Every finding on record at The Pines at Utica Center for Nursing and Rehab

Based on record review and interviews during an abbreviated survey (iQIES ID# 2648127), the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one (1) of three (3) residents (Resident #1). Specifically, Resident #1 had physician orders discontinuing their Unna boots (gauze bandage soaked in a wound treatment, wrapped from toes to knees that provided compression and remained in place for up to one week) on 10/03/2025, and there was documented evidence the Unna boots remained in place for seven (7) days without an order and without monitoring. On 10/10/2025, the resident complained of left leg pain and upon removal of the Unna boot, they were found with a new open wound on the left outer ankle that contained an infestation of maggots. Additionally, there was no documented evidence the resident's wounds were assessed timely upon admission and no documented evidence a physician ordered treatment was obtained timely.This resulted in harm that was not Immediate Jeopardy for Resident #1. Findings included:There was no documented evidence the facility had a policy that addressed non-pressure injury wounds. The resident had diagnoses including lymphedema (accumulation of lymphatic fluid in the body causing swelling), morbid obesity and difficulty walking. The 09/02/2025 admission Minimum Data Set (a resident assessment tool) documented the resident's cognition was intact; they needed substantial assistance with rolling left and right and partial/moderate assistance with chair/bed-to-chair transfer. The resident had three (3) venous ulcers (open sores that develop on the lower legs due to poor blood circulation). The 08/27/2025 Hospital Discharge Report documented the resident had multiple wounds (the report did not specify type, number, location or treatment). The 08/27/2025 admission Assessment completed by Wound Registered Nurse #1 documented the resident had a skin issue present. There was no documented evidence wound type, number of wounds, or location of wounds were identified, and there was no physician ordered treatment for wounds upon admission to the facility on [DATE]. The 08/27/2025 Comprehensive Care Plan documented the resident had an alteration in skin integrity with venous ulcers. Interventions included: monitor for signs and symptoms of infection, treatments as ordered, and weekly wound evaluations. The 08/29/2025 Skin and Wound Evaluation completed by Wound Registered Nurse #1 documented:- a venous ulcer, right top foot second toe, present on admission, 2 centimeters long x 1.2 centimeters wide, light serous drainage.- a venous ulcer, right front lateral (to the side of) lower leg, present on admission, 13.8 centimeters long x 5.2 centimeters wide, no drainage and intermittent pain.- a venous ulcer, left front lateral lower leg, present on admission, 6.2 centimeters long x 4.2 centimeters wide, no drainage, erythema (redness) in surrounding tissue and intermittent pain. Physician orders documented:- On 08/29/2025, Unna boots to right and left legs. - On 08/30/2025, to right foot (toe) wound, apply Xeroform (wound treatment) and bordered dressing daily.- On 09/01/2025, Unna boots to right and left legs applied every Monday for wound healing. There was no documented evidence the resident's wounds were assessed from 08/30/2025 through 09/23/2025. The 09/24/2025 Skin and Wound Evaluation completed by Wound Registered Nurse #1 and signed on 09/26/2025, documented the resident's left front lateral and right front lateral leg wounds resolved. From 09/24/2025 through 10/02/2025, the resident's physician ordered Unna boots continued as ordered. The 09/2025 Treatment Administration Record documented Unna boots were applied to the resident's left and right legs weekly with the last documented administration on 09/29/2025 by Licensed Practical Nurse #7. The 10/03/2025 physician orders documented to discontinue routine and as needed Unna boots. The notes section of the physician order for Unna boots documented resolved. There was no documented evidence the Unna boots were removed after 10/03/2025. The 10/06/2025 Nurse Practitioner #5 note documented the resident was assessed and observed in their wheelchair with dressings intact to both feet. The 10/07/2025 Skin and Wound Evaluation by Registered Nurse Manager #4 documented the resident's right second toe was assessed. A picture of the resident's right foot was attached to the evaluation. The picture showed the resident's right foot toes to just below the right ankle, and a pink tinged gauze bandage wrapped around the resident's foot (later revealed in interview with Wound Registered Nurse #1 this was an Unna boot). There was no documented evidence of current physician orders in the resident's record