and put them in a cup with approximately 100 milliliters of water and brought it to the resident. They did not watch them self-administer. In the past they had observed the resident pour the correct amount of feeding which was four of the eight-ounce cartons. If the order was for 320 milliliters of Jevity 1.5 four times a day, that is what they should be getting. The resident should also receive water flushes as ordered.During an interview on 9/24/2025 at 3:53 PM Dietitian #14 stated they expected their recommendations were followed. They expected a tube feeding dependent resident's weight would be stable if they were getting what they were supposed to; stable meaning no changes of plus or minus 3%. Resident #8's weight had been stable for the past 6 months. They were made aware yesterday the resident self-administered their feeding. If the resident was giving themself 200 milliliters instead of 320 milliliters and not doing the full 300 with medication flushes, they would be falling below their recommendations and falling short of what they needed. During an interview on 9/25/2025 at 11:38 AM, the Director of Nurses stated for a resident to self-administer medications it would have to be determined they were cognitively able to do so. Nursing and therapy had to assess, and the physician needed to be involved as well. The education would be documented in a note. The resident would also be required to demonstrate correct administration. If a resident was deemed appropriate to do so, there should be a physician order, it should be in the care plan, and it should be reassessed quarterly and as needed. Resident #8 had been self-administering since mid-2024. The dietitian's recommendations should be followed and if the order was for 320 milliliters of Jevity 1.5 that is what the resident should be getting. The resident should also be receiving the amount of water flushes reflected in the physician order. They expected if the nurses were signing the medication administration record, that they were directly supervising to ensure it was being administered correctly.During an interview on 9/25/2025 at 11:52 AM, Nurse Practitioner #16 stated they depended on the hospital discharge and the recommendations of the dietitian for determining tube feeding and flush orders. They expected their orders were followed. Resident #8 was dependent on their tube feeding for nutrition. They did not know until just recently that the resident self-administered their feeding but should have known. If the resident was supposed to be getting 320 milliliters of Jevity 1.5 four times a day, the resident should not be administering 200 milliliters.

Based on record review and interviews during the abbreviated survey (NY00297623), the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and resident choices for 1 of 1 resident (Resident #5) reviewed. Specifically, Resident #5 had an unwitnessed fall, complained of pain the following morning, an x-ray was ordered, the x-ray was completed 10 hours after the resident complained of pain, and results were received 14 hours after they were ordered. Subsequently, the resident was hospitalized and was diagnosed with a right hip fracture. Additionally, the resident was not medicated for complaints of pain. Findings include: The facility policy, Falls Prevention Program, last reviewed 1/2024, documented residents must be assessed in a timely manner for potential causes of falls. The physician would identify medical conditions affecting fall risk and the staff would evaluate and document falls that occurred while the individual was in the facility; for example, when and where they happened and any observations of the event. The Interdisciplinary Team, with the physician's guidance, would follow-up on any associated injury until the resident was stable and delayed complications had been ruled out or resolved. Delayed complications such as late fractures or major bruising may occur hours or several days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall. Resident #5 had diagnoses including pneumonia, chronic obstructive pulmonary disease (lung disease), and muscle weakness. The 5/25/2022 admission assessment documented the resident had moderate cognitive impairment; required partial/moderate assistance of 1 for toileting and sitting to stand position; substantial/maximum assistance of 1 for sitting to standing, chair to bed transfers, toileting transfers; had no previous falls; and had no pain. The Comprehensive Care Plan initiated 5/25/2022 documented Resident #5 was at risk for falls related to limited mobility, weakness, and a history of falls. Interventions included a clutter-free environment; call bell in reach; a safe environment; educate family and resident on what to do if a fall occurs; physical therapy evaluation and treatment; and re-educate on safety precautions when needed. A 5/25/2022 at 10:55 PM Licensed Practical Nurse #9 nursing progress documented Resident #5 was discovered on the floor during last room checks near the far wall. All changes in condition were reviewed with the on-call medical professional. The resident did not present with pain. There was no documented evidence of the results of the telephone assessment review by the on-call medical provider. There were no documented nursing notes from 5/25/2022 at 10:55 PM until 5/26/2022 at 9:38 AM. A 5/25/2022 at 10:55 PM Licensed Practical Nurse #9 fall risk evaluation documented a recent fall, the resident had a history of 1-2 falls over the last 6 months, was confined to a chair, was disoriented, and exhibited loss of balance with standing. The resident was evaluated at a high fall risk. A 5/25/2022 at 10:55 PM handwritten (black ink) Accident/Incident Report completed by Licensed Practical Nurse #9 documented the resident was on the floor near the wall, away from the bed during last checks. The resident stated they were looking for a family member. The level of injury was marked as none apparent in black ink. The level of injury was marked as major injury with a fractured right hip (in blue ink). Additional signatures and titles were illegible and signed on 5/26/2022. On 5/26/2022 at 9:27 AM, Assistant Director of Nursing #12 Interdisciplinary Team Meeting progress note documented a meeting was held for Resident #5. The resident's 5/25/2022 fall and physical and occupational services for the resident were discussed. A 5/26/2022 at 9:38 AM Assistant Director of Nursing #12 assessment documented the resident had a fall on 5/25/2022 at 10:55 PM. The resident was choosing not to ambulate or move their right lower extremity due to pain. The resident could not lift the leg on their own which they were previously able to do. The resident stated the pain was in their femur (thigh bone) and the right hip. There was point tenderness to the femur and hip area. The right upper leg was swollen, and there was no bruising or redness. The physician was notified and ordered X-Rays. A 5/26/2022 at 2:08 PM Licensed Practical Nurse #4 progress note documented the resident demonstrated or verbalized controlled pain levels with current interventions. The resident's right lower extremity range of motion was within normal limits. The note did not document the resident's previous fall, complaints of right leg pain, or orders for an X-ray. A 5/26/2022 at 5:10 PM Physical Therapy evaluation by Physical Therapist #17 documented the resident was seen for an initial evaluation and refused to get out of bed due to right hip pain. A 5/26/2022 at 9:35 PM Licensed Practical Nurse #21 progress note documented the resident demonstrated no signs or symptoms or verbalization of pain or discomfort. The resident's right lower extremity range of motion was within normal limits. The note did not document the resident's previous fall, complaints of right leg/hip pain, or if the X-rays were completed. The 5/26/2022 24 hour report sheet documented the resident was a new admit and was Day 1 of a fall. The 7:00 AM-3:00 PM shift documented awaiting right hip/femur X-ray. The 3:00 PM-11:00 PM shift documented X-ray completed awaiting results. The 11:00 PM-7:00 AM shift documented right hip fracture and right femur fracture. A 5/26/2022 X-ray company's order detail log documented: - at 12:16 PM, an X-ray order for Resident #5 was entered (two and one half hours after the X-ray was ordered). - at 6:36 PM the order was dispatched (6 hours after order was entered) - at 7:33 PM, the X-ray order was completed (7 hours after the order was entered). - at 11:16 PM, the X-ray results were uploaded to the facility (almost 4 hours from the X-ray completion). - at 1:29 AM, a verbal report of the resident's X-ray results was given to the facility (15 hours after the X-rays were ordered). The 5/26/2022 X-ray report documented impressions were an acute fracture of the right hip and right femur at the intertrochanteric region (where hip and thigh meet). A 5/27/2022 at 12:16 AM Registered Nurse Supervisor #10 progress note documented the resident's X-ray results were faxed to the facility at 11:17 PM with results of an acute fracture to the right hip. The resident was in extreme pain, more so with movement and the on-call physician was phoned. An order for narcotic pain-relieving medication was obtained, oxycodone 5 milligrams to be given by oral route twice a day for 3 days. The first dose would be taken from the facility's automatic medication dispenser. -At 2:50 AM, Registered Nurse Supervisor #10 documented the resident's X-ray results additionally showed a fracture to the right proximal (closer to center of body) femur at the intertrochanteric region. The 5/2022 Medication Administration Record documented: - extra strength Tylenol 500 milligrams, give 2 tablets by mouth every 6 hours as needed for pain or fever. There was no documented evidence the resident received the Tylenol from 5/25/2022-5/27/2022 when they were discharged to the hospital. - oxycodone 5 milligram capsule, give 1 capsule by mouth every 12 hours as needed for moderate to severe pain. The oxycodone was not documented as administered on 5/27/2022. - the resident's pain level was documented as 0 on all shifts on 5/26/2022 despite registered nurse and physical therapy progress note documenting the resident was in pain. A 5/27/2022 at 7:09 AM Licensed Practical Nurse Unit Manager #3 progress note documented the resident had a change in condition, a fracture to their right hip after a fall on 5/25/2022 and at 7:21 AM, and Physician Assistant #11 was notified. Physician Assistant #11 recommended to send the resident to the emergency room for evaluation. A 5/27/2022 at 7:54 AM Licensed Practical Nurse Unit Manager #3 progress note documented the resident was sent to the hospital via ambulance and the resident's representative was notified. A 5/27/2022 hospital emergency room progress note documented Resident #5 arrived at the emergency room at 8:28 AM, had a right hip fracture and their right leg was shortened and externally rotated (in an outward position away from the midline of the body). During an interview on 10/23/2024 at 9:20 AM, Licensed Practical Nurse #9 stated they used to work on the evening and overnight shifts as an agency nurse and did not recall Resident #5. They stated there was not a Registered Nurse Supervisor in the building most of the time they worked. The registered nurses were on-call. If a resident fell , they called the on-call registered nurse who would walk them through an assessment over the phone. The on-call registered nurse asked them to check the resident's arms and legs for injuries. Licensed Practical Nurse #9 stated when the phone assessment was completed, they filled out the accident/incident form. In-person assessments were often delayed as it depended on who the staff was. They were not comfortable filling out the assessment forms as it was beyond their scope of practice. It was not uncommon for a resident's hospital transfer to be delayed. X-ray results were often delayed depending on who the nurse was who obtained the order. During an interview on 10/25/2024 at 11:05 AM, the X-ray company's Operations Manager stated X-rays resulted based on their order input, whether they were placed as routine or as stat (emergent). Resident #5's x-rays orders were received on 5/26/2022 at 12:16 PM as a routine order. They stated on 5/26/2022 at 11:15 PM, the resident's x-ray results were uploaded to the resident's electronical medical records and faxed to the facility at 11:16 PM. During an interview on 10/28/2024 at 11:07AM, Licensed Practical Nurse Unit Manager #3 stated they did not remember the resident and looked up information in the resident's chart. The resident had a fall and suffered a fractured hip, and they sent them to the hospital the morning of 5/27/2022. They stated if a resident had a fall on the off-shifts (3:00 PM-11:00 PM or 11:00 PM to 7:00AM), an on-call registered nurse completed the assessment. Back in 2022 the staff were given calendars to notify them who was on-call. They stated Resident #5's x-rays were not done timely and there were problems in the past with results being delayed. They stated the resident should have been sent to the hospital immediately when the x-rays resulted instead of calling the medical provider for medication. Licensed Practical Nurse Unit Manager #3 stated the resident's transfer to the hospital was not done in a timely manner. During an interview on 10/29/2024 at 2:51 PM, Physician Assistant #16 stated they no longer worked at the facility and did not have access to Resident #5's records. They would occasionally take on-call assignments for the facility as a courtesy. They did not recall receiving a phone call regarding a resident with a hip fracture. Physician Assistant #16 stated if they received a phone call from an off-shift nurse relaying a resident had a fall and results were a fractured hip they would have recommended immediate stabilization and immobilization of the hip, calling 911, and notifying the resident's health care proxy as it was important to send them to the hospital immediately for a surgical consult. Administering a narcotic pain relieving medication only would not be appropriate. A delay in treatment could result in complications such as blood clots or extreme pain. Physician Assistant #16 stated if the resident's transfer to the hospital was 2 days after the fracture occurred, it was not appropriate. This could result in undue pain and suffering for the resident. During an interview on 10/30/2024 at 2:18 PM, Registered Nurse #14 stated they no longer worked for the facility, and they were the former Director of Nursing. Registered Nurse #14 stated they did not recall Resident #5 or the incident. They would often be on-call day at night and staff would call them if a resident fell . The Licensed Practical Nurse Supervisor or unit nurse would call, and a registered nurse would have to go into the facility. Phone assessments were done over the phone occasionally if the resident was a high fall risk and care planned as such. If a resident required x-rays and the x-rays were delayed it was unacceptable. They did not think it was appropriate for Resident #5's x-rays to have resulted late or their transfer to the hospital 2 days after a fall. During an interview on 11/4/2024 at 3:35 PM, Registered Nurse #12 stated they were the former Assistant Director of Nursing. Their duties included filling out incident reports if a resident had a fall. If a resident fell during the off shifts, there was supposed to be a Registered Nurse Supervisor available to perform an assessment. They were unsure if assessments were done over the phone or if a registered nurse was in the building at night. Registered Nurse #12 stated they did not recall the resident or the incident. If a resident fell and x-rays were ordered, the x-ray company was portable and the results were often delayed, sometimes up to 1-2 days. Registered Nurse #12 stated If they performed a fall assessment and the resident complained of pain, the criteria for sending a resident to the hospital would be extreme pain, swelling and/or symptoms of limited range of motion. 10 NYCRR 415.12

Based on observation, record review, and interview during the abbreviated survey (NY00303220) the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1 was not assisted with toileting timely. Findings include: The facility policy, Resident Rights, last reviewed 1/2024 documented residents' basic rights included to be treated with respect, kindness, and dignity. The facility policy, Resident Care with Activities of Daily Living, last reviewed 1/2022, documented to provide residents with adequate toileting, maintaining maximum level of toileting and continence staff would first review the resident care instructions prior to assisting the resident to ensure appropriate numbers of person were available for assistance. Residents on toileting program would be offered toileting every 2- 4 hours and as needed. During napping or hour of sleep resident would be provided the bed pan and/or urinal if preferred every 2- 4 hours and as needed. Resident #1 had diagnoses including Alzheimer's Disease and cerebrovascular accident (stroke). The 9/29/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, did not refuse care, required substantial/maximal assistance for toileting hygiene, supervision and touching assistance with toilet transfers, was frequently incontinent of urine and always incontinent of stool, and was not on a toileting program. The undated care instructions documented the resident always required 2 staff during care, required substantial/maximal assistance for toileting hygiene, was on every 45-minute safety checks, the resident's call bell was to be within reach and encouraged to be used for assistance. The 8/22/2024 Comprehensive Care Plan documented the resident had bowel and bladder incontinence, was at risk for falls, and for impaired skin integrity. Interventions included offer toileting every 2 hours or check resident every 2 hours, encourage resident to use their call bell for assistance, check skin for impairment every shift, minimize extended exposure of skin to moisture by providing incontinence care and prompt removal of wet/damp clothing or sheets as needed, identify voiding patterns, and initiate a toilet schedule if indicated. During an observation on the A unit on 10/17/2024 at 9:59 AM, there was a strong odor of urine and stool noted outside of Resident #1's room. Upon entering the room, Resident #1 was in their low bed with their head hanging off the left side. There was a pillow on the floor, and the resident's feet were off to the right side of the bed. The resident was dressed in blue pants and a green shirt, their bed sheet had a large brown circle and appeared wet. Their call bell was not in reach and was wedged behind the headboard of the bed and the wall. Licensed Practical Nurse #4 was notified by the surveyor the resident appeared to be falling out of bed and they stated, give me one minute and proceeded to walk away from the resident's room to the nurse's station. When Licensed Practical Nurse #4 entered the resident's room approximately 2 minutes later, they repositioned the resident in bed by pulling them over to the right and they covered the resident with a sheet. Licensed Practical Nurse #4 stated that not all residents were required to have their call bell. During an observation on the A unit on 10/17/2024 at 11:16 AM, Resident #1 was in their bed asleep with the sheet over them. The resident's call bell was tucked under their right side, and there was a strong odor of urine and stool. During an interview on 10/17/2024 at 11:18 AM, Licensed Practical Nurse Unit Manager #3 stated that Certified Nurse Aide #5 was assigned to care for Resident #1 but was on their break. During an observation at on 10/17/2024 at 11:20 AM, Licensed Practical Nurse #7 was applying antibiotic ointment to Resident #1's right eyebrow suture area and repositioned the resident straighter in the bed. They completed the treatment and exited the room. There was a strong odor of urine and stool in the room. During an observation and interview on 10/17/2024 at 11:30 AM, Licensed Practical Nurse #7 approached Certified Nurse Aide #6 to assist them with getting Resident #1 out of bed to change their clothing and wash them. They sat the resident on the edge of the bed and stood them up and the resident's green shirt was wet up their back and their blue pants were wet down to the back of their right leg. Certified Nurse [NAME] #6 stated the resident was wet with urine and they walked the resident to the bathroom and sat them on the toilet. The linen on the bed was wet with a brown ring on the sheet and the two soaker pads on the bed were wet. During an interview on 10/17/2024 at 11:41 AM, Certified Nurse Aide #5 stated they were assigned to Resident #1, but the nurse had told them in morning report to let the resident sleep until lunch and then wake them and provide care. They stated they went into the room at 10:40 AM and the resident had their call bell and was asleep. They did not notice an odor. They would typically wash residents in the morning but was told not to wake the resident up until lunch, so no care was provided to the resident. They stated it was important to not leave residents is urine soaked clothing or linen because this could lead to infection or skin irritation. The 10/17/2024 toileting and bathing tasks for Resident #1 documented the resident received bathing and bladder and bowel care by Certified Nurse Aide #5 at 2:59 PM. During an interview on 10/17/2024 at 1:26 PM, Licensed Practical Nurse Unit Manager #3 stated all residents should have their call bells in reach. No one reported to them about not providing care to Resident #1 and leaving them in bed. The resident should have been checked on and changed even if they were sleeping. The resident required assistance of 2 for assistance with care and they were always available to assist with toileting and bathing. The resident's linen should have been changed as soon as it was noted to be wet. During an interview on 10/18/2024 at 11:22 AM, the Director of Nursing stated Resident #1 had dementia and required substantial/maximum assistance with toileting and required two staff present for care due to the resident's behaviors. All residents should have a call bell in reach even if they could not use it. All residents should be checked and changed every 2 hours per policy. Leaving a resident in bed without their call bell and wet linen was not safe, was a dignity issue, and could lead to infections and skin integrity issues. They stated Resident #1 was on every 45-minute checks and staff should have noticed the resident was incontinent and cleaned them. 10NYCRR 415.12(a)(3)

Based on record review and interviews during the recertification survey conducted 1/22/2024- 1/26/2024 the facility failed to ensure residents' advance directives were documented for 6 of 14 residents reviewed (Residents #172, #174, #222, #223, #224, and #320). Specifically, Residents #172, #174, #222, #223, #224, and #320 were admitted within the last 30 days (12/26/2023- 1/23/2024) and did not have physician orders for advance directives. Subsequently, during a cardiac emergency event, staff would not know Residents #172's, #174's, #222's, #223's, #224's, and #320's wishes for life-sustaining treatment. This placed Residents #172, #174, #222, #223, #224, and #320 at risk for the likelihood of serious harm or death that was Immediate Jeopardy. Finding include: The facility policy Advance Directives revised 1/2022 documented: -Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if they chose to do so. - Prior to or upon admission, the Social Service Director or designee will inquire of the resident, their family members, or legal representative, about the existence of any written advance directives. - Information about whether the resident had executed an advanced directive should be displayed prominently in the medical record. - The Director of Nursing or designee will notify the attending physician of the advance directives so that the appropriate orders would be documented in the resident's medical record and plan of care. - The attending physician will provide information to the resident and legal representative regarding the resident's health status, treatment options, and expected outcomes during the development of the initial comprehensive assessment and care plan. The facility policy Emergency Procedure- Cardiopulmonary Resuscitation reviewed 1/2024 documented: -If the residents' do not resuscitate (allow natural death) status was unclear cardiopulmonary resuscitation (chest compressions and artificial breathing to restart the heart) would be initiated until it was determined that there was a do not resuscitate or physician order not to administer cardiopulmonary resuscitation -In an event that an individual was found unresponsive a staff member should verify the do not resuscitate or code status of said individual. 1)Resident #223 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive neurological disorder) and dementia. The 1/2/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition. The resident and the resident's family participated in the assessment and goal setting. The residents discharge packet from the previous skilled nursing facility, scanned into the electronic medical record, included a physician's order form that documented the resident wished to have a do not resuscitate order. The 12/26/2023 at 3:44 PM admission progress note by registered nurse #17 documented the resident entered the facility with their spouse/significant other and family at their bedside. The resident was alert and confused. There was no documented evidence of Resident #223's advance directive wishes. The Physician Order Summary report with active orders from 12/26/2023-1/24/2024 did not include orders for advance directives. The 12/26/2023 social work progress note by the Social Services Director documented the resident was admitted from another skilled nursing facility. The resident's spouse was their Health Care Proxy (a person designated to make health care decisions on behalf of the resident). The resident had moderate cognitive impairment based on a Brief Interview for Mental status score of 10. Advance Directives were reviewed with family and the resident was a full code (initiate cardiopulmonary resuscitation in the event of cardiac arrest). Medical provider progress notes dated 12/27/2023-1/16/2024 did not document discussions with the resident or Health Care Proxy regarding advance directive wishes or their current code status. A 1/22/2024 at 12:37 PM physician #28 progress note documented the resident was a full code. 2)Resident #224 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure, dehydration, and pneumonia. The 1/17/2024 Minimum Data Set assessment documented the resident was cognitively intact. The resident and the resident's family participated in the assessment and goal setting. The residents discharge packet from the previous skilled nursing facility, scanned into the electronic medical record, included a 12/20/2023 hospital admission history and physical that documented the resident wished to have a do not resuscitate order. The physician order summary report with active orders from 12/30/2023-1/24/2024 did not include orders for advance directives. The 12/30/2023 at 1:38 PM nursing admission progress note by registered nurse Supervisor #17 documented the resident was cognitively intact. There was no documented evidence of Resident #224's advance directive wishes. The comprehensive care plan initiated 1/11/2024 and reviewed by the Interdisciplinary Care Team on 1/15/2024 did not include advance directives. The 1/17/2024 2:02 PM physician #28 progress note documented the resident was admitted to the facility for short term rehabilitation. There was no documentation of discussion with the resident regarding advance directive wishes or their current code status. During an interview on 1/23/2024 at 4:07 PM, Resident #224 stated they did not want cardiopulmonary resuscitation. They stated if something were to happen (became unresponsive) to them they did not want anything done. 3)Resident #320 was admitted to the facility on [DATE] with diagnoses including hypertension and atrial fibrillation (an irregular heart rate). The 1/19/2024 entry tracking Minimum Data Set assessment did not include cognitive status for the resident. The resident was discharged from an assisted living facility on 1/19/2024. The discharge documents included an unsigned physician order that documented the resident wished to have a do not resuscitate order. The 1/19/2024 at 4:48 PM nursing admission note by registered nurse #20 documented the resident was cognitively intact. There was no documented evidence of Resident #320's advance directive wishes. The physician order summary report with active orders from 1/19/2024-1/24/2024 did not include orders for advance directives. The residents Medical Orders for Life-Sustaining Treatment was signed by the resident on 1/22/2024 at 3:45 PM and documented do not resuscitate. The physician signed the document on 1/24/2024 5 days after admission. During an interview on 1/23/2024 at 2:39 PM, licensed practical nurse #7 stated resident code status was listed in the electronic record on the medication administration record at the top of the electronic medical record. They stated if they needed to find a code status, they would look in the medication administration record or they could access the Medical Orders for Life-Sustaining Treatment book that was located at the nurse's station. During an interview on 1/23/2024 at 2:42 PM, licensed practical nurse #5 stated if a resident was a full code or a do not resuscitate this information would be at the top of the electronic medical record under their picture. Some residents had code status bracelets on their wrist or on their wheelchair. If staff were unable to find a bracelet or order, they would look in the Medical Orders for Life-Sustaining Treatment book at the nurse's station. During an interview on 1/23/2024 at 3:50 PM, licensed practical nurse #1 stated the resident order for code status was listed in the electronic record or could be accessed from the Medical Orders for Life-Sustaining Treatment binder at the nurse's station. If there was no order they would notify the supervisor, but the resident would be treated as a full code, and cardiopulmonary resuscitation would be completed until there was a physician order obtained for code status. During an interview on 1/23/2024 at 4:03 PM, Social Service Director stated they were responsible for ensuring the advance directives were in place for all newly admitted residents and for inquiring about their current wishes and what they wanted in the future. If the resident lacked the capacity, they would call their health care proxy or power of attorney and ask them to bring in copies of their documented wishes. Advance directive status should be completed as soon as possible. On 1/23/2024 at 5:56 PM, a list of the current residents and their code status orders was provided to the survey team. The provided current list did not include Residents #172, #174, #222, #223, #224, and #320. During an interview on 1/23/2023 at 6:55 PM, the Director of Nursing stated the facility policy for advance directives and code status included that every resident who was admitted to the facility should have a code status order and every resident should have a Medical Orders for Life-Sustaining Treatment completed with the assistance of the social worker. Code status could be obtained from the discharge paperwork for any new admission. When a resident was admitted , the registered nurses did the admission assessment and reviewed the discharge paperwork. If the resident code status was not documented, they should discuss this with the resident if they were alert and oriented. If the resident was disoriented, they should reach out to family. If the resident arrived with a Medical Orders for Life-Sustaining Treatment they should review it with the resident for accuracy, and this was scanned into the chart. The standard of care if a resident did not have a code status or a Medical Orders for Life-Sustaining Treatment was the resident would automatically be a full code. The staff should be calling the provider to obtain a full code order. It was important to have a medical order for code status so that they did not inadvertently harm someone or provide care the resident did not want. During an interview on 1/23/2024 at 7:06 PM, the Administrator stated they were not sure what the advance directive policy included and would refer to the Director of Nursing. They stated all residents should have a code status and should be listed with an order. This was important for the residents to make sure their wishes were met, and care was provided in the manner they requested. They were not aware there were residents in the facility without medical orders for their code status. During an interview on 1/24/2024 at 11:41 AM, the Medical Director stated they were not aware there were residents in the facility without documented orders for code status. The residents should have code status and all advance directives orders inputted in the medical record immediately upon admission. If a resident did not have their code status documented, it would be a medical and legal matter. The facility would want to be sure the residents' wishes were addressed for the safety of the resident. When a resident was admitted from an outside facility staff should ask the resident about their wishes, and if the resident was unable to answer they should speak to the resident health care proxy or legal representative to verify the resident's resuscitation wishes. During an interview on 1/24/2024 at 12:20 PM, the Assistant Director of Nursing stated if a resident was found unresponsive, they would call a code and would determine the resident code status from the electronic medical record or the Medical Orders for Life-Sustaining Treatment book. They were not sure if the advance directives were part of the admission evaluations, but they state the advance directives should be addressed upon admission by the Unit Managers, the Director of Nursing, or themself. They were not aware there were 6 residents without a documented code status order. It was important to have code status addressed upon admission for resident safety. Advance directives required a physician order. Admission orders should be reviewed with the physician on admission or the day after and if the provider was not in the facility, they could get advance directives orders. During an additional interview on 1/24/2024 at 12:41 PM, the Director of Nursing stated they were responsible for all the nursing staff and oversight of the appropriate documentation in the resident record. They stated when a resident was admitted their code status orders should be reviewed. They stated sometimes staff were able to review a resident's advance directives prior to the resident admission to the facility. The registered nurse admitting the resident was responsible for addressing the code status. They should ask the resident their status and if the resident was unable to answer they should reach out to the health care proxy or legal representative. The registered nurse should call the provider for orders and then put the orders in the electronic record and the provider would sign the order when they were in the facility. They stated Residents #172, #174, #222, #223, #224, and #320 did not have their codes status addressed upon admission. According to their policy and procedure it was nursing's and social work responsibility to ensure the resident code status was addressed upon admission. The interdisciplinary team should ensure the resident code status was addressed upon admission and the provider had been made aware of the order for their code status. ____________________________________________________________________________________ Immediate Jeopardy was identified, and the facility Administrator was notified on 1/23/2024 at 8:59 PM. Immediate Jeopardy was removed on 1/24/2024 at 1:30 PM prior to survey exit based on the following corrective actions taken: -On 1/24/2024 at 12:04 PM, Residents #172, #174, #222, #223, #224, and #320 physician orders were updated to reflect code status. All the residents and/or their representatives had advance directives reviewed and code status was updated appropriately. - The facility identified all the residents could be affected. As a result, a facility wide audit was conducted to ensure all resident had an order for their code status. There were no other issues identified. - All staff were re-educated on Advance Directives and an understanding of what to do if a resident was found without an order for their code status. A posttest was initiated to ensure the retention of the training information. They had 68% of their staff trained and the goal was to have 100% of their staff trained. They had 100% of all working staff trained. - the facility planned to do daily audits on all new admissions to ensure that they had an order for code status. This would be done daily for 60 days and then weekly for four weeks. The results would be discussed with the interdisciplinary team. The Director of Nursing would be responsible for this audit and the continued staff education. 10NYCRR 400.21(c) 46276

Based on record review and interview during the recertification survey conducted 1/22/2024 through 1/26/2024, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries for 3 of 3 residents (Residents #271, 272, and 273) reviewed. Specifically, Residents #271, #272, and #273 were discharged to home and were not provided with Notice of Medicare Non-Coverage (Centers for Medicare and Medicaid Services-10123) for Medicare Part A as required. Findings include: The Centers for Medicare and Medicaid Services instructions for the Notice of Medicare Non-Coverage form 10123 documents a Medicare provider or health plan (Medicare Advantage plans and cost plans, collectively referred to as plans) must deliver a completed copy of the Notice of Medicare Non-Coverage to beneficiaries/enrollees receiving covered skilled nursing, home health (including psychiatric home health), comprehensive outpatient rehabilitation facility, and hospice services. The Notice of Medicare Non-Coverage must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. The facility policy, Cut Notices revised 5/2022 documents [Minimum Data Set] staff will issue the Notice of Medicare Non-Coverage to the resident/family and follow the rules for the patient's rights to appeal for Health Maintenance Organization A (medical insurance group that provides health services for a fixed annual fee) and Medicare A residents. Resident #271 was admitted to the facility with diagnoses including acute kidney failure, cardiomegaly (an enlarged heart), and essential hypertension (high blood pressure). The Minimum Data Set, dated dated dated [DATE] documented it was a planned discharge and was a Skilled Nursing Facility Part A Prospective Payment System discharge assessment. The resident was cognitively intact. Resident #272 was admitted to the facility with diagnoses including lack of coordination, history of falling, and osteoarthritis of the knee. The Minimum Data Set, dated dated dated [DATE] documented it was a planned discharge and was a Skilled Nursing Facility Part A Prospective Payment System discharge assessment. The resident was cognitively intact. Resident #273 was admitted to the facility with diagnoses including paroxysmal atrial fibrillation (an abnormal heart rhythm) and osteoporosis without a fracture. The Minimum Data Set, dated dated dated [DATE] documented it was a planned discharge and was a Skilled Nursing Facility Part A Prospective Payment System discharge assessment. The resident was cognitively intact. There was no documented evidence Residents #271, #272, and #273 were provided with Notice of Medicare Non-Coverage Centers for Medicare and Medicaid Services-10123 at least two calendar days before Medicare covered services ended. During an interview on 1/23/2024 at 4:31 PM, the Regional Director of Admissions stated they and the Social Services Director issued the managed Medicare notices. They did not issue Medicare A notices and facility policy stated the Minimum Data Set Coordinator should have issued the notices. During an interview on 1/25/2024 at 4:32 PM, registered nurse Minimum Data Set Coordinator #32 stated they had worked in the facility since May 2023 and had never issued a Notice of Medicare Non-Coverage Centers for Medicare and Medicaid Services form 10123 to a resident. The Regional Director of Admissions and Social Services Director issued the notices; they kept track of which residents were due to be cut and wrote it down in a book for tracking. They did not know how to fill out the forms the surveyor handed in regarding the Notice of Medicare Non-coverage and had to call their regional boss to find out how to fill them out. Registered nurse Minimum Data Set Coordinator #32 stated the Regional Director of Admissions and Social Services Director received electronic mailings on which residents needed a notice. During a follow-up interview on 1/25/2024 at 4:46 PM, the Regional Director of Admissions stated they never issued Notice of Medicare Non-Coverage Centers for Medicare and Medicaid Services-10123 forms to Medicare A residents being discharged home because the residents agreed to the discharge. They stated they issued Notice of Medicare Non-Coverage Centers for Medicare and Medicaid Services-10123 forms to managed Medicare patients to explain their appeal rights because the resident's insurance determined they were ready for discharge. They stated they didn't realize if a resident wanted to go home it was considered a facility-initiated discharge. During an interview on 1/25/2024 at 5:11 PM, the Social Services Director stated the facility initiated the discharge planning process. They met with the resident and/or family, assessed whether the resident's goals were met, set up home health services and follow up medical appointments and gave the resident discharge paperwork to sign on the day of discharge. They stated they gave one-week notice before discharge and had never had a situation arise when a resident was not ready for discharge and was discharged . 10 NYCRR 415.3(g)(2)(iii) 48052 48895

Based on observation, interview, and record review during the recertification survey conducted 1/22/2024-1/26/2024, the facility did not maintain equipment in safe operating condition for the main kitchen and for 1 of 2 resident wings (B-unit). Specifically, the main kitchen hood exhaust fan was not functional; and there was no ice-dispenser machine available for resident use on the B-unit. Findings include: Main Kitchen exhaust: During an observation on 1/22/2024 at 6:15 PM, the kitchen hood exhaust was not functional when tested . The undated kitchen exhaust fan outage timeline of events documented on the morning of 12/13/2023 it was discovered that the exhaust fan in the kitchen hood was not functioning, and maintenance attempted repairs. During an interview on 1/22/2024 at 6:15 PM, the Kitchen Supervisor stated they knew the hood motor blew a couple of weeks ago. They believed a part was ordered and needed to be replaced. They were not sure when the exhaust fan would be functional. They stated the kitchen staff left the windows open for ventilation when cooking. During an interview on 1/23/2024 at 11:39 AM, the Food Service Director stated the exhaust fan motor has not been working for weeks and staff left the windows open for ventilation. During an interview on 1/24/2024 at 2:42 PM, the Maintenance Supervisor stated about a month ago they found the exhaust fan motor had burnt out and not functioning. The part should have arrived and corporate was supposed to install the part tomorrow. They believed the kitchen staff opened the windows in the kitchen for ventilation until the exhaust was fixed. Ice-dispenser machine: During an observation on 1/23/2024 at 11:01 AM, there was no ice-dispenser machine available for resident use on the B-unit. Inside the B-unit kitchenette there was no ice-dispenser machine installed like the A-unit had. There was a 32-quart cooler with ice and an ice scoop on a rolling cart adjacent to the nurse's station. During an interview on 1/23/2024 at 11:01 AM, the Director of Facilities stated there had been no ice machine on the unit for years as it went bad. They were not aware of any attempt to replace the ice-dispenser machine for the unit. During an interview on 1/23/2024 at 11:35 AM, the Food Service Director stated the B-unit did not have an ice-dispenser machine and they used a cooler full of ice that came from the kitchen. Kitchen staff filled the cooler three times a day and delivered it to the unit. During an interview on 1/24/2024 at 2:42 PM, the Maintenance Supervisor stated the B-unit did not have an ice machine. The nursing staff had a cooler that was filled with ice and a drink cooler with water and ice for the residents. They were not aware if there was going to be an ice machine for the unit. During an interview on 1/25/2024 at 2:52 PM, certified nurse aide #24 stated the ice in the cooler was filled two or three times a day. The kitchen staff also provided the ice scoop for the ice cooler. They knew the A-unit had an ice machine and was not sure why the B-unit did not have one. 10NYCRR 415.29 10NYCRR 713-2.5