for Unna boots on 10/07/2025. The 10/10/2025 Director of Nursing note documented they were called to assess the resident's left lower extremity. It was noted the resident had a new wound to the lateral left lower extremity that was found to have small maggots noted. The site was cleansed with saline and the maggots were removed, however upon removal, more pieces of skin began to peel back and reveal more maggots. The physician was notified, and the nurse practitioner was consulted. The 10/10/2025 Nurse Practitioner #5 Note documented the resident's Unna boots were removed due to increased pain, a new wound was discovered on their left lateral ankle and there were maggots in the wound. The wound was new and due to the Unna boot. The resident was very upset and reported pain level 10 out of ten. The resident was sent to the hospital due to multiple maggots and intractable pain. During an interview on 10/31/2055 at 12:23 PM, Certified Nurse Aide #6 stated the resident had dressings on both legs that went from their knees to their feet. The dressings had to be covered during a shower, so they did not get wet. They cared for the resident on 10/07/2025 and 10/09/2025, and recalled the dressings to both legs were in place when they provided care. On 10/10/2025, they gave the resident a shower and covered both legs to protect the dressings. During an interview on 11/03/2025 at 9:49 AM, Licensed Practical Nurse #7 stated Unna boots were a medicated wrap that stayed in place for a week at a time. The skin below the Unna boot could not be visualized while the boot was in place. On 09/29/2025, they changed the resident's Unna boots and recalled the skin to their legs was intact but scaly. On 10/08/2025, they did a skin integrity check on the resident and believed the Unna boots were in place at that time. During an interview on 11/04/2025 at 10:26 AM, Licensed Practical Nurse #9 stated they worked the day and evening shift on 10/09/2025 (the day before the resident discharged ) and they did a treatment to the resident's right foot second toe on the day and evening shifts. The resident had Unna boots in place to both legs on 10/09/2025. During an interview on 11/04/2025 at 10:10 AM, Licensed Practical Nurse #10 stated on 10/10/2025, the resident complained of pain in the left leg and the resident asked them to remove the leg wrap. They were not sure if the resident's wraps were Unna boots, however, the resident had the same type of wrap also on their right leg. They removed the left leg wrap, noticed an odor and saw an infestation in an open wound on the resident's left outer ankle. They notified Wound Registered Nurse #1, the Director of Nursing, and Nurse Practitioner #5. During an interview on 11/04/2025 at 1:50 PM, Wound Registered Nurse #1 stated during the admissions assessment, the nurse completed a full head to toe assessment and if wounds were found, orders were obtained the same day. The wounds would be documented in the Admissions Report including type of wound, location and measurements. Wounds would be reassessed by a registered nurse every seven (7) to 10 days and they were assessed at that frequency so new wounds were not missed, and current wounds were not worsening. On 08/27/2025, they were not sure why the resident's wounds were not documented and not sure why there were no ordered treatments. Upon admission, they recalled the resident had both legs reddened and swollen with dried peeling skin and a wound on their right second toe. Orders should have been in place within 24 hours of admission. When the resident went from 08/30/2025 to 09/23/2025 without a wound assessment, they stated they were short staffed, and the facility had lost the unit manager during that time frame. On 10/03/2025, they stated both the resident's lower legs healed, and they discontinued the Unna boots. Wound Registered Nurse #1 showed the surveyor a picture taken on 10/07/2025 of the resident's right foot from toes to just below the ankle. The picture showed a pink tinged gauze wrapped around the foot. When questioned, Wound Registered Nurse #1 stated that was an Unna boot. They stated they would not have expected an Unna boot to be in place as there was no physician order for Unna boots. They stated on 10/10/2025, the Unna boot would not have caused trauma to the resident's left outer ankle. They had witnessed the resident scratching at their legs and putting things down the Unna boot to scratch. During an interview on 11/05/2025 at 10:39 AM, Nurse Practitioner #5 stated if a resident had wounds upon admission, they expected nursing to obtain orders within 24 hours. They expected wounds to be assessed by nursing weekly or more frequently if needed. The facility required residents have physician orders for all medications and treatments and that was required because they wanted the correct orders in place. They were not aware the resident went greater than two (2) days without a treatment order, was not aware the resident went four (4) weeks without a documented wound assessment and stated that was not timely. On 10/10/2025, when they documented the resident's wound was due to the Unna boot, they should have said the wound occurred when the Unna boot was on. They heard from staff the resident was non-compliant and messing around with their Unna boot. They were not sure how the resident got an infestation when the Unna boot was in place. They were not aware the Unna boot was discontinued on 10/03/2025 and not aware there was no physician order for Unna boots that were in place on 10/10/2025. 10 NYCRR 415.12

Based on observations, record review, and interviews during the recertification survey conducted 7/16/2025 - 7/22/2025, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five (5) of five (5) residents (Residents #2 #11, #13, #17 and #80) reviewed. Specifically:Resident #11's urinary catheter (drains urine from the bladder) collection bag was directly on the ground without a barrier, and the resident did not have appropriate transmission-based precaution signage posted.Registered Nurse Unit Manager #5 did not wear appropriate personal protective equipment when providing central line catheter (intravenous access site) care to Resident #2.Resident #13 had a urinary catheter and a colostomy (a surgical opening from the bowel for collection of stool) and did not have appropriate transmission-based precaution signage posted.Resident #17 had nephrostomy (drains urine from the kidneys) tubes and a catheter and did not have appropriate transmission-based precaution signage posted.Resident #80 had a contact isolation sign posted on their door with no available gowns and gloves. Housekeeping entered the room without donning gown and gloves.Findings include: Findings include:The facility policy Clinical Services: Precautions to Prevent Infection, revised 6/2024, documented transmission-based precautions were for patients who were known or suspected to be infected or colonized with infectious agents. Enhanced barrier precautions was an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission of infections when contact precautions did not apply. The category of transmission-based precaution determined the type of personal protective equipment and should be readily available at the entry of the room. Residents who had indwelling medical devices such as central lines, urinary catheters would be on enhanced barrier precautions. Gown and gloves were to be worn for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Clear signage was posted on the resident's door indicated type of precaution and required personal protective equipment. Residents with indwelling medical devices or wounds would have enhanced barrier precautions remain in place until resolution of wound or discontinuation of indwelling medical device. The facility policy Clinical Services: Urinary Catheterization, revised 4/2024, documented enhanced barrier precautions are indicated for residents with indwelling catheters. The catheter should be replaced if there are breaks in aseptic technique, disconnections of tubing, leakage from the bag, if catheter becomes contaminated. The drainage bags should always be covered and placed below the level of patient's bladder. The outlet valve must not be contaminated. 1) Resident #2 had diagnoses including osteomyelitis (bone infection) of the right foot/ankle and extended spectrum beta lactamase resistance (a bacteria enzyme resistant to antibiotics). The 6/9/2025 Minimum Data Set assessment documented the resident had intact cognition and had central intravenous access. Physician orders documented: 5/16/2025 resident was to have care done in room due to isolation precautions. 6/4/2025 contact precautions. During an observation and interview on 7/16/2025 at 12:08 PM, Resident #2 had an orange contact precaution sign on their room door and a 3-drawer plastic bin filled with blue gowns, gloves, masks, and shields outside their room. Resident #2 stated nurses usually wore a gown and gloves when they provided wound care but never when they provided care for the central line. At 3:03 PM Registered Nurse Unit Manager #5 performed a central line dressing change without donning a gown. During an interview on 7/22/2025 at 10:09 AM, Certified Nurses Aid #7 stated they knew a resident was on precautions by the sign on the door. The sign informed staff what type of personal protective equipment was needed and when to wear it. For enhanced barrier precautions staff could go into the room without a gown or gloves but needed to put them on if doing hands on care. Resident #2 was on contact precautions, which meant a gown and gloves should be worn every time so that infection did not spread. During an interview on 7/22/2025 at 10:33 AM, Licensed Practical Nurse #4 stated the sign on the resident's door let staff know if the resident was on precautions. The Unit Manager decided who was on precautions and put the sign up. Resident #2 was on contact precautions for an infection in their foot. It was confusing to determine what to wear to go into their room because they had multiple different precaution type signs on their door. They went into the room with just a mask and gloves and put on a gown when they provided care. A gown should be worn every time if the resident was on contact precautions. During an interview on 7/22/2025 at 11:30 AM, Registered Nurse Unit Manager #5 stated Resident #2 was on contact precautions for a wound infection, which meant all staff entering their room were required to wear a gown and gloves. The resident did have multiple precaution signs on their door which was very confusing to staff. Staff may not know what sign to follow, with enhanced barrier precautions staff needed to wear a gown and gloves when providing care, and with contact precautions they needed a gown and gloves every time the room was entered. They stated did not wear a gown and gloves when changing the central line dressing for Resident #2, which increased the risk of spreading infection. 2) Resident #17 had diagnoses including renal abscesses (collection of pus), osteomyelitis (bone infection), and discitis (inflammation of spinal disc). The 5/12/2025 Minimum Data Set assessment documented the resident had intact cognition, required maximum assistance or was dependent for most activities of daily living, and had an ostomy and indwelling catheter. The Comprehensive Care Plan initiated on 1/2/2025 documented the resident required enhanced barrier precautions due to an indwelling urinary catheter and nephrostomy tube. Physician orders did not include enhanced barrier precautions. During an observation on 7/16/2025 at 11:40 AM, Resident #17 had no transmission-based precaution signage posted and no personal protective equipment readily available outside their room. During an interview on 7/22/2025 at 11:30 AM, Licensed Practical Nurse Unit Manager #18 stated residents were supposed to be on enhanced barrier precautions if they had a wound, catheter, or any opening in their body. They were unsure if Resident #17 was on precautions prior to 7/17/2025 and they did not hang the enhanced barrier precautions signage outside their room. 3) Resident #11 had diagnoses including end stage renal disease, extended spectrum beta lactamase resistance, and heart disease. The 6/26/2025 Minimum Data Set documented the resident had severely impaired cognition, required minimal to moderate assistance for most activities of daily living, and had an indwelling catheter (drains urine from the bladder). The Comprehensive Care Plan initiated 9/18/2024 and revised 9/27/2024 documented the resident had an indwelling urinary catheter. Interventions included have enhanced barrier precautions and the urinary collections bag was to be kept off the floor. The following observations were made: On 7/16/2025 at 11:29 AM, Resident #11's urinary catheter bag was lying directly on the floor mat without a barrier. On 7/16/2025 at 2:39 PM, Resident #11's urinary catheter bag was dragging on the floor behind the resident in the hallway. On 7/16/2025 at 3:38 PM, enhanced barrier precautions signage was posted on or near Resident #11's door and there was no personal protective equipment readily available at the entrance of the resident's room. During an interview on 7/22/2025 at 10:34 AM, Licensed Practical Nurse #13 stated staff should wear a gown and gloves for enhanced barrier precautions. A central line and a urinary catheter were considered indwelling devices and required enhanced barrier precautions. A gown and gloves should be worn when providing central line care to a resident on enhanced barrier precautions. They stated they did not wear a gown and gloves when they provided care to Resident #11 because there was no signage or personal protective equipment cart at the door. Resident #17 had a urinary catheter and a nephrostomy tube and should have been on enhanced barrier precautions, but there was not a sign on their door. During an interview on 7/22/2025 at 11:42 AM, the Infection Prevention Consultant stated there were enhanced barrier precautions and contact precautions. Enhanced barrier precautions were for any resident with a urinary catheter, wound, or central line and staff would know a resident was on precautions because a sign was placed outside their room by the Infection Prevention Consultant or nursing supervisor. A