Based on observation, interview, and record review during the recertification and abbreviated (NY00314269) surveys conducted 1/22/2024-1/26/2024, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of infection for 4 of 5 residents (Residents #7, #29, #64, and #270) reviewed. Specifically, Resident #64's wound care was completed without appropriate hand hygiene and precautions to prevent contamination of the wound or clean supplies; and Residents #7, #29, and #270 had their blood glucose (blood sugar) checked and the glucometer (device used to measure blood sugar levels using a droplet of blood) was not disinfected between use or disinfected with an appropriate high-level disinfectant. Findings include: The facility policy Hand Hygiene - Guidelines for Hand Washing and Hand Antisepsis reviewed 1/2020 documented situations that required hand hygiene included before and after performing any invasive procedure, before and after assisting a resident with personal care, before and after changing a dressing (bandage), before and after assisting a resident with toileting, after handling used linens and dressings, after performing personal hygiene, and after removing gloves or other personal protective equipment. The facility policy Wound care reviewed 1/2024 documented to put on exam gloves to remove the bandage, use the glove to cover the bandage to dispose of it, put on another pair of gloves and other personal protective equipment if needed, and use a no-touch technique to apply ointments or creams. If the wound required physical touching sterile gloves were to be worn, and exam gloves were needed to dress (apply new bandage) the wound with the no-touch technique. The facility policy Cleaning and Disinfection of Glucometer reviewed 1/2024 documented that reusable items and durable medical equipment would be cleaned and disinfected according to current Center for Disease Control recommendations for disinfection and the Occupational Safety Health Act bloodborne pathogen standard. Glucometer cleaning should take place before and immediately after each use to prevent the spread of pathogens from blood or body fluids. In cases where the manufacturer had no cleaning recommendations, the use of an Environmental Protection Agency-register high-level disinfectant was the standard. Glucose meters used in a clinical setting for testing multiple persons must be cleaned and disinfected between patients. Infection Control Not Maintained During a Dressing Change Resident #64 was admitted to the facility with diagnoses including stroke, Alzheimer's dementia, and osteoporosis. The 9/14/2023 Minimum Data Set assessment documented the resident had severely impaired cognition, required extensive assistance of 1 for personal hygiene, extensive assistance of 2 for bed mobility, transfers, and toileting, was frequently incontinent of bladder and bowel, and did not have any pressure ulcers. The comprehensive care plan initiated 9/21/2023 documented the resident had bowel incontinence related to cognitive impairment. The comprehensive care plan initiated on 11/13/2023 documented the resident had impaired skin integrity related to deep tissue injury on bilateral heels. Interventions included treatment per medical orders, evaluate the wound for size, depth, margins, and monitor for sign and symptoms of infection. The care plan initiated on 12/14/2023 documented the resident had alterations in skin integrity related to actual pressure ulcers. Physician orders documented: - on 12/28/2203 cleanse coccyx (end of tail bone) wound with wound cleanser, pat dry, apply calcium alginate (dressing used to absorb wound fluid) cut to fit wound bed, cover with silicone dressing as needed when soiled and in the morning for pressure injury. -on 1/11/2024 cleanse and dry the left heel and apply hydrogel (a dressing used to maintain the wounds moisture), then abdominal pad (thick gauze dressing) and wrap with Kling (elastic gauze) once a day for heel care. During an observation on 1/25/2024 at 6:55 AM, licensed practical nurse #19 and certified nurse aide #22 assisted Resident #64 with morning care and dressing changes. Licensed practical nurse #19 completed hand hygiene and put gloves on. They set up a border gauze (an absorbent dressing) and tape marked with the current date. They removed the old bandage from the left heel and rolled it up in the old gauze and placed it in the trash bin near the bed. They did not change their gloves or perform hand hygiene and sprayed with wound cleansing spray. They did not change their gloves or perform hand hygiene and the new bandage was placed with dry gauze and Kling and secured with tape. Licensed practical nurse #19 then assisted certified nurse aide #22 with dressing the resident and providing incontinence care. They removed the resident's dirty incontinence brief and rolled the resident to their left side. The dirty brief and bed pad were rolled up and left under the resident's left hip. Licensed practical nurse #19 cleansed the resident's bottom with a wet soapy washcloth. They did not change their gloves or perform hand hygiene. The wound was sprayed with wound cleanser, wiped with a wet soapy washcloth from the water bin from morning care, and dried with a white towel from the linen cart. They did not change their gloves or perform hand hygiene. A small piece of hydrogel from the package was placed on the wound, without cutting it to the size of the wound, and dated border gauze was applied over the area. The licensed practical nurse removed their gloves and completed hand hygiene. During an interview on 1/25/2024 at 2:41 PM, licensed practical nurse #19 stated the correct order of a dressing change was to get staff assistance, unwrap and remove the old dressing, clean the wound as best as possible, apply a new dressing, and wash their hands. They stated they would put on gloves before removing the old dressing and should have changed their gloves after the old dressing was removed. The resident did not require a sterile or clean technique for their wound care/dressing change. It was important to change their gloves between the removal of the old bandage and the application of the new bandage because the old bandage could transfer unknown substances to the gloves that could then be transferred to the wound or the new bandage. During an interview on 1/25/2024 at 3:20 PM, registered nurse #20 stated wound care was done with a clean technique and should include barriers, several pairs of gloves, and hand sanitizer. Hand hygiene and glove changes should occur between the removal of the old bandage and the application of the new bandage. Additionally, hand hygiene and glove changes should occur after the removal of an incontinence brief and before the start of wound care. It was important to change gloves because it should be a clean procedure, and incontinence briefs and old bandages were not clean. Changing gloves was important to prevent cross-contamination between the old bandage and the new bandage. The lack of hand hygiene and glove changes could negatively affect the resident's quality of care. During an interview on 1/26/2024 at 10:01 AM, registered nurse #18 stated the expectation of performing a dressing change was to gather all required supplies, complete hand hygiene, apply gloves, remove the old dressing, clean the wound per orders, complete hand hygiene, put on new gloves, and apply a clean dressing with the date and time. Hand hygiene should be completed after supplies were cleaned up and when they exited the resident's room. Gloves should be changed between dressing changes to get rid of potential bacteria and for infection control. It was not appropriate to maintain the same pair of gloves for 2 dressing changes and assistance with morning care. This process could contaminate the wound with new bacteria from the incontinence brief change and general morning care. Infection control was important to keep residents safe, healthy, and reduce potential for resident compromise. During an interview on 1/26/2024 at 10:11 AM, registered nurse #21 stated they were working toward their infection preventionist certification. The expectation of wound care was that it be completed with clean technique and depending on the wound and resident with sterile (totally clean free from bacteria or microorganisms) technique. Gloves were required to be changed between dressings to avoid cross-contamination from the old dressing to the new dressing. The best practice was to remove the old dressing, put on new gloves, and apply the new dressing. It was not appropriate to maintain the same gloves for both dressing changes and morning care that included changing a dirty incontinence brief. Every task should start with a new pair of gloves. There were several bacteria that could be introduced to a wound that come from an incontinence brief change. During an interview on 1/26/24 at 10:22 AM, the Director of Nursing stated gloves should be changed between wound treatments. The importance of changing gloves between tasks was to reduce cross-contamination between wounds. One wound could have bacteria and it should not be given the opportunity to move to the other wounds. This could compromise the resident's health. It was not appropriate to maintain the same pair of gloves for changing a brief and then providing wound care. The process should have been to clean the resident, wash their hands, put on new gloves, then proceed with the wound care bandage change as ordered. The importance of changing gloves was patient safety. Glucometer Not Disinfected Between Residents The following was observed during a medication administration observation on 1/25/2024 with licensed practical nurse #19: - at 11:50 AM, licensed practical nurse #19 completed a blood glucose finger stick on Resident #270. They wiped the resident's left index finger with alcohol, obtained a blood sample, and put the multi-person use glucometer back in top drawer of medication cart without disinfecting the device. The injected 9 units of insulin in the right upper deltoid after sanitizing the site with alcohol. Licensed practical nurse #19 did not wear gloves. - at 11:59 AM, licensed practical nurse #19 completed a blood glucose finger stick on Resident #7 in the hall in front of the medication cart. The same glucometer that was used for Resident #270 was removed from top drawer of the medication cart. Licensed practical nurse #19 put gloves on, prepped the glucometer, wiped the resident's right index finger with alcohol, obtained a blood sample, discarded the supplies, and removed their gloves. The resident's insulin pen was removed from the top drawer, and 8 units were injected in the left abdomen after the area was cleaned with alcohol. Licensed practical nurse #19 put the glucometer back in the top drawer of the medication cart without disinfecting. Licensed practical nurse #19 stated they were done and did not perform hand hygiene. During a medication administration observation on 1/25/2024 at 12:19 PM, registered nurse #26 completed a blood glucose finger stick on Resident #29. Registered nurse #26 set the glucometer on the bare overbed table without a clean barrier, put on their gloves, wiped the resident's finger with an alcohol pad, obtained a blood sample, and returned the glucometer to the overbed table. Insulin was administered to right abdomen, and they discarded their supplies. The glucometer was disinfected with alcohol wipes, and then set on the metal shelf in the bathroom while the nurse washed their hands. They exited the resident room holding the glucometer in their ungloved hand. During the observation, the Director of Nursing interjected and corrected registered nurse #26 to disinfect the glucometer again after picking it up from the metal shelf before placing it back in the medication cart. During an interview on 1/25/2024 at 3:37 PM, registered nurse #20 stated glucometers should be placed on a sanitized table with a barrier. After the blood glucose finger stick, the glucometer should be sanitized with alcohol, placed on a clean barrier, and staff should wash their hands after removing gloves. They should not put the glucometer on a dirty surface after cleansing it and should put a barrier on top of the cart or place the machine in the top drawer of the cart. Gloves should be worn when obtaining blood glucose finger sticks as standard infection control precautions/prevention, the same goes for disinfecting of the glucometers. The glucometer should also be disinfected between residents. They stated Residents #7, #29, and #270 did not have bloodborne pathogen concerns. During an interview on 1/26/2024 at 11:22 AM, licensed practical nurse #19 stated infection control education was done annually and as needed and it covered hand hygiene. Hand hygiene should be completed before any dressing changes, when they passed out meals, before a medication pass, when toileting residents, before taking care of a resident, and after taking care of a resident. Gloves should probably be worn when using the glucometer due to possible exposure to blood. They stated they forgot to put them on prior to using the glucometer. They were supposed to sanitize their hands prior to and after glucometer use and disinfect the glucometer in between each resident to prevent spread of infection. The top of the cart and the top drawer was contaminated thus possibly contaminating other objects on the top of the cart and in the top drawer. They stated they did not wear gloves the first time they used the glucometer and was not sure if they sanitized their hands. During an interview on 1/26/2024 at 11:48 AM, registered nurse #18 stated they did not know the last time glucometer education occurred. They expected a yearly competency to be done for infection control, and glucometer procedures. Staff were supposed to put on gloves prior to obtaining blood samples. They were supposed to sanitize hands between residents. During an interview on 1/26/2024 at 11:59 AM, registered nurse #21 stated staff should put on their gloves prior to cleaning the glucometer, change gloves and sanitize their hands, put on new gloves, perform the finger stick, take off their gloves, sanitize their hands, put on new gloves, disinfect the glucometer with alcohol wipes, remove their gloves, and sanitize their hands. They were supposed to put the glucometer on a barrier when in a resident's room to prevent cross contamination and prevent blood from getting on their skin and transmitting to others. The purpose of hand washing was to prevent spread of germs even if not visible. They were supposed to sanitize their hands between each resident and glove changes. The purpose of sanitizing the glucometer between residents was to prevent germs from going from resident to resident. If they put a non-sanitized glucometer on top of cart or in top drawer, items touching those surfaces were then contaminated. During an interview on 1/26/2024 at 12:10 PM, the Director of Nursing stated staff should sanitize glucometers before and after each use to prevent cross contamination of infection. They were supposed to use gloves during blood glucose finger sticks to prevent potential bodily fluids exposure. They were supposed to sanitize their hands before putting on gloves, during each glove change, after taking gloves off, and between each resident to prevent cross contamination of germs. 10NYCRR 415.19(b)(1) & 415.19(b)(4)

Based on observation, record review, and interviews during the recertification and abbreviated (NY00321647 and NY00323860) surveys conducted 1/22/2024-1/26/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 4 residents (Residents #11 and #37) reviewed. Specifically, Resident #11 was not assisted with nail care and had food particles on their clothing; and Resident #37 was not assisted with personal hygiene and clothing changes. Findings include: The facility policy Resident Care with Activities of Daily Living effective 7/2021 and reviewed 1/2022 documented residents would receive accurate assistance and support with their needs for activities of daily living. Staff were to review the resident's care plan to assess for any special needs and notify the Supervisor if the resident refused the procedure. The facility policy Care of Fingernails/Toenails reviewed 1/2024 documented nail care included daily cleaning and regular trimming. The procedure for cleaning fingernails documented the resident should soak their hands in warm soapy water for approximately 5 minutes and dirt should be gently removed from under each nail with an orange stick. 1) Resident #11 had diagnoses of muscle weakness, lack of coordination, and need for assistance with personal care. The 12/10/2023 Minimum Data Set assessment documented the resident was cognitively intact, used a walker and a wheelchair, required assistance of 2 for transfers, substantial/moderate assistance for bathing, and partial/moderate assistance for personal hygiene. The comprehensive care plan revised 9/18/2023 documented the resident required assistance with activities of daily living related to weakness. Interventions included extensive assistance of 1 with personal hygiene, and assistance of 2 with bathing and transfers. The 1/2024 resident care instructions documented the resident required extensive assistance of 2 for personal hygiene, dressing, bathing, and used a wheelchair. Resident #11 was observed: - on 1/23/2024 at 10:06 AM, sitting in their wheelchair in the front lobby wearing a gray shirt, black pants, and brown shoes. There were food crumbs on their shirt and wheelchair cushion. The resident had a dark brown substance under all 10 of their fingernails and white stains on their shoes. - on 1/24/2024 at 2:20 PM, dressed in a red shirt, red plaid pajama pants and brown shoes. The resident had a dark brown substance under all 10 fingernails. There were food crumbs on their red shirt and white stains on their brown shoes. - on 1/25/2024 at 10:02 AM, the resident had a dark brown substance under all 10 of their fingernails. During an interview on 1/25/2024 at 3:17 PM, certified nurse aide #10 stated they looked up how to care for a resident in the resident's care profile in the electronic record. Resident #11 was dependent on staff for care and morning care included nail care. Certified nurse aide #10 stated the resident did not refuse care. During an interview on 1/26/2024 at 8:27 AM, licensed practical nurse #13 stated the resident required total care with their activities of daily living and did not refuse care. A dark substance under the resident's nails was not appropriate or dignified. During an interview on 1/26/2024 at 9:49 AM, licensed practical nurse Unit Manager #14 stated the resident was dependent on morning care, required assistance of 1 with personal hygiene, and could not clean their own nails. Licensed practical nurse Unit Manager #14 stated nurses were responsible for cutting the resident's nails, but anyone could clean them. During an interview on 1/26/2024 at 10:44 AM, the Director of Nursing stated Resident #11 was diabetic, required assistance with personal hygiene. Nail care was part of morning care but could be performed at any time. If nursing staff observed dirty nails, they expected them to be cleaned right away. If the resident was diabetic, they would expect licensed nurses to perform nail care due to risk of infection and would expect certified nurse aides to alert the licensed nurses that the resident needed nail care. 2) Resident #37 had diagnoses of muscle weakness and need for assistance with personal care. The 10/12/2023 Minimum Data Set assessment documented the resident was cognitively intact, required supervision/touch assistance for personal hygiene and supervision/touch assistance with dressing. The comprehensive care plan revised 12/01/2023 documented the resident required assistance with self-care and mobility related to impaired balance and limited mobility. Interventions included partial/moderate assistance with bathing, supervision/touch assistance with personal hygiene, and supervision/touch assistance with upper and lower body dressing. The 1/2024 resident care instructions documented to encourage the resident to change their shirt when soiled, the resident required partial/moderate assistance of 1 for bathing and supervision with setup for dressing. Resident #37 was observed: - on 1/22/2024 at 7:22 PM wearing a rust-colored shirt, black pants, black sneakers, and had a beard. They were drooling while holding a chocolate milk container in their hands. They had a tan liquid substance in their beard and their clothing was soiled. - on 1/23/2024 at 8:23 AM, wearing the same soiled clothing from 1/22/2024, a rust-colored shirt and black pants. The resident was self-propelling their wheelchair in the lobby wearing a clothing protector around their neck. At 11:19 AM, the resident was self-propelling in their wheelchair around the unit and had drool and food substances in their beard and was wearing soiled pants. - on 1/25/2024 at 10:14 AM, exiting their room wearing a gray hooded sweatshirt jacket, blue track pants, and a green shirt. The resident had drool, liquids, and food substances in their beard and on their clothing. Their wheelchair was soiled with a food substance. - on 1/26/2024 at 8:14 AM, propelling their wheelchair up the hall wearing the same soiled clothing from 1/25/2024, a gray hooded sweatshirt, blue track pants, and a green shirt. During an interview on 1/25/2024 at 10:24 AM certified nurse aide #11 stated they knew how to care for a resident by looking at their care profile in the electronic record. Resident #37 required assistance of 1 for personal hygiene, drooled a lot, did not usually refuse care, and got up for the day on the night shift. Certified nurse aide #11 stated during the day shift if they noticed the resident's clothing was soiled, they would assist them with changing their clothes. It was not dignified to wear soiled clothing. During an interview on 1/26/2024 at 8:27 AM, licensed practical nurse #13 stated Resident #37 was somewhat independent and tried to dress themselves but needed assistance of 1 for personal hygiene. All nursing staff were responsible for personal hygiene and the resident should be assisted with clothing changes every day. It was not dignified for the resident to wear soiled clothing. During an interview on 1/26/2024 at 9:49 AM, licensed practical nurse Unit Manager #14 stated the resident was independent with dressing and transferring but required assistance of 1 with personal hygiene. Licensed practical nurse Unit Manager #14 stated the resident should be assisted with changing their shirt if it was soiled. It was not dignified to wear soiled clothing. The certified nurse aides should document if they refused care. During an interview on 1/26/2024 at 10:44 AM the Director of Nursing stated the resident drooled a lot and often soiled their beard and clothing. They stated the resident needed assistance with personal hygiene. The resident should be assisted with changing their soiled clothing and they expected the nursing staff to assist them. If the resident was observed for several days wearing the same soiled clothing with liquid and food substances in their beard and on their clothing, it gave the appearance the resident was not being cared for and was not dignified. 10NYCRR 415.12 (a)(3)