cart with personal protective equipment was centrally located on the unit and for contact precautions the cart would be at the resident's door. The nursing supervisor or licensed practical nurse on the unit should check every shift to ensure the carts were stocked. Enhanced barrier precautions protected the resident and the staff member. A resident diagnosed with clostridium difficile would be on contact precautions because spores could land anywhere in the resident room; you would not want to get spores on your clothing and spread it to other residents. When care was provided for residents on enhanced barrier or contact precautions, gowns and gloves had to be worn. Before entering a resident's room staff should read the signage, wash their hands, and put on appropriate personal protective equipment. 10 NYCRR 415.19(a)(b)

Based on observations and interviews during the recertification survey conducted 7/16/2025-7/22/2025, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for two (2) of three (3) medication carts (2nd floor low end medication cart and the 4th floor low end medication cart) and one (1) of two (2) medication rooms (2nd floor medication room) reviewed. Specifically, the 2nd floor low end medication cart had one expired inhaler and one opened and undated insulin pen; the 2nd floor medication room had one opened, undated bottle of liquid gabapentin (seizure medication); and the 4th floor low end medication cart had one bottle of expired multidose eye drops and one open and undated insulin pen.Findings include:The undated facility policy Medication Storage, documented prior to and after opening, all medications would expire on the date specified by the manufacturer on the product label, unless the manufacturer had specifically indicated a shortened expiration once opened on the product label itself. The policy did not include instructions for labeling multidose vials or discarding expired medications. During an observation on 7/16/2025 at 12:02 PM, the 2nd floor low end medication cart contained one opened and undated Lispro insulin pen and one ipratropium and albuterol inhaler dated as opened on 5/6/2025.During an observation on 7/16/2025 at 12:19 PM, the 2nd floor medication storage refrigerator contained one open and undated bottle of liquid gabapentin (seizure medication).During an interview on 7/16/2025 at 12:26 PM, Licensed Practical Nurse #8 stated all nurses were responsible for checking the medication carts and refrigerators for expired items and ensuring all items were dated. If medications were not dated or past their expiration date they should be discarded. Inhalers and insulin should be discarded after 30 days as the efficacy of the medications diminished. They stated they were unsure why the open undated medications were still in the medication cart or medication refrigerator.During an observation on 7/16/2025 at 12:42 PM, the 4th floor low end medication cart contained one opened bottle of eye drops dated 6/13/2025 and one opened and undated Basaglar insulin pen.During a telephone interview on 7/22/2025 at 11:30 AM, Licensed Practical Nurse #17 stated all nurses should check the medication cart for expired medications and checking to ensure all items were dated when opened. Insulin pens and eye drops were good for 30 days once opened. All medications should be dated when opened. If a medication was expired or not dated, it should be discarded. They stated they were unsure why those medications were still in the medication cart.During an interview on 7/22/2025 at 1:30 PM, Licensed Practical Nurse Unit Manager #18 stated all nurses should check the medication carts to ensure all medications were labeled and were not expired. If the items were unlabeled or expired, they should be discarded and not used.10NYCRR 415.18(d)

Based on observations, record review, and interviews during the recertification survey conducted 7/16/2025 - 7/22/2025, the facility did not ensure each resident received food that accommodated resident allergies, intolerances, and preferences for four (4) of four (4) residents (Residents #20, #57, #100, and #112) reviewed. Specifically, Residents #20, #57, #100, and #112 did not receive items documented on their meal tickets.Findings include:There was no documented facility policy regarding accuracy of meal trays. 1) Resident #20 had diagnoses including multiple myeloma (blood cancer). The 4/29/2025 Minimum Data Set assessment documented resident had moderately impaired cognition and required set up assistance for eating. The 11/20/2024 Comprehensive Care Plan documented the resident had nutritional problems related to a diagnosis of multiple myeloma and was receiving chemotherapy. Interventions included house diet, encourage fluids, encourage food related activities, monitor for weight loss, and evaluate food and beverage intakes. The 4/16/2025 Registered Dietitian #20 progress note documented Resident #20 had a nutritional goal of adequate oral/fluid intake to promote weight gain/maintenance, prevent skin breakdown, and promote a normal body mass index. The resident continued a regular diet with fortified cereal at breakfast, fortified pudding at lunch, and Ensure and 2 Cal HN (liquid nutritional supplements) daily for additional calories and protein to promote weight gain. During an observation on 7/16/2025 at 12:18 PM, the resident's lunch meal ticket documented a dinner roll and 2% milk. The lunch tray did not include either item. During an observation and interview on 7/17/2025 at 12:20 PM, the resident's meal ticket documented cornbread, fortified chocolate pudding, and 2% milk. The lunch tray did not include these items. The resident stated they wanted the cornbread and the pudding and would eat it if they had it. During an observation on 7/17/2025 at 12:22 Certified Nurse Aide #2 asked Resident #20 if they wanted their missing cornbread and milk. The resident stated they wanted the cornbread but did not want the milk. They were not asked about the fortified chocolate pudding. Certified Nurse Aide #2 gave the resident a piece of cornbread which the resident consumed. 2) Resident #57 had diagnoses including dementia, abnormal weight loss, and moderate protein-calorie malnutrition. The 4/22/2025 Minimum Data Set assessment documented the resident had moderately impaired cognition and required set-up assistance for eating.The 4/9/2025 Comprehensive Care Plan documented the resident was at risk for malnutrition related to dementia. Interventions included encourage favorite foods, monitor food/fluid intake, monitor weights, provide 60 milliliters of 2 Cal HN (nutritional supplement) four times a day, Mighty Shake (nutritional supplement) at bedtime, and honor food preferences. The 5/29/2025 Registered Dietitian #21 progress note documented Resident #57 had several interventions along with weekly weights in place for low body mass index and weight loss. The resident had a weight decline over the last six months. Interventions in place included fortified cereal at breakfast, sandwich at lunch and dinner, 60 milliliters of 2 Cal HN four times a day, and Mighty Shake at bedtime. During an observation and interview on 7/16/2025 at 12:20 PM, the resident's lunch meal ticket documented a peanut butter and jelly sandwich. The lunch tray was missing the peanut butter and jelly sandwich and the resident stated they would eat it if they had it.3) Resident #112 had diagnoses including end stage renal (kidney) disease and severe protein calorie malnutrition. The 6/18/2025 Minimum Data Set assessment documented the resident had moderately impaired cognition and required set-up assistance for eating. The 2/13/2025 Comprehensive Care Plan documented the resident was malnourished related to a new diagnosis of renal dialysis (filtering of blood). Interventions included allow sufficient time to eat, monitor food/fluid intake, monitor weighs, and honor food preferences. The 6/5/2025 Registered Dietitian #22 progress note documented Resident #112's body mass index was 16.8 which was underweight related to end stage renal disease and increased nutritional needs. The resident was to continue double portions of entree, starch, cereal, and beverage. During an interview on 7/17/2025 at 11:15 AM, Resident #112 stated they attended dialysis Monday, Wednesday, and Friday at 5:00 AM. Prior to leaving for dialysis the nurse made them toast, one cereal, and cranberry juice. They returned to the facility at approximately 10:45 AM in time for lunch. They were losing weight and trying to gain weight back by eating more. During an observation and interview on 7/18/2025 at 12:32 PM, the resident's lunch meal ticket documented one pound of meat sauce with spaghetti noodles. The meal tray had a single portion of spaghetti and meat sauce. The resident stated they were still hungry. They stated they never received double portions and would love them, especially when they had eggs. They often asked for seconds of the main entree and if there was enough leftover they received them. If there was not enough leftover, they did not receive the second helping. They stated they would prefer not having to ask for the second helping. The resident ate all the first helping of meat sauce with spaghetti and 75% of the second serving of meat sauce with spaghetti. During an interview on 7/21/2025 at 9:32 AM, Certified Nurse Aide #2 stated the kitchen staff was responsible for making sure all items listed on the meal ticket were on the resident trays. The food service aide working the floor was the second check and staff who delivered the tray