Based on observation, record review, and interviews during the recertification and abbreviated surveys (NY00298057, NY00320417, and NY00326044) from 1/22/2024-1/26/2024, the facility did not ensure residents were free from abuse for 2 of 5 residents (Residents #14 and #28) reviewed. Specifically, the facility did not implement plans to protect residents from abuse and prevent resident to resident abuse when Residents #14 and #28 did not have safety checks as planned and Resident #28 did not have a stop sign across their door as planned and continued to have access to their reacher device (a tool to grab out of reach items) after they hit someone with it and the plan was for the reacher to be removed. Findings include: The facility policy Abuse Prevention Program/Abuse and Neglect-Clinical Protocol/Abuse Investigation and Reporting reviewed on 1/2024 documented residents have the right to be free from abuse to include protecting resident from abuse from other residents. The administration would implement measures that addressed factors that may lead to abusive situations, identify and assess all possible incidents of abuse, protect residents during abuse investigations, and implement changes to prevent future occurrences of abuse. If an investigation involved a resident's behavior, revisions in care plan were completed with an appropriate evaluation. Resident to resident interactions would then be monitored. 1) Resident #28 had diagnoses including mood affective disorder, bipolar disorder (a mental health condition that causes extreme mood swings), and dementia without behavior disorder. The 12/21/2023 Minimum Data Set assessment documented the resident had moderately impaired cognition, exhibited no behavioral symptoms, and required moderate to maximal assistance for all activities of daily living. The comprehensive care plan, revised 1/14/2024, documented the resident had verbally and physically aggressive behaviors that included hitting another resident and throwing food. They had resident to resident altercations on 10/13/2023 and 1/14/2024. Additional Interventions included: - intiated 10/13/2023 remove the personal grabber (reacher) from the resident's room and apply a stop sign up at the resident's room door. - initiated 10/15/2023 30-minute safety checks - initiated on 1/14/2024 15-minute safety checks and a stop sign up at the resident's room door. The 10/13/2023 incident report completed by Licensed Practical Nurse #36 for a resident-to-resident documented Resident #28 intentionally struck another resident with their personal item grabber when the other resident came into Resident #28's room and was touching items on Resident #28's bedside table. The interventions from the incident summary report registered nurse supervisor #16 included to put a stop sign up on Resident #28's door, to keep the residents apart in common areas, to place Resident #28 on 30-minute safety checks, to educate Resident #28 to call for help if another resident wandered into their room, and to remove Resident #28's personal item grabber. The 1/14/2024 incident report completed by registered nurse supervisor #16 for a resident-to-resident documented another resident, not Resident #14, wandered into Resident #28's room and was touching Resident #28's items on their bedside table. Resident #28 hit the other resident in the head with their room phone. The interventions from the incident report included to put a stop sign up on Resident #28's door, to keep the residents apart in common areas, to place Resident #28 on 15-minute safety checks, and to educate Resident #28 to call for help if another resident wandered into their room. The interventions initiated were similar to the 10/13/2023 incident interventions. The 10/15/2023 physician's order documented nurses were to do a behavior note every shift. The treatment administration record documented the behavior notes were not completed consistently on every shift each month. The January 2024 certified nurse aide care record documented Resident #28 was on 15-minute safety checks. The following were the only 15-minute safety checks documented: -On 1/14/2024 four times in a row the 15 minute safety checks, which all stated 7:57 PM, one time which stated 8:13 PM, four times in a row the 15 minute safety checks, which all stated at 9:01 PM, one time which stated 9:20 PM, and which stated at 10:39 PM. -On 1/15/2024 at 2:22 AM, 11:25 AM, 4:34 PM, and 11:41 PM. -On 1/16/2024 at 10:41 AM, 6:35 PM, and 11:26 PM. -On 1/17/2024 at 12:07 PM and 5:39 PM. -On 1/18/2024 at 1:39 AM, 12:01 PM, and 3:45 PM. -On 1/19/2024 at 12:27 AM, 9:20 AM, 3:37 PM, and 11:42 PM. -On 1/21/2024 at 8:23 AM, 4:35 PM, and 11:49 PM. -On 1/22/2024 at 8:28 AM, 3:47 PM, and 11:21 PM. -On 1/2023/2024 at 12:24 PM and 9:39 PM. -On 1/2024/2024 at 1:48 AM and 12:58 PM. The following observations were made of the resident's stop sign: - On 01/22/2024 at 7:55 PM, was not across the doorway with the door open and the resident was in bed. - On 01/24/2024 at 2:12 PM, was down on the floor, not across doorway, with the door open and the resident in bed. At 2:26 PM, certified nurse aide #23 took the stop sign down to exit the room with a resident lift device, re-entered the room, then exited the room and did not replace the stop sign. Stop sign was hanging down on ground. At 2:31 PM, the stop sign was still down. At 2:47 PM, certified nurse aide #24 left the resident's room after answering their call light and the stop sign remained down. -On 01/25/2024 at 6:14 AM, Resident #28's door was closed with no stop sign over door. Additionally, from 12:55 PM until 5:09 PM, several staff members walked by the residents door with the stop sign down and did not replace it or put is up across the door as care planned. Those staff that walked by the resident's room with the stop sign down and did not replace it included an unidentified laundry staff member, an unidentified certified nurse aide, the Social Services Director, certified nurse aide #24 and #22, licensed practical nurse #19, licensed practical nurse #1, and the Administrator. The following observations were made of the resident's personal item grabber: -On 1/22/2024 at 6:38 PM, the resident had a personal item grabber on their nightstand within reach. -On 1/25/2024 at 11:32 AM, the resident had a personal item grabber on their nightstand within reach. The following continuous observations were made of the resident's door and room on 1/25/2024: -From 9:26 AM, when certified nurse aide #24 left the resident's room with breakfast tray and shut resident's door, to 10:48 AM no nursing clinical staff had opened the resident's door or entered resident's room for 15-minute safety checks. -From 10:48 AM, when certified nurse aide #25 went into resident's room and left within the same minute with linens in hand, to 11:32 AM no nursing clinical staff had opened the resident's door or entered resident's room for 15-minute safety checks. -From 1:22 PM, when certified nurse aide #25 left the resident's room, to 1:40 PM, no nursing clinical staff entered resident's room for 15-minute safety checks. During an interview on 1/22/2024 at 6:42 PM, Resident #28 stated they recently had an altercation with another resident who wandered into their room. They stated they warned the other resident verbally and by hitting their table with their phone. They stated the other resident left then came back and started going through their stuff. Resident #28 stated they hit the other resident in the head with their phone because they were going through their stuff. Resident #28 stated staff told them the other was hard of hearing and Resident #28 could not hit other residents. Resident #28 stated they would do it again because that resident was going through their stuff. During an interview on 1/25/2024 at 3:45 PM, certified nurse aide #22 stated stop signs were supposed to be always across resident the resident's door. If the stop sign is down, staff should put it back up. They stated Resident #28 has a stop sign due to two resident-to-resident altercations. They stated if the stop sign was down and a resident-to-resident occurred, the staff would be liable due to not following the care plan. They were unaware of any restrictions Resident #28 had regarding their personal item grabber. They should follow the care plan as the residents could get hurt if the staff does not follow the care plan. During an interview on 1/25/2024 at 4:10 PM, licensed practical nurse #1 stated the stop signs should always be across a resident's door. They stated if the sign was down, a staff member should check the resident's room to make sure nothing had happened while the sign was down and then put the sign up. They stated the stop signs were a bright color for a reason. If a resident got confused and went into a room that wasn't theirs thinking it was, they could hurt the actual occupant of the room. They stated that Resident #28's stop sign had been taken down totally due to no resident-to-resident altercations and then put back into place about a week ago. They were unaware of any restrictions Resident #28 had regarding their personal item grabber and state they knew the resident had one. They stated staff should always follow the resident's plan of care to ensure resident safety. During an interview on 1/26/2024 at 9:31 AM, certified nurse aide #29 stated on 1/14/2024 they had witnessed another resident had wheeled themselves into Resident #28's room. Resident #28 was yelling at the other resident to get out of their room. Certified nurse aide #29 stated when they walked into the room as Resident #28 threw their room phone at the other resident. The base of the phone had remained in Resident #28's hand and the receiver of the phone struck the other resident in the head. Certified nurse aide #29 stated Resident #28 had a stop sign at the time of the incident but did not know if it was up prior to the other resident rolling into Resident #28's room. During an interview on 1/26/2024 at 9:39 AM, registered nurse Unit Manager #20 stated a resident's stop sign should always be up even if the door was shut. Registered nurse Unit Manager #20 was unaware if Resident #28 should have their personal grabber or not. They stated if it was care planned that the resident's personal grabber was removed, they should not have it. They stated care plans were updated in an interdisciplinary team meeting quarterly, annually, and as needed. During an interview on 1/26/2024 at 11:22 AM, Director of Nursing stated a resident's stop sign should be always across a resident's doorway, especially if a resident has remained in bed all day. If a staff member was to come across a downed stop sign, they should put it back up. This applied to all staff members. They stated they were unaware if the original personal grabber for Resident #28 was removed and then provided back. They stated if the resident was provided the personal item grabber back, the care plan should have been updated. 2) Resident #14 had diagnoses of vascular dementia with agitation, hypertension (high blood pressure), and chronic obstructive pulmonary disease (lung disease). The 11/24/2023 Minimum Data Set assessment documented severely impaired cognition, exhibited physical and verbal behavioral symptoms, moderate assistance for most activities of daily living and moderate assistance for wheelchair mobility and management. The 10/13/2023 incident report completed by Licensed Practical Nurse #36 documented Resident #14 had entered Resident #28's room and was hit in the head with a personal item grabber by Resident #28 when the resident did not hear the Resident #28's directive to leave. Resident #14 sustained a laceration to the head. Resident #14 was placed on 30-minute safety checks and was to be kept apart from Resident #28 in common areas. The comprehensive care plan, revised 1/21/2024, documented the resident had exhibited behavioral symptoms which included being physically aggressive, throwing objects, and resident to resident altercations. The resident had 10 documented resident to resident altercations on: 1/31/2023, 2/25/2023, 3/12/2023, 3/25/2023, 7/16/2023, 7/17/2023, 9/18/2023, 9/19/2023, 10/13/2023, and 12/7/2023. The interventions included 15-minute safety checks from the incident dated 7/17/2023, 30-minute safety checks from the incident dated 10/13/2023, and 15-minute safety checks from from the incident dated 12/7/2023. Psychiatric-Mental Health Nurse Practitioner #34's note dated 12/11/2023 documented the resident had an altercation where they attacked another resident on 12/7/2023 which caused both residents to fall with injury to the other resident. The resident had shown increased agitation with their wandering. The resident did not participate in dicussion with Psychiatric-Mental Health Nurse Practitioner #34. They recommended a medication increase for management of agitation and aggression with dementia. The 12/7/2023 incident report completed by registered nurse supervisor #37 documented the resident had entered another resident's room and an altercation occurred which resulted in a fall for both residents. Resident #14 was sent out to the hospital for evaluation. There was no documented evidence the resident was on a current safety check or that the safety checks were being completed. The following observations were made of Resident #14: -On 01/22/2024 at 8:06 PM, they were laying in bed alone, no staff around. -On 01/23/2024 at 8:41 AM, they were sleeping in bed on a bare mattress, no staff around. At 11:04 AM, they were sleeping in bed on a bare mattress, no staff around or have checked on resident. -On 01/24/2024 at 2:19 PM, they were laying in bed alone, no staff around. During an interview on 01/22/24 08:06 PM, Resident #14 had not wanted to engage in questions. During an interview on 1/25/2024 at 3:45 PM, certified nurse aide #22 stated that certified nurse aides were supposed to make a direct observation of a resident who was on safety checks at the interval specified. They were unsure if any resident was on 15-minute safety checks currently. They stated the safety checks were documented by the certified nurse aides in the electronic medical record. They stated the task for certified nurse aides turned yellow every 15 minutes when a resident was on 15-minute safety checks, so it triggered the certified nurse aide to document. If the safety checks were not completed, it could be a safety issue for the resident or other residents. During an interview on 1/25/2024 at 4:10 PM, licensed practical nurse #1 stated currenlty there were no residents on 15-minute safety checks. They stated if a resident was on 15-minute safety checks, the nurses have a check list to make sure they were adhered to. They stated 15-minute safety checks should be done every 15 minutes but there were different degrees of urgency based on the reason for the safety checks. They stated if the safety checks were not conducted, a lot could happen as a lot of the residents are naturally confused. During an interview on 1/26/2024 at 9:39 AM, registered nurse Unit Manager #20 stated 15-minute safety checks were conducted by rounding on the resident and the staff had to have make a direct observation of a resident. They stated certified nurse aides should document in the electronic medical record every 15 minutes when a resident was on 15-minute safety checks. They stated that if a resident was removed from safety checks, it should have been removed from their care plan. They stated Resident #14 should have had the safety checks removed from their care plan. If an intervention was no longer applicable to the resident or resident situation, it should have been removed from the care plan, so the staff had a clear directive of the resident's plan of care. During an interview on 1/26/2024 at 11:22 AM, Director of Nursing stated the certified nurse aides should document in the electronic medical record at the time interval the safety check is designated. The certified nurse aides should make a direct observation of a resident when a safety check was conducted. They stated if the safety checks were not conducted, it could have a negative impact on the resident. The care plan should also be updated when a safety check was no longer applicable to a resident. They stated Resident #14 should have had the safety checks removed from their care plan after they were completed. If the care plan was not updated, it could cause confusion with the staff and the care for that resident. 10NYCRR 415.4(b)

Based on observation, record review, and interviews during the recertification survey conducted 1/22/2024-1/26/2024, the facility did not ensure a resident received respiratory care consistent with professional standards of practice for 1 of 1 resident (Resident #11) reviewed. Specifically, Resident #11 had a physician order for 2 liters of oxygen and received 1.5 liters and was observed not wearing oxygen as ordered. Findings include: The facility policy Oxygen Administration reviewed 1/2024 documented staff were to verify there was a physician order for oxygen. Staff should review the physician's orders and the resident's care plan to assess for any special needs; check the tubing connected to the oxygen cylinder to assure it is free of kinks; place appropriate oxygen device on the resident (mask, nasal cannula, nasal catheter) and adjust the oxygen delivery device so that it was comfortable for the resident and the proper flow of oxygen was being administered. Resident #11 had diagnoses including acute respiratory failure with hypoxia (low oxygen levels in the blood), congestive heart failure (heart does not pump blood efficiently), and chronic obstructive pulmonary disease (lung disease). The 12/10/2023 Minimum Data Set assessment documented the resident was cognitively intact and required oxygen therapy. The comprehensive care plan revised 7/6/2023 documented Resident #11 had an alteration in cardio-vascular function related to hyper/hypotension (high and low blood pressure), atrial fibrillation (abnormal heart rhythm), and congestive heart failure. Interventions included to administer medications as ordered, assess oxygen needs and provide oxygen as ordered by the physician, monitor blood pressure and vital signs, and offer for resident to go back to bed after meals for rest periods. The 1/2024 resident care instructions documented critical supplies for the resident included oxygen. The 1/19/2024 physician #15 orders documented oxygen at 2 liters per minute via nasal cannula every shift, check oxygen tank level every 4 hours, and change oxygen tubing weekly on Monday night shift. During an observation on 1/23/2024 at 10:05 AM, Resident #11 was sitting in their wheelchair with a portable oxygen tank attached to the back of their chair and nasal cannula tubing in their nose. The dial on the oxygen tank was set at 1.5 liters, the nasal cannula was twisted near their neck, and the tank was almost empty. At 11:40 AM, the resident was sitting in their wheelchair with a portable oxygen tank attached to their chair. The oxygen tank dial was set at 1.5 liters per minute. The oxygen tank gauge needle was almost in the red refill area of the gauge. During an observation on 1/24/2024 at 2:20 PM, Resident #11 was transferred via mechanical lift into their bed and assisted with toileting needs. At 2:32 PM, the resident was transferred back to their wheelchair and their oxygen nasal cannula tubing was not applied. The oxygen tubing was observed lying towards the back of the wheelchair near the right wheel. During an interview on 1/25/2024 at 3:17 PM, certified nurse aide #10 stated the resident required oxygen. If the resident's oxygen tubing was displaced and was not on the resident, they would go and get a nurse for assistance. They stated certified nurse aides were not allowed to handle oxygen or the tubing. During an interview on 1/26/2024 at 8:27 AM, licensed practical nurse #13, stated the resident was dependent for care and oxygen needs. The physician order for the resident's oxygen was for 2 liters, nurses were responsible to check the oxygen and the tubing and to ensure it was on the correct flow rate. If the tank was set to 1.5 liters that was not the correct amount. Certified nurse aides were only allowed to check the tank to see if it was full or empty and they should notify a nurse if the resident required assistance with their oxygen. During an interview on 1/26/2024 at 9:49 AM, licensed practical nurse Unit Manager #14 stated the resident was dependent on oxygen and their physician order documented 2 liters. They stated nurses were responsible for the resident's oxygen orders. 1.5 liters was not the correct amount of oxygen for the resident and the risk of the resident not receiving the ordered amount of oxygen could result in their blood oxygen levels decreasing and they could develop shortness of breath and end up in the hospital. During an interview on 1/26/2024 at 10:44 AM, the Director of Nursing stated licensed nurses were responsible for residents on oxygen as it was a medication order. The resident had significant cardiovascular medical conditions, was dependent on oxygen and their physician order was for 2 liters per minute. If the resident's oxygen tank was set to 1.5 liters, they would not receive the prescribed amount of oxygen and the resident could develop shortness of breath and their blood oxygen levels could decrease. Oxygen tubing should also be properly placed on the resident so they would receive the oxygen therapy. 10NYCRR 415.12 (k)(6)

Based on record review and interview during the abbreviated survey (NY00296649), the facility failed to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation of an alleged violation was in progress for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1 alleged a staff member was rough during care and the resident sustained a skin abrasion. The staff member was not removed from access to Resident #1 or other residents following the allegation, and the resident's injury was not assessed timely. Findings include: The facility policy Abuse Prevention Program/Abuse and Neglect-Clinical Protocol/Abuse Investigating and Reporting revised 1/2022 documented: - All reports of alleged mistreatment, neglect, abuse, or misappropriation of resident property or exploitation would be responded to immediately and an intervention would be initiated. - The nurse would assess the individual and document related findings. - Staff would protect residents from harm during the investigation. - If an investigation involved an employee, the employee would be suspended pending outcome of the investigation. - All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source should be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Resident #1 had diagnoses including diabetes, chronic obstructive pulmonary disease (COPD, lung disease), and polyneuropathy (peripheral nerve damage). The 4/26/22 Minimum Data Set (MDS) assessment documented the resident had intact cognition and required extensive assistance of one for bed mobility and personal hygiene, and extensive assistance of two for toileting and dressing. The comprehensive care plan (CCP) initiated 4/21/22 documented the resident required assistance with activities of daily living (ADLs) related to limited mobility. Interventions included encourage the resident to fully participate possible with each interaction and provide extensive assistance of one with the trapeze bar for bed mobility. The 5/27/22 at 1:40 AM Incident Report initiated by licensed practical nurse (LPN) Supervisor #5 documented: - Resident #1 had an approximate 4-inch abrasion to the front right hip. The resident stated it happened when the certified nursing assistant (CNA) was changing their brief and the brief was pulled/yanked out from under them with the tape stuck to their skin. When it was pulled away, it left a 4-inch abrasion. First aid was not administered, and the physician was notified in the morning, with no time specified. - LPN Supervisor #5's statement documented Resident #1 reported CNA #2 responded to their call bell and the resident stated they needed to be changed. The CNA pushed the resident over instead of waiting for the resident to roll themselves and yanked the brief from under them, with some of the tape stuck to their side leaving an abrasion. The CNA was rushing and was rough with the resident. The CNA stated they were working alone and left the room. The CNA left wet soaker pads under the resident and the resident was not wiped or cleaned. The resident stated they were afraid and hesitant to ring the call bell again in fear it would be CNA #2 to respond. The resident put the call bell on, and CNA #6 came in. The resident told CNA #6 they did not want CNA #2 to step foot in their room again. CNA #6 cleaned Resident #1 and ensured they were comfortable. Resident #1 was very upset and wanted something done. - CNA #6's statement documented they entered Resident #1's room and noted the resident was on their side and asked if everything was all right. The resident stated CNA #2 just changed them and they were uncomfortable. CNA #6 checked the resident and noted their brief was halfway on the resident and when adjusting it, found a clump of stool on the resident's vagina and rectum but the brief was completely clean. The resident stated to CNA #6 that CNA #2 rushed out and was not professional and asked that CNA #2 not come back in their room. - There was no statement from CNA #2 included in the report. The 5/27/22 at 2:33 AM nursing progress note entered by LPN Supervisor #5 documented the resident had a 4-inch abrasion to the right hip. The resident stated it happened when the CNA yanked/pulled the brief from under them when the tape was still stuck to the resident's skin and left a sore. There was no documentation related to notification of the Director of Nursing (DON), a registered nurse (RN), medical provider, or that an assessment or treatment was provided. There was no documented evidence CNA #2 was removed from resident access following the abuse allegation. CNA #2's timecard documented they clocked in on 5/26/22 at 10:51 PM and clocked out on 5/27/22 at 7:00 AM. The 5/27/22 at 1:00 PM physician progress note did not include documentation related to the allegation of abuse or the skin abrasion to the resident's right hip. The 5/27/22 at 1:27 PM progress note entered by DON #3 documented the resident was evaluated for an abrasion to the anterior right hip caused by the brief. The area was 0.5 centimeter (cm) x 4 cm (upon clarification, this was in inches). No other areas were noted at the time. The undated Event Summary/Conclusion completed by DON #3 documented on 5/27/22 at 1:40 AM, Resident #1 reported to a staff member that CNA #2 was rough while removing the resident's brief causing a 4 cm (upon clarification, it was noted to be inches, not cm) abrasion to the right anterior hip. The resident stated they were fearful and hesitant to ring their call bell again in fear that CNA #2 would be the one to answer. CNA #2 refused to give a statement and terminated their employment on their own accord via phone in the morning after being asked to go to the facility to provide a statement. The incident was reportable to NYS DOH based on inappropriate physical contact resulting in injury or likely to harm a resident. During an interview with Resident #1 on 12/5/22 at 11:30 AM, they stated when CNA #2 provided care in 5/2022, they were rough with them, and when removing their incontinence brief, they ripped it out from under them with the tape still on their skin. This caused a large skin abrasion of several inches on the resident's hip, and they complained to the staff about the CNA, stating they did not want CNA #2 to ever come back into their room. Multiple attempts were made to contact CNAs #2 and 6 and they were not able to be reached for interviews. During a telephone interview with LPN Supervisor #5 on 1/6/23 at 2:53 PM, they stated they supervised the night shift (11 PM- 7AM) on 5/26-5/27/22. During the night, Resident #1 reported CNA #2 was rough during care. The adhesive from the incontinence brief was stuck to the resident's skin, and CNA #2 ripped the brief out from under the resident instead of rolling them to remove it. This caused a 4-inch abrasion on the resident's right hip. The LPN stated no treatment was necessary and they did not notify the DON. The incident was an abuse allegation against CNA #2. The LPN Supervisor spoke to CNA #2 that night, CNA #2 denied it happened, and the LPN Supervisor told CNA #2 to not go back into Resident #2's room. The LPN Supervisor stated they had not previously addressed abuse allegations although they did have the authority to send staff home during the shift if they felt it was necessary. The LPN Supervisor stated they did not suspend CNA #2 due to not being certain they had sufficient information to suspend the CNA, as they denied the allegation. The LPN Supervisor stated they did not think Resident #1 was wrong and the LPN observed the abrasion on their hip, which was consistent with the size of the adhesive strip of an incontinence brief. The LPN Supervisor reported the incident to DON #3 the following morning. The LPN stated they understood when there was an allegation of abuse, the other residents required protection as well and that CNA #2 worked the rest of the shift and should not have. The LPN Supervisor thought that ensuring CNA #2 did not go back to Resident #1's room was sufficient to protect Resident #1, as they passed the information on to other staff working. The LPN Supervisor stated they were also on a medication cart on another unit that night. The LPN Supervisor stated they did not ensure the safety of the other residents in the facility. They stated as an LPN they could not complete assessments, no assessment was completed at the time, and DON #3 assessed the area the following day. The LPN supervisor stated they began the investigation, obtained statements from Resident #1 and CNA #6 but the investigation was not completed. During a telephone interview on 1/11/22 at 12:56 PM, acting DON #8 stated anytime there was an abuse allegation, the accused staff should be sent home pending outcome of the investigation. It was considered an abuse allegation if there was potential for harm, and if abuse was suspected the supervisor on duty should send the staff member home immediately to protect residents. When abuse was suspected, the supervisor on duty was to notify the DON immediately to report the circumstances and provide information about the resident's condition to receive further instruction. 10NYCRR 415.4 (b)(2)(3)

Based on observation and interview during the recertification survey conducted 8/16-8/19/21, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for the main kitchen, the main dining room and 2 of 2 resident units (A unit and B unit). Specifically, fruit flies were observed on the walls and tiles near the dish washing area in the main kitchen, in resident rooms on A and B units, on ceiling tiles in the A and B Unit hallways, in the main dining room, around the nursing stations, and in nursing offices. This is evidenced by: The facility policy Pest Control dated 1/2021 documented the facility would implement a continuing and effective pest control prevention and monitoring program to maintain the facility as pest and rodent free as possible. A technician from a contracted licensed extermination service will provide periodic and as needed visits to the facility. Monitoring of pest control is part of weekly environmental rounds and follow-up of findings is performed by Building Services, Performance Improvement and department supervisory staff. The following observations were made on 8/16/21: - at 10:00 AM, over 30 fruit flies were in the kitchen, mostly on the walls and ceiling tiles near the dish washing area. - at 11:10 AM, there were over 30 fruit flies on the ceiling tiles in the hall between rooms B2 and B6 on B Unit. - at 11:14 AM, there were 5 fruit flies on the ceiling tiles over the B Unit nursing station and at 12:48 PM there were 2 fruit flies around the B Unit nursing station. - at 1:05 PM, there was a fruit fly landing on Resident #40's sandwich on their bedside table and on snacks located on a shelf in the resident's room located on the A Unit. The following observations were made on 8/17/21: - at 10:27 AM, Resident #62 was lying in bed in their room on the A unit and 2 fruit flies were flying around the resident and their bed. - at 12:00 PM, there were multiple fruit flies observed in the kitchen. - at 12:25 PM, there were fruit flies around the B Unit nursing station. - at 2:00 PM, there were 10 fruit flies in hall near B unit nursing station. - at 2:01 PM, there were two fruit flies in resident room B4. - at 2:02 PM, there was one fruit fly in hall wall outside B7. - at 2:19 PM, during the Resident Council meeting, 2 fruit flies were flying throughout the room. At 2:49 PM, 3 residents stated there had been fruit flies in the facility, it had improved, but the fruit flies continued. One fruit fly was flying through the meeting at the time of the question. The following observations were made on 8/18/21: - at 9:47 AM, there was a fruit fly around the B Unit nursing station with 6 residents seated by nursing station. - at 3:21 PM, 1 fruit fly was flying in the large dining area near the kitchen exit. At 3:34 PM, a fruit fly was in the same area as a resident stood in that location. The following observations were made on 8/19/21: - at 12:34 PM, a fruit fly was in the nursing office on A Unit. - at 12:59 PM, a fruit fly was in the nursing office on B Unit. During an interview on 8/17/21 at 4:35 PM, the Director of Plant Operations was not aware of fruit flies in the facility. The Director of Plant Operations stated that kiosks located in the hallways could access a pest control section in which specific issues could be entered by staff, and once entered could be modified/completed as needed. There had been no fruit fly sighting entries from facility staff since 8/2020. 10NYCRR 415.29(j)(5)

Based on observation, record review and interview during the recertification survey conducted from 8/16-8/19/21, the facility did not ensure 3 of 4 residents (Residents #20, 34 and 74) received the necessary services to maintain good grooming and personal hygiene. Specifically, Residents #20 and 34 were not assisted with timely nail care and shaving and Resident #74 was not assisted with shaving. Findings include: The facility policy Quality of Life-Dignity reviewed on 1/2021 documented residents shall be groomed as they wish to be groomed (hair styles, nails, facial hair, etc.). 1) Resident #34 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/14/21 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired and required supervision with hygiene. The comprehensive care plan (CCP) initiated 4/11/21 documented the resident required supervision with set up help for hygiene. The CCP had no documentation pertaining to the resident's preference for facial hair, plan for nail care, or history of declining/refusing care/assistance. The 8/18/21 care instructions documented the resident required supervision/set up help with hygiene. Staff were to encourage and assist the resident to practice good hygiene. The CNA instructions did not specify the resident's preference for facial hair, nor that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Interdisciplinary progress notes between 8/1-8/18/21 did not document the resident had refused or declined assistance with care. During an interview with the resident on 8/17/21 at 9:35 AM, the resident was observed with long fingernails on both hands with thick dark build up under the fingernails. The resident stated they wanted their fingernails trimmed and cleaned. The resident stated they had asked a staff member to do their nails recently and the staff never came back to do the nails. They stated they did like to be shaved, could shave themself, but did not know if they had a razor available. The resident stated, I need a manicure. The resident was observed with facial hair growth and long, unclean nails on 8/17/21 at 2:05 PM; and on 8/18/21 at 11:35 AM, 2:07 PM, 3:34 PM, and 4:20 PM. During an interview with certified nursing assistant (CNA) #14 on 8/19/21 at 11:20 AM, the CNA stated they had been assigned to the resident on 8/18/21 and gave the resident a shower. The CNA stated when they worked with the resident, they set the resident up with items for self-performance of personal hygiene. The CNA stated the resident did not seem to initiate care on their own. CNAs were responsible for filing and cleaning nails and the nursing staff would clip nails. The CNA stated they had checked the nails during the shower on 8/18 and there was not that much buildup under the resident's nails, and they did not seem long. The CNA stated there was a list at the nursing station that had the resident's scheduled shower days. The CNA instructions did not mention any specifics about resident's preferences for care or behaviors during care. During an interview with CNA #12 on 8/19/21 at 11:36 AM, the CNA stated the resident required a lot of reminders and encouragement with care. The CNA stated the resident needed assistance with upper body hygiene as the resident would not initiate it on their own. Staff were responsible for shaving the resident and checking the resident's nails, as the resident would not ask or approach staff for help with this. During an interview with licensed practical nurse (LPN) #13 on 8/19/21 at 11:45 AM, the LPN stated they had not done nail care or been asked to complete nail care on the resident. During an interview with LPN Unit Manager #3 on 8/19/21 at 12:59 PM, the LPN stated the resident required assistance with care, including shaving. The resident did not have their own razor and staff would have to retrieve a disposable razor. The resident would decline care and staff would have to re-approach or come up with ideas to encourage the resident to accept care. The LPN stated nail care should be done with showers. The LPN stated the resident's record and did not note if the resident refused care or a plan on how to address it if they did. The LPN stated the care plan did state that staff were to encourage good hygiene. The LPN stated if a resident declined care by a CNA the CNA was to notify nursing and then there should be a note in the resident's record that they had declined care. 2) Resident #74 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/23/21 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired and required supervision with set up help with personal hygiene. The comprehensive care plan (CCP) initiated on 4/11/21 documented the resident was independent and required no assistance for personal hygiene. There was no documentation of the resident's preference for facial hair or that the resident refused/declined participation in care. The care instructions active on 8/17/21, documented the resident was independent with hygiene and staff were to encourage good hygiene. Interdisciplinary progress notes dated between 8/1-8/18/21 had no documentation the resident refused or declined participation in care. The activities of daily living (ADL) record documented the resident was independent with personal hygiene on most dates, and supervision with hygiene on 8/15/21. During an interview with the resident on 8/16/21 at 10:50 AM, the resident stated they were able to shave themself, but had not recalled when they last shaved. The resident felt their face and stated, oh I guess I have not done it in a while. The resident stated they used to wear a suit and tie and shave every day and liked to have a clean-shaven face. The resident was observed with a thick layer of facial hair growing on their mouth, cheek, and chin. The resident was observed with long facial hair on 8/16/21 at 3:32 PM and on 8/17/21 at 1:32 PM. During an interview with certified nursing assistant (CNA) #11 on 8/19/21 at 12:02 PM, the CNA stated the resident completed their own care and was able to complete shaving. The CNA stated they had never watched to make sure the resident shaved before. During an observation in the resident's room on 8/19/21 at 12:27 PM there was no available razor in the room. During an interview with licensed practical nurse (LPN) Unit Manager #9 on 8/19/21 at 12:34 PM, the LPN stated the resident required assistance from staff with shaving. The LPN stated a CNA had shaved the resident on 8/18/21, but the LPN was not aware how long the facial hair growth had been before the resident had been shaved. 3) Resident #20 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/24/21 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, felt down depressed/hopeless and required supervision with hygiene. The 4/28/21 comprehensive care plan (CCP) documented the resident required extensive assistance with hygiene. The care instructions, active on 8/17/21, documented the resident required extensive assistance with hygiene. There was no documentation of the resident's preference for shaving or nail care. Interdisciplinary progress notes between 8/1-8/18/21, had no documentation the resident refused/declined care. The certified nursing assistant (CNA) activities of daily living (ADL) record documented provision of personal hygiene with extensive assistance on 8/16-8/18/21. On 8/16/21 at 11:25 AM the resident was observed sitting outside the facility entrance with long, unclean fingernails on both hands and facial hair growth. The resident preferred to discuss topics other than ADLs (activities of daily living). During an interview with CNA #11 on 8/19/21 at 12:02 PM, the CNA stated staff had to provide all care to the resident as the resident was unable to do their own care. The CNAs were responsible for shaving and providing nail care to the resident. The CNA had provided nail care to the resident in the past but had not completed it that week. During an interview with task aide (TA) #10 on 8/19/21 at 12:18 PM, the TA stated staff had to provide all care to the resident as the resident was unable to complete their own personal hygiene. The TA stated they had worked with the resident but had not shaved them. The TA stated they were able to clean the resident's nails, and had, but the resident got their nails dirty after meals. The TA stated they had never trimmed the resident's nails and did not feel they were long when the TA had seen them. During an interview with licensed practical nurse (LPN) Unit Manager #9 on 8/19/21 at 12:34 PM, the LPN stated the CNAs should do nail care at least weekly, unless the resident was diabetic, then a licensed practical nurse (LPN) would cut the nails. The LPN stated if staff were signing off that hygiene and showers were completed, it was expected that would include nail care and shaving. The LPN stated they were aware the resident did not maintain cleanliness during meals and the resident likely got their nails dirty often. The LPN stated the resident would require a plan of care to address the nails more frequently, and that was not currently in place. 10NYCRR 415.12(a)(3)

Based on observation, record review and interview during the recertification survey conducted 8/16-8/19/21, the facility failed to maintain a safe, clean, comfortable and homelike environment for 2 of 2 nursing units (Units A and B). Specifically, observations included damaged walls, different colored paint, dried drips, duct tape on a wheelchair, and spackling on a wall throughout the nursing units and maintenance work orders were not reported or addressed timely. For Residents #34 and 74 the facility did not ensure a homelike environment with personalized décor. Resident #3 continued to reside in a room during repairs to the walls that included sheetrock replacement, mudding, and painting. Additionally, Resident #3's room had loose electrical outlets, loose curtain rods, and missing baseboards that were not repaired timely. Findings include: The undated facility policy Work Order Policy documents in the event there was a need for a repair or general maintenance, staff were to enter the request into the maintenance care application located on the touchscreen kiosks located throughout the building. Examples of items that were to be entered: anything in the resident's room that was in disrepair or broken, anything electrical (cords, personal devices), plumbing issues or damage to walls. Any repairs that take more than two days to complete are to be evaluate by the Director of Plant Operations to determine if the project needs to be outsourced. The facility policy Quality of Life: Homelike Environment dated 1/2021 documents residents are provided a safe, clean and comfortable homelike environment and encouraged to use their personal belongings to the extent possible. The facility shall maximize those characteristics of the facility that reflect a personalized homelike setting including inviting colors and decor and personalized furniture and room arrangements. Resident Equipment During an observation on 8/16/21 at 10:30 AM, the left arm of Resident #53's geriatric chair was ripped/torn. On 8/17/21 at 2:15 PM, the residents left chair arm had duct tape placed over the rip. During an observation on 8/17/21 at 9:10 AM, the back of Resident #56's wheelchair was unclean. During an interview with the Director of Plant Operations on 8/17/21 at 2:15 PM, the Director stated duct tape was not an appropriate way to fix a tear in the arm of a wheelchair. Resident Room/Areas: During an observation on 8/16/21 at 10:45 AM, the main dining room wall corner had a loose corner protector with sharp exposed edges. During an observation on 8/16/21 at 11:20 AM, Resident #8's room had a section of wall near the bathroom that was damaged with exposed corner bead. During an observation on 8/16/21 at 11:50 AM, Resident #12's room wall had a section of wall near the bathroom that was damaged with exposed corner bead. During an observation on 8/17/21 at 9:35 AM and 1:44 PM, Resident #34's wall parallel to the resident's bed had patches of different colored paints and 2 streaks of food particles. There were 6 screws visible in the wall with no attached items. During an observation on 8/17/21 at 9:10 AM, Resident #56's room had multiple unfinished/unpainted spackled areas. At 1:49 PM, Resident #56's room wall had patches of different colored paint, there was sheetrock on one wall that was pulled away from the wall, and there were areas of white spackle. During an observation on 8/17/21 at 9:23 AM, Resident #4's room walls had areas of dried plaster and were unpainted. During an observation on 8/17/21 at 2:06 PM, Resident #76's room had a crack down the wall where the wall settled and paint peeled, from floor to ceiling. The edge of the wall was damaged/cracked. During an observation of Resident #3's room on 8/18/21 at 11:07 AM there were 2 electrical outlets that were visibly loose and able to be pulled out of an interior and exterior wall. There was clear lineage on wall where a new piece of sheet rock had been placed in an L shape and approximate 5 feet at base and from floor to six feet in height. There were dry patches on the wall and mudding along edges. The baseboard was missing the full length of the interior wall, and approximately a foot into the exterior wall, under the television. The resident's bed was pulled away from the wall about 3 feet. The curtain was off from the hook on the curtain rod. The resident stated they had some water in their room that morning, but the facility had started working on their room about a month prior. They stated the facility had not worked on it in sometime and they were living in the room while it had been worked on. At that time there was dripping from the casing over the ceiling pipes. During an observation on 8/19/21 at 10:30 AM, Resident #3's room smelled of paint fumes. The resident's interior wall was newly painted and 1 electrical socket was now tight to wall, and the other was now a solid plate, tight to the wall. The resident stated the facility staff had come in that morning and painted their room. The curtain remained off the hook and the resident stated no one had tried to adjust that before. The resident stated they had remained in the room that morning during repairs. A maintenance work order documented as created on 7/29/21 to repair a leak above the TV in Resident #3's room. The Director of Plant Operations noted on the order, dated 7/30/21, the room needed to be taped and mudded, a couple gaps here and there, and we are going to need an oversized place cover for the left wall. Please try to get the first coat on tomorrow. There were no additional work orders for the resident's room until 8/18/21 at 12:45 PM. The 8/18/21 work order documented a socket under the TV was out of the wall and the air conditioning was dripping on the floor. The work order did not document disrepair of additional outlets, missing wall paint and baseboards. During an interview with the Director of Plant Operations on 8/17/21 at 4:45 PM, the Director stated they were not aware of the damage to the main dining room and Residents #4, 8, 12, 34, 56 and 76 rooms. The damage was not reported in the facility kiosk used for maintenance requests. The Director stated these issues should have been entered using the facility kiosks located throughout the facility. During an interview with the Director of Plant Operations on 8/19/21 at 11:00 AM, they stated two work order tickets were entered on 8/18/21 for the resident's room. The Director of Plant Operations noticed an electrical outlet was out of wall, the air conditioning unit was on, and both windows were open. The Director stated there was a leak in Resident #3's room last week, and new sheetrock was put up/seamed and completed last week on Monday. The wall was prepped and ready for paint. The Director of Plant Operations thought there was a ticket for the original leak repairs. During an interview with the Maintenance Supervisor on 8/19/21 at 12:00 PM, they stated there were work orders put in for the Resident #3's room repairs. The Supervisor stated that a few new staff members had asked how to use the work order ticket system and were shown how to use it. All the repair issues should have been entered using the facility kiosks located throughout the facility. During an interview with certified nurse aide (CNA) #11 on 8/19/21 at 12:02 PM, they stated Resident #3 completed most of their own care and the CNA only brought meal trays into the resident. The CNA had not noticed any maintenance or work needed on the resident's room. The CNA stated if a resident needed something fixed, there was an electronic tablet to enter work orders for maintenance. The CNA stated they had not done this for Resident #3's room. During an interview with licensed practical nurse (LPN) Unit Manager #9 on 8/19/21 at 12:34 PM, they stated maintenance had been completing work on Resident #3's room for a while and they did not know why. The Manager stated the resident had been residing in the room while maintenance continued to work on the room, as there had not been another room to move the resident to. Maintenance had worked on the wall a couple weeks ago and finished it a week or two ago. The Manager stated at one point there had been plastic on the wall while the sheetrock was changed. They stated they had not put in a ticket until yesterday because of sockets coming out of the wall in the room. Homelike Environment Resident #74 had diagnoses including dementia and major depressive disorder. The 7/23/21 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired and required supervision with most activities of daily living. The 1/31/21 comprehensive care plan (CCP) documented staff were to provide the resident with a homelike environment, visible clocks, a calendar, low glare light, and familiar objects. An 8/9/21 physician progress note documented to stimulate the resident both mentally and physically to maintain highest functional level. An 8/11/21 psychiatry progress note documented the resident found pleasure in framing pictures as this was the resident's business in the past. During an interview on 8/16/21 at 10:50 AM, the resident stated they used to enjoy photography and framing photos. The resident stated they used to have photos hanging in their room at home and they liked having photos and decorations on the wall. The resident's room was observed with 3 empty/undecorated walls and two 8-inch paper butterflies hanging on the center of one wall. The resident's room was observed with the same limited decorations/personalization on 8/19/21 at 12:27 PM. During an interview with certified nurse aide (CNA) #11 on 8/19/21 at 12:02 PM, the CNA stated they had not noticed the lack of decorations in the resident's room. During an interview with task aide #10 on 8/19/21 at 12:18 PM, the task aide stated the resident had never mentioned their room and the task aide had not noticed. The task aide was not aware of a process in the facility to notify anyone if a resident needed personalization to their room. During an interview with licensed practical nurse (LPN) Unit Manager #9 on 8/19/21 at 12:34 PM, the Manager stated the concierge, and the Director of Activities were responsible for ensuring room personalization. The Manager stated they had not been notified the resident's room lacked personalization. During an interview with the Director of Activities #8 on 8/19/21 at 12:52 PM, the Director stated residents were able to bring in their own decorations. If they did not, families could bring items in. Sometimes the activity department was able to purchase or locate items to personalize resident rooms. The Director had not been notified the resident's room lacked a home-like environment and they would have liked to be notified so they could make the resident's room more, homey. 10NYCRR 415.5(h)(1)(j)(1)

Based on record review and interview during the recertification survey conducted from 8/16/21-8/19/21, the facility failed to ensure that residents who require [CONDITION(S)] (a process of purifying the blood of a person whose kidneys are not working normally) receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident (Resident #42) reviewed. Specifically, the facility did not maintain ongoing communication and collaboration with the [CONDITION(S)] facility regarding Resident #42's [CONDITION(S)] care and services and proper infection control precautions required for the resident. Findings include: The facility policy [CONDITION(S)] revised 1/2021 documents the facility will maintain a communication log with the respective [CONDITION(S)] centers on all its residents who go out for [CONDITION(S)] in order to communicate the resident's needs and response to the [CONDITION(S)] treatments. Inter-facility communications will be tracked and followed up on. Resident #42 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Diff; a highly infectious bacteria causing inflammation of the colon). The 6/29/21 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance with most activities of daily living (ADLs), was occasionally incontinent of urine and frequently incontinent of bowel, was on a therapeutic diet, received insulin and a diuretic (water pill) and received [CONDITION(S)]. The 6/11/21 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A 6/14/21 physician history and physical documented the resident was on an antibiotic for C. Diff. There was no documentation between the facility and the [CONDITION(S)] center regarding the resident's scheduled [CONDITION(S)] day on 6/14/21. There was no documentation the [CONDITION(S)] center was notified of the resident's C. Diff diagnosis. There was no documentation of communication between [CONDITION(S)] and the facility on scheduled [CONDITION(S)] days of 6/30, 7/2, 7/5, 7/12 and 7/14/21. The 7/16/21 [CONDITION(S)] communication form had no documentation by the facility. The [CONDITION(S)] center requested the facility send the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/16/21 at 11:49 AM nursing progress note documented licensed practical nurse (LPN) Unit Manager #3 spoke with the [CONDITION(S)] charge nurse about a better communication system and that LPN Manager #3 found 5 communication folders in the resident's bag as the resident did not turn the forms in to the facility. The note documented LPN Unit Manager #3 made the [CONDITION(S)] charge nurse aware the physician removed the resident from precautions (contact). The 8/16/21 at 2:10 PM nursing progress note documented the resident was placed back on antibiotics until 8/26/21. There was no documentation the resident's [CONDITION(S)] forms were uploaded into the electronic record or nursing communication with the [CONDITION(S)] center. When interviewed on 8/18/21 at 9:54 AM, LPN Unit Manager #3 stated the resident was sent to each [CONDITION(S)] appointment with a communication form and any returned forms were uploaded into the resident's electronic chart. The LPN stated resident concerns would be communicated via telephone with the [CONDITION(S)] center and should be documented in a progress note. When interviewed on 8/18/21 at 11:03 AM, [CONDITION(S)] center charge nurse #7 stated resident communication should be done on communication forms and the center did not receive them on a routine basis. The charge nurse stated she was unaware the resident was on contact precautions, and special procedures would have been in place to prevent the spread of infection. When re-interviewed on 8/18/21 at 11:49 AM, LPN Unit Manager #3 stated the facility had just found 5 folders with communication forms in the resident's [CONDITION(S)] bag, the forms were given to medical records to scan, the physician was called, and the resident was going to be taken off precautions. The Manager stated the process with the [CONDITION(S)] communication forms was for the facility night staff to send the resident's [CONDITION(S)] folder with any communication forms to [CONDITION(S)] on each treatment day, and the center was to call with questions. Upon the resident's return, the resident was supposed to hand the folder to the receptionist for scanning and processing. The receptionist was to ask for the folder if the resident did not provide it. The form went in a unit mailbox at the reception area for the LPN Unit Manager to review and ensure the physician saw it. Nursing was to ensure the physician reviewed the form and it was then filed. The LPN Unit Manager stated the Manager was to review the form to ensure any changes were acted on. The LPN Unit Manager was unaware of any [CONDITION(S)] center issues, did not ask the receptionist if the forms were returned, and had not called the [CONDITION(S)] center to inquire why the forms were not being returned with the resident. When interviewed on 8/18/21 at 12:41 PM, night shift registered nurse Supervisor (RNS) #4 stated communication with [CONDITION(S)] was done via phone or a form in the resident's packet. The resident's communication form was sent with the resident to [CONDITION(S)] by the night shift nurse and the LPN Unit Manager was supposed to check the packet when the resident returned from treatment. When interviewed on 8/19/21 at 12:29 PM, receptionist #5, who also worked in medical records full time, stated the receptionist was to get the [CONDITION(S)] communication folder from each resident coming back from [CONDITION(S)] or a consult, the forms were to be copied by medical records and put in the appropriate mailboxes behind the reception desk. The receptionist was to ask for the folder if not given by the resident. The receptionist stated multiple communication forms for Resident #42 were scanned on 8/18/21 that had not been done so prior. The receptionist stated the facility had not been getting the communication forms from the resident on a routine basis. The receptionist had not asked why the forms were not being returned or scanned. When interviewed on 8/19/21 at 12:58 PM, the Director of Nursing (DON)/Infection Preventionist stated LPN Unit Managers were expected to read, look at recommendations and follow up with any consult forms and [CONDITION(S)] communication forms. The DON expected the nurses to document in the resident's progress notes any recommendations and [CONDITION(S)] communication. The DON expected the Managers to report to her if communication forms were not being returned to the facility for processing. The DON stated the communication forms were necessary to provide continuity of care for the resident and for prevention of the spread of a disease, such as C. Diff, which was highly contagious. 10NYCRR 415.12(k)

Based on observation, record review, and interview during abbreviated surveys (NY 637 and NY 8) the facility did not provide the necessary services to residents to maintain good grooming and personal hygiene for 6 of 11 residents reviewed (Residents #3, 15, 25, 26, 27, and 28). Specifically, Residents #3 and 15 were not provided with timely incontinence care and Residents #25, 26, 27, and 28 were not assisted with timely bed changes when needed. Findings include: 1) Resident #3 had [DIAGNOSES REDACTED]. The 5/24/20 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition and required total assistance of 2 staff for toileting and bed mobility. The comprehensive care plan (CCP) dated 7/22/20 documented the resident had bladder incontinence related to a past [MEDICAL CONDITION] (stroke) and decreased ability to communicate the need for toileting. Interventions included to check for incontinence and change the resident every 3 to 4 hours. The 8/20/20 certified nurse aide (CNA) care instructions documented the resident was dependent on 2 staff for toileting and required extensive assistance of 1 person for personal hygiene. The following observations of the resident were made on 8/17/2020: - At 10:15 AM, the resident was in bed, calling out help, help. The resident was wearing a hospital gown. - At 11:01 AM, the resident's call bell was on. - At 11:06 AM, a staff member entered the resident's room, left the room, and two staff entered together and quickly left. The resident was calling out help, help. - At 11:09 AM, the resident was calling out help, help and there was a strong fecal odor near the doorway of the room. A nurse entered the room and quickly left. - At 12:28 PM, the resident's call bell was on. - At 12:52 PM, the resident's call bell was off. - At 12:59 PM, the resident's call bell was on. - At 1:02 PM, CNA #15 delivered the resident's lunch tray and quickly exited the room. The resident's roommate was entering the room as CNA #15 was leaving and asked if Resident #3 was okay as she was hooting earlier. The CNA's response was not heard. - At 1:12 PM, the resident stated loudly pee pee and look to the surveyor and pointed to the lower half of their body. The incontinence pad under the resident was soaked with a large brown stain down to the mid-thigh, up beyond the hips, and extending out from the body several inches. The side of the resident's incontinence brief was showing, and the resident pointed to it. The stain on the incontinence pad had a urine odor. - At 2:10 PM, the resident was calling for help and could be heard from several rooms away. The resident was in the same position as they were at 1:12 PM with a large brown stain under their body. The surveyor tried to talk to the resident and the resident stated no, no, no. The resident was crying, there was a strong odor of urine in the room, and the resident's call bell was on the floor. The resident remained in a hospital gown. On 8/17/2020 at 3:43 PM, the surveyor asked licensed practical nurse (LPN) Manager #19 to observe the resident. LPN Manager #19 stated the resident needed to be changed. The resident was observed with the same brown, large stain under their body, the incontinence pad was soaked, and there was a urine stain under the resident from above the hip, extending almost to the edge of the bed pad. Immediately following the observation, the surveyor checked the CNA documentation for the day and there was no documentation that care was provided to the resident during the day shift. On 8/17/20 at 3:45 PM CNA #15 stated in an interview, she did not provide any care to the resident today during her shift which started at 7 AM. She stated there were only 2 CNAs working so they did not have specific residents they were assigned to care for. The resident required assistance of 2 for cleaning and changing. She did not know if the resident's call bell was on during the day. She brought the resident a lunch tray and said the call bell was not on at that time. On 8/18/2020 at 10:05 AM, LPN #26 stated in an interview, the resident was able to call for help and used her call bell. The resident did not call out for no reason, they usually said pee which meant the resident needed to be changed. The LPN stated if the resident's bed pad was visually wet, the resident should be changed. In an interview with LPN Manager #19 on 8/18/2020 at 2:37 PM, he stated when he observed the resident with the surveyor, the resident was soaked and had a urine stain spreading out from the incontinence pad beyond their body. The area of wetness was large and the LPN Manager stated the resident was not changed in a while. The resident had on a brief that was soaked through. LPN Manager #19 stated there were 2 CNAs on the unit that day so there were no specific staff assignments. The CNAs came in at 7 AM and were working together to get everyone up. He stated all residents should be checked every 2 hours. The resident was dependent on staff, heavily incontinent, and would holler out for help. He stated the resident should have been changed if she was hollering out for help. 2) Resident #15 had [DIAGNOSES REDACTED]. The 2/8/2020 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance of 2 staff for bed mobility, transfers and toileting and was frequently incontinent of urine and bowel. The 1/10/2020 comprehensive care plan (CCP) documented the resident required assistance with activities of daily living (ADL) related to mobility, pain, weakness, history of falls, and impaired cognition. The resident needed extensive assistance from two staff with toileting. Statements obtained by the facility documented on 2/10/2020: - Unit helper #27 reported the resident was ringing the call bell, had diarrhea, and needed to be changed. The unit helper informed the certified nurse aides (CNA) the resident needed help and they were busy with other residents. - CNA #28 reported she did not hear the resident calling for help as she was helping other residents at the time. When she responded to the resident's call bell, she learned the resident was waiting for help for a long time. - The Activities Director reported at approximately 10 AM, she heard the resident ringing the bell and calling for help as the resident needed to be cleaned and had an accident. She told the CNAs and they were helping another resident at that time. At 10:30 AM, the resident was yelling and banging on the overbed table. The speech language pathologist (SLP) went to the resident's room and said she would find someone to help. At 10:45 AM, the Activities Director heard the resident calling for help and she told the CNAs who were busy with other residents. The resident was helped about 10-15 minutes after that. On 2/11/2020, the Ombudsman Coordinator reported to the New York State Department of Health (NYS DOH) that on 2/10/2020: - the resident called their office at 10:20 AM and reported they was screaming and ringing the call bell since 9:50 AM as they had diarrhea and needed help. - The resident reported they had a manual call bell as the call bell system at the facility was not operational at that time. - The resident screamed loudly help me for 2 minutes while the Ombudsman Coordinator remained on the phone. A non-nursing staff member entered the room and stated they were trying to find help for the resident. - The resident yelled for help on and off for 20 minutes and at 10:43 AM, another non-nursing staff member entered the room and said they would find help. - At 11 AM, the resident yelled for help and one of the non-nursing staff members returned to the room. - At 11:05 AM, a person who identified themselves as a nurse came into the room and spoke with the Ombudsman Coordinator. She stated the staff could not hear the resident was calling for help and help was being provided. - The Ombudsman Coordinator was on the phone with the resident for 50 minutes before care was provided. On 2/14/2020 at 11:25 AM, the Ombudsman Coordinator stated in an interview, she reported her concerns to the Administrator. On 2/26/2020 at 3 PM, the Administrator stated in an interview, the facility's call bell system was down for a few weeks in 2/2020 and was repaired on 2/20/2020. He stated when the system was down, residents were given tap bells and placed on hourly checks which were documented. He stated the Ombudsman Coordinator reported the resident's concern about call bell response time. He stated the resident's call bell was not unattended as activities staff and rehabilitation staff responded to the call bell. He stated normally he conducted a full investigation when the ombudsman reported complaints to him but in this case he did not as he did not feel the resident's timeline was accurate. The Director of Nursing (DON) was present during the interview and stated she obtained statements from the staff working at the time of the incident and gave them to the Administrator. The surveyor requested the documentation on the resident for 2/10/2020. On 2/26/2020 at 3:45 PM, the resident stated in an interview, on the day of the incident, the resident rang their call bell and waited and waited when they needed to be changed. The resident stated it took a long time to get help that day and this also happened on other days too. On 2/26/2020 at 4 PM, the DON stated in an interview, she could not locate documentation that hourly rounds were completed for the resident's unit on 2/10/2020. On 8/17/2020 at 10:09 AM, the resident was observed lying in bed. She brought up the time in 2/2020 when she had diarrhea and waited a long time to be changed. On 8/20/2020 at 12:16 PM, unit helper #27 stated in an interview, the resident complained a lot about not being assisted when needed. She remembered when the resident had a manual call bell and answered it when it rang. Since she was not a CNA, she had to tell one of the CNAs the resident needed help. She stated at the time of this incident, the CNAs were busy helping other residents. On 8/20/2020 at 12:43 PM, the Activities Director stated in an interview, on the day of the incident, she could hear the resident's call bell because her office was right near the resident's room. She did not know how long the resident waited and the resident told her it was 45 minutes. 3) Resident #25 had [DIAGNOSES REDACTED]. The 7/27/2020 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition and required extensive assistance for bed mobility, transferring, and dressing, and limited assistance with toileting and personal hygiene. Resident #26 had [DIAGNOSES REDACTED]. Resident #27 had [DIAGNOSES REDACTED]. The 7/6/2020 MDS assessment documented the resident had moderately impaired cognition and required extensive to total assistance with ADLs. Resident #28 had [DIAGNOSES REDACTED]. The 7/6/2020 MDS assessment documented the resident had moderately impaired cognition and required limited assistance with bed mobility, transferring, ambulation, and dressing. On 8/17/2020 between 11:05 AM and 11:10 AM, the following was observed: - Resident #25 was lying in their bed and there were no sheets on the bed. The resident was awake. - Resident #26 was asleep in their bed and there were no sheets on the bed. - Residents #28 and 28 were sitting in wheelchairs next to their beds and their beds had no linens on them. On 8/17/2020 at 2:50 PM, certified nurse aides (CNAs) #15 and 18 stated in an interview, the planned staffing was for 4 CNAs on the unit and on this day, there were 2 CNAs. They stated when they came in at 7 AM that day, many residents had not been assisted overnight, their beds were soaked, and they needed full bed changes. They stated they stripped the beds and cleaned the residents up but did not have time to put sheets on the beds. In an interview with licensed practical nurse (LPN) Manager #19 on 8/18/2020 at 2:37 PM, on 8/17/2020 there were 2 CNAs working on the unit. He stated they came in at 7 AM and were working together to get everyone up in time for breakfast. 10NYCRR 415.12(a)(3)

Based on observation, record review and interview during the recertification survey the facility did not ensure all residents received care, consistent with professional standards of practice, to promote healing, and prevent new pressure ulcers from developing for 2 of 4 residents (Residents #3 and 52) reviewed for pressure ulcers. Specifically, Resident #52 developed a pressure ulcer and interventions were not implemented timely, there was no monitoring by qualified professionals of the area, and the pressure ulcer worsened. Resident #3 did not have interventions in place to prevent pressure ulcers from developing, the resident was not turned and repositioned, did not have skin assessments by qualified staff, and the resident developed a pressure ulcer that worsened. This resulted in actual harm to Resident #52 which was not immediate jeopardy. Findings include: The 2011 Preventing Pressure Sores policy documents by reporting and documenting the first stages of pressure sores, early treatment can facilitate quicker healing and prevention of infection. The procedures included: observing skin every shift, reporting any changing, keep resident clean and dry, reposition residents in bed every 2-3 hours or as designated, notify therapy and dietary to evaluate resident if signs of possible alteration in skin integrity appears. The 2011 Skin Care Program policy documents a care plan will be developed to reflect preventative skin care measures. Should an area develop, the care plan will be reviewed and revised to address the break in skin integrity and the interventions initiated to promote healing. The 11/2017 Turning and Repositioning Residents policy documented an effective way to prevent pressure injury is by moving and changing position frequently. The frequency of turns should be individualized to your resident including such factors as resident's tissue tolerance, level of activity and mobility, general medication condition, overall treatment objectives, skin condition and comfort. 1) Resident #52 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 09/13/18 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired; required extensive assistance for bed mobility and was totally dependent on staff for dressing, toilet use, and personal hygiene. The resident was incontinent of bowel and bladder, at risk for pressure ulcers, did not have any unhealed pressure ulcers and had a device to her bed and chair for pressure ulcer treatment. The 09/12/18 physician orders [REDACTED]. The 09/13/18 Braden Scale (used to predict risk for pressure ulcer development) documented the resident was at high risk for pressure ulcer development. The 09/19/18 comprehensive care plan (CCP) documented the resident was at risk for impaired skin integrity and pressure ulcer development related to impaired mobility, incontinence, and fragile skin. The resident required total dependence on staff with dressing, bathing, toilet use and hygiene, and extensive assistance with bed mobility. Staff were to turn and reposition per facility protocol, use a lifting device and draw sheets to reduce friction. The 09/20/18 and 09/27/18 Braden Scales documented the resident was at low risk for pressure ulcer development. A 09/22/18 licensed practical nurse (LPN) progress note documented there were two red areas on the resident's coccyx and one in between her legs, no open areas, and barrier cream was applied. physician's orders [REDACTED]. The 10/2018 treatment administration record (TAR) documented starting 10/02/18 at 07:00 AM to cleanse the open area on the buttocks with soap and water, apply silicone dressing every AM and prn for skin breakdown. The 10/02/18 nurse practitioner (NP) progress note documented the resident had an open area on the sacrum which was being followed by the wound care nurse. There was no further documentation regarding the resident's open area following this date by any medical provider. The weekly nursing skin checks had no documentation they were completed between 09/06-10/02/18. On 10/03/18 and 10/10/18 the licensed practical nurse (LPN) documented there were no new skin alterations. The 09/2018 and 10/2018 certified nurse aide (CNA) activities of daily living (ADL) record documented the resident was to have a skin observation on shower days every Wednesday on the 03:00 PM-11:00 PM shift; the resident was to have extensive assistance with bed mobility, and was totally dependent on staff for toilet use. There was no documentation that toilet use was provided to the resident on each shift on 10/6, and 10/09-10/14/18. There was no documentation the resident was provided bed mobility on each shift as planned on 10/6 and from 10/10-10/14/18. The 10/2018 certified nurse aide (CNA) care instructions documented the resident's brief was to be checked and changed every 3-4 hours and as needed. Staff were to check for skin impairment every shift and report any changes. Turning and repositioning was to be provided per facility protocol by using a lift device/draw sheet to reduce friction. The care instructions noted the resident CAN NOT assist with rolling on and off the lift sheet and required the use of a mechanical lift. During an interview on 10/15/18 at 02:31 PM, CNA #23 stated there was a policy to reposition residents every two hours but she usually moved Resident #52 more frequently. She stated the resident was incontinent of urine and stool so they would have to put her back in bed to change her. The resident should go back to bed in the morning to be changed but that did not always happen because of interruptions. She stated the resident had an open area on her coccyx that she acquired at the facility not very long ago but she could not remember the exact date. She stated when she noticed a new skin area she reported it to the nurse. She stated she told four LPNs and two RNs before something was ordered. During an interview with registered nurse (RN) Unit Manager #8 on 10/15/18 at 03:20 PM, she stated she did not know if the resident had current open areas. She stated the resident had a physician order [REDACTED]. She stated LPN #5 was documented as entering the order. She stated there was no documentation the area was assessed by an RN or qualified professional. She stated a weekly skin check was completed by a LPN on 10/03/18. She stated she did not know why the order was implemented on 10/01/18. She stated if the wound nurse saw the resident's skin area a note or evaluation would have been entered, and there was not one in the resident's record. She stated CNAs were to apply protective barrier cream on any resident that was incontinent and the resident may have a cushion in place on her chair. She stated if a resident had an open area the consulting Wound physician would see the area, he was here the week prior, and did not see the resident. The RN reviewed the CNA documentation in the computer and stated staff were to provide extensive assistance with bed mobility which meant turning and assisting the resident from side to side. She stated this was not documented as being completed each shift on 10/06, 10/11, 10/12, 10/13 or 10/14. She stated staff should toilet the resident between 2-4 hours and the CNA. She stated she did not recall if she spoke with the wound nurse regarding the resident, she was not sure if she would have documented it, and she did not recall if a CNA reported an open area on the resident to her or not. She stated the treatment order was entered by a LPN who cannot assess skin wounds and the resident should have been assessed by a RN. On 10/15/18 at 04:00 PM, the resident was observed resting in bed. She was turned on her side and a sponge dressing was removed from her coccyx (lower end of spine) by RN Unit Manager #8. There was a moderate amount of bloody and straw-colored drainage on the old dressing. Stool was dried onto the skin surrounding the area. RN Unit Manager #8 assessed the wound as an Unstageable pressure ulcer (the base of the wound is not visible) with slough (moist, dead tissue). The wound measured 2.8 centimeters (cm) long x 3.5 cm wide x 0.1 cm deep. There was also a deep tissue injury (deep red maroon or purple discoloration usually extending into tissue) located near the coccyx that had an open area measuring 1.0 cm x 1.0 cm. The area resembled a blood blister similar in size to the end of a thumb. The RN stated she was going to call the provider for new treatment orders. A mosaic air cushion was observed in the resident's wheelchair. During an interview with the facility's wound nurse, RN #37, on 10/15/18 at 04:14 PM, she stated she had not been notified of any skin areas for Resident #52. She stated if the resident had been seen by an RN it would be entered in the electronic record. RN #37 reviewed the electronic record and stated there was no documentation by an RN that the resident had an open area that had been assessed. She stated the LPNs were completing routine weekly skin monitoring. If any staff found a skin area there was a form that had been implemented by the facility in the past that would document the location and a copy of the form was put in to members of the interdisciplinary team mailboxes so that the resident could be reviewed during morning report. The RN reviewed the electronic record and stated the resident had an order in place that included a silicone dressing being applied to the area. She stated it was important to be notified of new skin areas so that the interdisciplinary team could come up with a plan on how to address it. She stated she had no documentation or referrals for the resident and the resident had not come up in morning report. She stated a CNA should report skin concerns to an LPN if they find an open area, if they were not getting a response they are to follow up with the RN Unit Manager or herself. During a telephone interview with physician #41 on 10/15/18 at 04:31 PM, he stated he could not recall the specifics of the initial order for the silicone dressing on 10/01/18. He stated if the resident's skin continued to have further breakdown he should have been notified so that the wound care physician could see the resident and make recommendations for treatment to promote wound healing. The resident should have been assessed, monitored and followed by qualified staff and it was not timely that the area was not observed by a RN until 10/15/18. He stated if he had been notified an order could have been implemented for a treatment measure that could have been better suited to heal the resident's skin. During a telephone interview with LPN# 6 on 10/15/18 at 04:41 PM, she stated the resident had an order in place for a silicone border dressing near her coccyx area. The dressing was initially ordered in the beginning of 10/2018. When she was assigned to the resident in 10/2018 the resident had an open area. She asked the RN Unit Manager to come in and assess the area. She stated a skin treatment was started the same date. She stated after this the resident was to be changed and placed back to bed after both meals or one meal. The LPN stated there were no scheduled times to position or toilet the resident. The resident would often ask to go back to bed related to discomfort with positioning, and she did not have a positioning device for her chair. 2) Resident #3 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 09/29/18 Minimum Data Set (MDS) assessment documented the resident was severely impaired cognitively. She required extensive assistance of two or more staff for bed mobility, total dependence for transferring, eating, toileting and bathing, and extensive assistance of one staff for personal hygiene. The resident was always incontinent of bowel and bladder. The resident was risk for developing pressure ulcers and there were no pressure ulcers stage I or higher. The 10/05/18 comprehensive care plan (CCP) documented the resident was risk for pressure ulcer development related to/ impaired mobility. Interventions included minimizing extended exposure of skin to moisture by providing frequent incontinence care and promptly removing wet/damp clothing or sheets as needed and turning and repositioning per facility protocol. The resident was at risk for impaired skin integrity related to fragile skin, impaired mobility and incontinence. The interventions were keeping skin dry, clean and well lubricated, applying protective/preventive skin care, and observing skin weekly during shower on Tuesdays. A 09/24/18 registered dietitian (RD) nutrition assessment documented the resident had a wound with a pin hole sized opening to the right rear iliac crest (lower lateral bony prominence on the back). The 09/22/18 physician order [REDACTED]. The 10/01/18-10/31/18 treatment administration record (TAR) documented that the resident did not receive the [MEDICATION NAME] once on 10/07/18 and twice on 10/10/18. The TAR documented weekly skin checks were completed by licensed practical nurses (LPNs) on 09/25/18, 10/02/18, and 10/09/18 with no new findings. The resident was observed lying in bed on her back on 10/10/18 at 10:25 AM, 11:55 AM, 12:04 PM, 03:26 PM, and 05:05 PM with no changes to her positioning. On 10/11/18, the resident was observed positioned in bed on her back at 10:34 AM, 12:04 PM, and 12:22 PM. On 10/11/18 at 12:22 PM certified nurse aide (CNA) #14 was observed providing care to Resident #3. The resident's incontinence brief and saturated gown were removed. The resident had reddened skin visible in the labia folds and creases by the thighs. These were not washed by the CNA. The resident had an area on the right iliac bony prominence that was discolored, similar in size to a postage stamp with a hole in the skin similar in size to a pencil eraser. No protective ointment or creams were applied. The resident was placed in a brief and positioned on her back. CNA #14 stated she was going to get help to get the resident out of bed and exited the room. During an observation on 10/11/18 at 02:39 PM and 04:02 PM the resident was observed lying in bed on her back sleeping. During interviews on 10/11/18 at 12:22 PM and 02:47 PM, CNA #14 stated she never saw the wound on Resident #3's lower back before. She stated that Resident #3 required a Hoyer (a mechanical lift requiring two staff) to get into her recliner. When she went to get help, she stated she was told to go to the dining room and not worry about Resident #3, other staff would take care of her later. She never got the resident out of bed. She stated she did not know if the resident was on a repositioning schedule or a schedule for incontinence care, that she usually just did as she was directed. She also stated she did not know if there was any special positioning for the resident while in bed or where to go to get that information. She was not aware if there was a CNA care card, she was told there was nothing like that. She stated she did not know if Resident #3 required any special cream for her skin, but CNAs could use barrier cream or lotions at any time. During an interview on 10/11/18 at 05:04 PM, RN Unit Manager #8 stated there was no policy for repositioning but it was usually every 2 hours. Staff could look up resident specific information in the plan of care or the task section of the computer. She stated that she was told late that afternoon that the resident had some type of wound on her hip. She told the RN supervisor to go look at it. During an interview on 10/11/18 at 05:15 PM, RN Supervisor #21 stated Resident #3 had a stage II (partial-thickness skin loss) pressure ulcer that measured 1 centimeter (cm) long x 1 cm wide x 0.2 cm deep on the right upper buttock. Orders were obtained to cleanse with soap and water, apply calcium alginate (an absorbent dressing) to the wound bed, then cover with border gauze daily and follow up with the wound care physician. On 10/12/18 from 08:51 to 11:13 AM, Resident #3 was observed lying in bed on her back. During an interview on 10/12/18 at 11:13 AM, LPN #6 stated that the repositioning schedule for residents who needed extensive assistance was in the computer for the CNAs. The CNAs were the ones who repositioned the residents. If the resident wasn't getting repositioned she reported it to the RN. She stated Resident #3 should be repositioned every two hours. Her skin was very frail. She stated she was not told if the resident had any open areas on her skin. She stated the resident might have a dressing ordered but she would have to look it up in the computer. 10NYCRR 415.12 (c)(1)

Based on observation, record review, and staff interviews conducted during the standard survey, it was determined the facility did not ensure the necessary treatment and services were provided to prevent the development of pressure ulcers and promote healing for 1 (Resident #2) of 4 residents reviewed with pressure ulcers. Specifically, the facility did not routinely monitor Resident #2's compromised skin after admission; did not monitor and assess the resident's pressure ulcers in a timely manner; was unaware of new pressure ulcers; did not ensure the resident was assessed by qualified professionals; and did not reassess the appropriateness and effectiveness of the resident's toileting plan, in relation to her coccyx pressure ulcer. This resulted in actual harm that is not immediate jeopardy. Findings include: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The December 3, 2010 Braden Scale (for predicting pressure ulcer risk) documented the resident was at moderate risk for pressure ulcer development and had risk factors including limited sensory perception, moist skin, chairfast status, very limited mobility, probably inadequate nutrition, and the potential for friction/shearing. The December 3, 2010 admission nursing assessment documented the resident had a "dimple" area near her tailbone, and a 1 cm (centimeter) open blister below the "dimple" area on the left buttock. The comprehensive care plan (CCP), initiated on December 3, 2010, did not document the resident's compromised skin areas on her buttocks area and did not document a pressure-relieving mattress was provided. The CCP specified the resident was at risk for skin breakdown; had a pressure relieving cushion for the chair, and was to be repositioned every 2-3 hours and as needed. Review of nursing progress notes between December 4 and 18, 2010 revealed the resident had intermittent confusion, used a bed pan, was occasionally incontinent, and was transferred with a mechanical lift. During this time, there was no documentation the "dimple" area on her tailbone and the "open blister" on her left buttock (identified on admission) were routinely monitored. The CCP, updated December 5, 2010, documented the resident was to be assisted with toileting every 2-4 hours, checked and changed every 2-4 hours, toileted "per schedule," (schedule was not specified), and offered the bed pan when in bed. The December 15, 2010 Minimum Data Set (MDS) assessment noted the resident was cognitively intact, dependent on staff for transferring, frequently incontinent of bowel and bladder, not on a bowel toileting program, required extensive assistance for bed mobility, at risk for pressure ulcers, and did not have a pressure ulcer. On December 18, 2010, a pressure ulcer tracking form was initiated and documented the resident had a 1 cm Stage II pressure ulcer on the right buttock, and a quarter size pink area on the left upper buttock. On the same date, a verbal physician's orders [REDACTED]. There was no documented assessment that specified whether the resident's right buttock Stage II pressure ulcer, and the quarter size area on her left buttock, were the same areas documented on December 3, 2010 admission nursing assessment. The December 18 and 19, 2010 nursing progress notes documented the resident was incontinent of bowel and bladder. The CCP, updated December 18, 2010, documented the resident had a Stage II open area on the right buttock; and a "quarter size" pink area on the left buttock. Treatments were ordered for 7 days, with the plan to be re-evaluated. The CCP documented a referral was given to physical therapy. On December 20, 2010, the CCP documented a Roho cushion was provided to the resident. A December 23, 2010 nursing progress note documented the resident was spoken to about reports of "willful incontinence." The note documented the resident was encouraged to continue to progress towards going home, by requesting the bed pan when needed; the plan was to assist the resident to the bathroom "upon demand." Review of the CCP revealed no documented evidence the resident's plan of care was re-assessed to determine whether the current plan for toileting the resident on the bed pan was appropriate, in view of her documented skin concerns and issues with her continence. The December 24, 2010 nursing note documented the resident was incontinent of urine and used the bed pan for bowels. The December 26, 2010 nursing progress note documented the skin around the open area on the resident's buttock was "pink and irritated." There was no evidence the area was re-assessed by a registered nurse (RN) at that time. The December 27, 2010 nursing progress note documented the resident was incontinent of urine and encouraged to use the bed pan. On December 28, 2010, the wound tracking form documented the areas on the resident' right and left buttocks were merged into 1 open, circular area on the coccyx. There were no measurements documented, the area specified to be a Stage II, with no drainage. On December 28, 2010, an order was written to discontinue the [MEDICATION NAME] and [MEDICATION NAME] treatments and to cleanse the area on the coccyx with normal saline and apply wound gel. The physician signed this order on July 29, 2010. The currently used, undated certified nurse aide (CNA) care sheet (used when providing care and documented in pencil) was updated on December 30, 2010 to specify the resident went to therapy 5 times a week to work on bed mobility, strength, and transferring. The care sheet specified the resident was transferred with a Hoyer lift; required extensive assistance of 1 - 2 for toileting; did not use heel boots and did not have a body pillow. Review of the December 29 and 31, 2010 and January 5, 2011 medical notes revealed there was no documented evidence the physician was notified when the 2 areas on the resident's buttocks merged, increased in size, and were measured as 1 area. A January 9, 2011 licensed practical nurse (LPN) progress note documented the resident developed a new pressure ulcer on the left heel that was described as a dime size, unopened blister. There was no documented evidence a wound tracking sheet was initiated, or that the area was assessed by an RN at that time. On January 9, 2011, the CCP was updated to specify the resident had a "blister" on her left heel. The resident's heel was to by elevated off the mattress and Skin Prep was to be applied every shift. Nursing progress notes, dated January 10 and 11, 2011, documented the resident was incontinent of bowel and bladder and used a bed pan. An undated order, written by an LPN, documented the resident's left heel blister was to be covered with a "dry dressing, after Skin Prep was applied, every shift until opens, then cleanse with normal saline, apply [MEDICATION NAME] dressing and change every 3 days for 10 days then re-evaluate." The physician signed these orders on January 11, 2011. A January 16, 2011 nursing progress note documented the area on the resident's coccyx was soft and "tender." On January 18, 2011, a wound tracking sheet was initiated and documented the resident had an intact blister on the left heel measuring 2 cm x 2 cm. The stage of the blister was not documented. The wound tracking sheet was initiated 9 days after the pressure ulcer was first identified. On January 18, 2011, the wound tracking form documented the resident's coccyx had a Stage II pressure ulcer, measured 5 cm x 3 cm x 0.3 cm (first time depth was measured), and was "moist." The form did not document whether slough was present. During the initial tour of the unit on January 18, 2011 between 10 and 10:25 AM, the LPN Manager told the surveyor that the resident had a Stage II pressure ulcer on the coccyx, and a blister on the left heel, that developed in the facility. On January 19, 2011 at 10:40 AM, the surveyor and a unit LPN observed the resident lying on a foam mattress and found to have 4 pressure ulcers. The resident told the surveyor she was told "last week" that her pressure ulcers were "getting worse". She said her physician "will be furious" when he finds out that "I have a bed sore." The resident said the areas on her coccyx "hurt". The surveyor and unit LPN observed the resident At 10:50 AM on January 19, 2011, the Director of Nursing (DON) entered the resident's room and measured the resident's pressure ulcers, as the surveyor requested. The DON took the following measurements: - the coccyx measured 4.2 cm x 4 cm x 0.2 cm. The DON stated slough was present and she would stage it as a "Stage II leaning towards a Stage III." She stated this was the stage, as she did not know what was underneath the slough (the area was not documented to have slough the prior day and increased in size). - an open area below the coccyx pressure ulcer measured 1.5 cm x 0.6 cm. The DON stated it was a Stage II. There was no wound tracking form documented for this area. - the resident's left buttock measured 1.6 cm x 0.9 cm; and the DON stated it was a Stage II. This area had no documented wound tracking form. - the resident's left heel, was a brown, circular, fluid filled area. The DON stated it was a Stage II, and was not sure what was underneath the blister. The DON stated the area measured 2.7 cm x 2 cm (increased in size from the previous day). The DON was interviewed on January 19, 2011 at 11:12 AM. She stated the resident's heel was a Stage II when it was discovered and remained a Stage II "even though it was darkened." She stated it was facility practice to stage pressure ulcers at the same stage they were as when they were discovered, even if they worsened. She stated for MDS purposes, the heel would be staged higher than a Stage II, as it was darkened. The DON said a newly hired RN and the LPN Manager completed skin rounds "yesterday". When the surveyor asked, the DON stated the RN and LPN had not completed competencies at the facility in pressure ulcer assessments. She stated the LPN could measure pressure ulcers, but could not assess them. The DON stated she was unaware someone told the resident last week that her pressure ulcers were worse. On January 19, 2011 at 12:45 PM, the DON was re-interviewed and stated the resident was admitted with "dimpling" on the buttocks/coccyx area, and said the area opened on January 18 or 19, 2011. She stated the "dimpling" area was not tracked as it was "not an area of concern." The LPN Manager, who was present during this interview, stated skin rounds were done weekly, or every other week, and could be done without measuring wounds. The LPN Manager said if the pressure ulcers were not measured during skin rounds, the LPNs doing the treatments would measure the areas. When the surveyor asked the LPN why the resident's pressure ulcers were not measured between December 18, 2010 and January 18, 2011, she did not respond. The DON stated the resident's areas could have worsened as she had "no motivation" to get out of bed, and liked to be incontinent on herself. She stated the resident was toileted on demand. On January 19, 2011 at 1:17 PM, when the MDS RN was interviewed, she stated she "eye balled" the resident's pressure ulcers on December 28, 2010 and did not measure them. She stated she did not measure the areas, as she was told (sometime around December 2010) that she was not to attend wound rounds anymore, as she was to focus on other job responsibilities. Upon request, on January 19, 2011 at 2:20 PM, the DON provided a copy of the facility's "Skin Care Policy". This policy was dated to be "effective December 2010". The DON stated they were trying to fully implement the policy throughout the facility. The policy documented a "pressure reduction mattress will be utilized on beds." At 2:40 PM on January 19, 2011, the facility provided the requested specifications of the resident's mattress. The mattress was determined to be a "Global Pressure-Reducing Foam Mattress", designed to keep the skin "cool and dry". There was no documentation when this mattress was provided to the resident; no current staff were able to state when this mattress was implemented for this resident. On January 19, 2011, a Toilet Schedule Flow Sheet and a turning schedule were initiated and filed with the resident's CNA documentation. The CNA care sheet was updated on January 19, 2010, and documented in pencil that the resident was to be toileted every hour, was to have her heel elevated off the mattress and was to have a Roho cushion. On January 20, 2011 at 8:10 AM, the resident's CNA told the surveyor that the resident was not on a toileting schedule, as she needed to be lifted with a mechanical lift. The CNA stated the resident was offered a bed pan every 2 hours. On January 20, 2011 at 9:40 AM, the DON provided the surveyor with a communication sheet she sent to the registered dietitian (RD) on January 19, 2011. The form documented "buttocks/coccyx - no improvement - now 3 areas with yellow slough." On January 20, 2011 at 12:05 PM, the surveyor conducted a telephone interview with the physician. The physician stated he was unable to answer questions related to the resident's pressure ulcers, as he did not have the medical record in front of him. In summary, Resident #2 experienced harm with the development of 4 pressure ulcers that increased in size and severity (presence of slough), as: - the facility did not monitor the "dimple" area on "her tailbone" and the open blister on the left buttock. - after the resident developed 2 pressure ulcers that merged into one, the facility did not routinely assess and monitor these areas. - the facility was unaware 2 additional pressure ulcers developed on her coccyx, and did not ensure these areas were assessed and treated in a timely manner. - the facility did ensure a registered nurse, or other qualified professionals assessed the resident's heel pressure ulcer timely. - the facility did not monitor the resident's heel pressure ulcer until 9 days after it was discovered. - the facility did not re-assess the resident's plan for toileting by using a bed pan, in view of her skin breakdown on the coccyx area. The facility did not ensure the resident was consistently transferred to a toilet. 10 NYCRR 415.12 (c)(1) (2)

Based on record review and staff interviews conducted during the standard and abbreviated survey (#NY 097), the facility did not ensure the resident received appropriate treatment and services to prevent urosepsis from developing for 1 (Resident #10) of 6 residents reviewed for infections. Specifically, when Resident #10 experienced abnormal urinary tract symptoms, the facility did not ensure the resident was assessed by the RN or another qualified professional, when she exhibited lethargy, feelings of "generalized" illness, frequent bloody drainage in her incontinence brief, and an episode of vomiting. The facility did not notify the physician timely of the resident's lethargy, blood clots, and gross hematuria; and did not ensure the resident's urine was obtained and submitted timely for testing in July 2010. The resident subsequently developed urosepsis (a secondary infection spread through the blood stream) and was hospitalized . This resulted in actual harm that is not immediate jeopardy. Findings include: Resident #10 had [DIAGNOSES REDACTED]. The resident's comprehensive care plan (CCP), dated December 31, 2009, specified the resident had a urinalysis (U/A), with a culture and sensitivity (C&S). The results specified the bacteria Eschericia coli (E. Coli) was present. The plan was not to treat the resident, as she was asymptomatic. On March 25, 2010, the CCP was updated and documented the resident's Foley catheter was discontinued, with no evidence of retention. The June 2, 2010 "Care Plan Interdisciplinary Progress Note" documented the resident was incontinent of bowel and bladder; and on a toileting schedule of ever 2-4 hours as needed. The resident's Minimum Data Set (MDS) assessment, dated June 3, 2010, documented the resident had moderately impaired cognition; needed extensive assistance with toileting and personal hygiene; and was incontinent of urine and stool. The resident's last physician note in her medical record was dated July 23, 2010. The physician documented the resident "has been doing quite well at her baseline which is that of worsening dementia." The plan was to adjust her medical regimen as her condition and labs dictate." A licensed practical nurse (LPN) progress note, dated July 23, 2010 at 3:30 PM, documented 2 family members reported their concern regarding the resident's lethargy. The LPN documented the registered nurse (RN) was "aware". The LPN note specified a "hat" (urine collection device) was placed in the resident's room to get a urine sample. There was no documented evidence the physician was notified of the resident's lethargy and family's concerns, and no documented evidence the RN assessed the resident at that time. When the surveyor interviewed the licensed practical nurse (LPN) on January 20, 2011 at 1:40 PM, he stated he did not remember Resident #10. The LPN read his nursing progress note (dated July 23, 2010) and stated he notified the RN, and thought the RN was "handling" it. The LPN stated the RN no longer worked at the facility and unavailable for interview. The 24-hour report, dated July 23, 2010 for the day shift, documented the resident's urine was needed for a dip stick (detects urine abnormalities). The 24-hour report dated July 24, 2010, for the day shift, documented the resident's urine was needed for a dip stick; and if the results were positive, the urine was to be sent to the laboratory (lab) for a U/A with a C&S. There was no documented evidence the physician was notified of the resident's symptoms. The 24-hour report dated July 25, 2010, did not contain any information relating to the resident. There were no nursing notes documented in the resident's medical record on July 24, 2010 or July 25, 2010. Nursing notes, dated July 26, 2010 at 12:15 PM, and a physician's telephone order, dated July 26, 2010 at 12:15 PM, documented staff may straight catheterize the resident to obtain a urine sample; if dip stick is positive, the resident's urine specimen was to be sent to the lab for a U/A with a C&S. An LPN nursing note, dated July 26, 2010 at 9:15 PM, documented the resident had a "positive dip" after urine specimen was obtained (via straight catheterization); and specified "obtained UA and C&S." The note documented they would "call the lab to pick up". The 24-hour report, dated July 26, 2010 for the evening shift, documented the resident's urine specimen was in the refrigerator and was to be picked up in the morning. The surveyor interviewed the Director of Nursing (DON) on November 20, 2011 at 11:35 AM. She stated she was unaware the resident's family had concerns the resident was lethargic on July 23, 2010. The DON stated she expected a U/A and C&S to be done as soon as possible after they were ordered. She said there was no definitive time frame that specified when to notify the physician if a urine sample was unable to be obtained from the resident. The DON stated it usually took between 24 and 48 hours. The 24-hour report dated July 27, 2010, for the day shift, documented the resident's U/A C&S were pending. There were no nursing notes dated July 27, 2010 that addressed the resident's pending UA and C&S. The resident's urinalysis report, dated July 28, 2010, documented the resident's urine was collected on July 26, 2010 at 9:15 PM; was received by the lab on July 28, 2010 at 2:50 PM; and the results were verified at 3:05 PM on July 28, 2010. The urinalysis findings, faxed to the facility at 3:30 PM that afternoon, documented the resident's urine was red, cloudy, and had a large amount of blood and leukocytes (white blood cells) present. There was no documented evidence the physician was notified of the urinalysis results; and no documented evidence the resident's CCP was updated. (The physician signed this UA report on August 3, 2010.) When the surveyor re-interviewed the DON on January 20, 2011, she stated that without looking at the resident's medical record, she did not know why it took from July 23, 2010 until July 26, 2010 to obtain a physician's orders [REDACTED]. The DON stated she did not know the reason a physician's orders [REDACTED]. During an interview with the physician on January 20, 2011 at 12:15 PM, he stated if he ordered a U/A and C&S, he expected he would be notified within 24 hours, if a urine sample was not obtained. The resident's urine culture results were faxed to the facility on [DATE] at 2:01 PM. The results specified the bacteria Proteus mirabilis was present. (The physician signed this C&S on August 3, 2010.) A nursing note, dated July 31, 2010 at 4 PM by a registered nurse (RN), documented the resident's "urine C&S (was) reviewed with" the physician; "ordered [MEDICATION NAME] (antibiotic), 250 mg for 5 days. An order was documented by RN, dated July 31, 2010 at 4 PM, documented the resident was to start 250 mg [MEDICATION NAME] daily for 5 days. (The order was signed by the physician on August 3, 2010.) An LPN note, dated August 1, 2010 at 2:40 PM, documented the resident's temperature was 97.3 degrees and specified an antibiotic was started the previous day. On August 2, 2010 at 3:32 AM, an LPN note documented the resident's temperature was 96.8 degrees; and noted the resident had a small amount of bloody drainage on the evening shift. There were no notes by an RN that documented the resident was assessed during that time. The LPN progress notes, dated August 2, 2010 at 1 PM documented the resident continued on the antibiotic, and specified a CNA (certified nurse aide) reported the resident had a moderate amount of bloody drainage in her incontinence brief. The note specified this information was reported to the RN. The resident's temperature was 97 degrees. There was no documented evidence an RN assessed the resident at that time. There was no documented evidence the physician was notified of the resident's new symptom. On August 3, 2010 at 3:55 AM, an LPN progress note documented the resident's temperature was 96 degrees. The note specified the resident had "bloody drainage noted." There was no documented assessment by an RN at that time. On August 3, 2010 at 2:30 PM, an LPN progress note documented the resident's temperature was 98 degrees and specified the resident "complained of feeling generalized sick". The note documented the resident had a moderate amount of bloody drainage in her incontinence brief. There was no documented RN assessment of the resident's status. An LPN progress note, dated August 4, 2010 for 6 PM to 6:30 AM shift, documented the resident had a small amount of bloody discharge in her incontinence brief. The resident's temperature was 97.6 degrees. The nursing note, dated August 5, 2010 for the 10:30 PM to 6:30 AM shift, documented the resident's temperature was 98 degrees, and a small amount of bloody drainage was noted in her incontinence brief. The note specified the resident "was restless" with pericare. On August 6, 2010 at 3:50 AM, the LPN note documented the resident's temperature was 95.3 degrees. The note specified the resident had a small amount of bloody drainage during the evening shift and "moderate amounts on this night shift." There was no documented assessment by the RN and no documented evidence the physician was notified. The next nursing note was dated 1:45 PM on August 6, 2010, documented the resident's temperature was 97.6 degrees, and she presented with lethargy. The note specified the physician gave an order to obtain a UA and C&S. A telephone physician's orders [REDACTED]. At 2:25 PM on August 6, 2010, an LPN progress note documented it was reported the resident had moderate amount of bloody drainage found in her incontinence brief; and specified "supervisor aware." There was no RN assessment documented at that time in the resident's medical record. The LPN nursing note, dated August 6, 2010 at 4:00 PM, documented the physician was called as the resident had "gross hematuria" (blood visible in the urine) when staff catheterized the resident. The note documented the physician wanted the urine processed "stat" (immediately); ordered [MEDICATION NAME] (antibiotic) intramuscularly (IM) for 3 days; staff were to push fluids; and if signs or symptoms of dehydration occurred, the resident was to be transferred to the hospital. At 6:30 PM, the LPN documented the resident was administered the IM antibiotic. At 10:30 PM, the LPN noted the resident's temperatures were 96.6 and 97.2 degrees, and specified the resident vomited a large amount. There was no documented RN assessment during this time. An LPN progress note, dated August 7, 2010 from 11:30 PM to 6:30 AM, documented the resident's hematuria continued, and her temperature was 95.9 degrees. An LPN note, dated August 7, 2010 at 7:35 AM, documented that a physician was called at 6:45 AM regarding the resident's condition. The resident's temperature was 95.1 degrees, she had a large amount of blood clots in her brief; her respirations were shallow; her skin was pale; and her skin was mottling. Nursing notes documented the resident was sent to the emergency room at 7:00 AM. The "Physician Certification of Medical Necessity for Ambulance Transportation" form, dated August 7, 2010 and signed by the LPN, documented the resident was treated for [REDACTED]. (Nursing staff who documented progress notes dated August 2 through August 6, 2010 related to the resident's daily bloody drainage in her incontinence brief, her generalized ill feeling on August 3, 2010 and her lethargy on August 6, 2010, were unavailable for interview, as they no longer worked at the facility.) The hospital's triage sheet, dated August 7, 2010, documented the resident's symptoms started 2 weeks prior transfer to the emergency room . The sheet specified the resident had a UTI at the nursing home, completed a course of antibiotics 5 days prior to the transfer. The triage sheet documented the resident's urine was rechecked on August 6, 2010; and a urinary tract infection was still present. The resident's symptoms were continuous in nature. The note specified the resident was incontinent, and had hematuria. The resident's emergency room urinalysis documented the resident's urine was red, turbid (thick and cloudy), and contained a large amount of blood. The resident was diagnosed with [REDACTED]. In summary, Resident #10 experienced harm , as the resident developed urosepsis and required hospitalization , as the facility: - did not ensure the resident was assessed by the RN or another qualified professional, when the resident exhibited lethargy; feelings of "generalized" illness, frequent bloody drainage in her incontinence brief; and an episode of vomiting; - did not notify the physician timely of the resident's lethargy, blood clots, and gross hematuria; - did not ensure the resident's urine was obtained and submitted timely for testing in July 2010. 10 NYCRR 415.12(d)(1)