to the resident was the third check to make sure trays were accurate. Items were often missing from trays. Last week Resident #20 was missing cornbread, and they asked the food service aide for a piece of cornbread. They did not realize the resident was missing their fortified pudding. Resident #57 was trending for weight loss and often did not eat the main entree but usually ate the peanut butter and jelly sandwich in addition to their main entree. It was important for them to get the sandwich and without it they might not get the protein and calories they needed. There were two residents on double portions. Double portions were documented on the meal ticket as double portions and highlighted in yellow. Resident #112 was not on double portions and the ticket did not document double portions. The resident often asked for seconds and received them when available. During an interview on 7/21/2025 at 9:58 AM, Food Service Aide #3 stated they were responsible for serving residents meals. They prepared resident trays with cups, silverware, and condiments prior to the mobile serving steam cart arriving on the unit. There were times residents did not get items listed on the tickets because the Food Service Director did not order enough. They stated there were no dinner rolls available for the 7/16/2025 lunch meal, they ran out of cornbread on 7/17/2025, and no substitutions were made for the missing items. There was no fortified pudding on 7/17/2025 for Resident #20 and it was important for resident to get all the listed items to prevent weight loss. They had two residents that received double portions, but double portions were not documented anywhere on the meal ticket. Resident #112 was not on double portions but often asked for seconds. During an interview on 7/21/2025 at 1:08 PM, Licensed Practical Nurse #15 stated anyone who passed a meal tray was responsible for making sure all items documented on the tickets were on the tray. They noticed trays missing items and notified the food service aide. There were times items listed on the tickets were not available. Residents who lost weight might have fortified puddings, protein supplements, or preferred substitutions. Resident #57 often did not eat their main entree but usually ate their peanut butter and jelly sandwich. Resident #57 was losing weight, and it was important for them to get their sandwich. They were not sure why it was not on the tray. Double portions were usually ordered because a resident required additional calories or protein, and it was documented on their meal ticket. During an interview on 7/21/2025 at 1:30 PM, Registered Nurse Unit Manager #16 stated there were times items were missing from resident meal trays. They notified the food service aide who gave them the missing item. At times they ran out of an item and a substitution was made. Resident #57 always got a peanut butter and jelly sandwich with lunch and dinner because they often refused the main entree and would eat the sandwich. Residents should get double portions at the request of the dietitian and if ordered they should get them. They were unsure if Resident #112 received double portions. During an interview on 7/22/2025 at 7:31 AM, Registered Dietitian #21 stated when a resident was at risk for malnutrition or weight loss, they usually recommended supplements, and they entered the recommendation into the computer. They worked closely with families and the Food Service Director. When a recommendation was made, they added it to the care plan and expected it to be carried out. They recommended double portions for residents who had increased healing or protein needs. Fortified pudding was recommended for Resident #20, and they expected the resident to get the item. Resident #112 had weight loss and double portions were recommended. Double portions was listed on their ticket as x 2 next to the entree. Double portion was not documented anywhere on the meal ticket. They were not sure if staff knew the meal tickets did not say double portions or where to look when a resident required double portions. Resident #57 was being monitored for weight loss, and they preferred a peanut butter and jelly sandwich which was listed on all lunch and dinner meal tickets, and they expected it to be on the resident's tray. During an interview on 7/22/2025 at 9:18 AM, the Food Service Director stated the food service aide was responsible for making sure trays were accurate and all items on the ticket were on the tray. If an item was missing, they should call the kitchen. Last week dinner rolls were accidently not put on the third-floor cart. Food Service Aide #3 never called the kitchen to notify them the item was missing and did not ask for a replacement. When an item was missing the Food Service Director expected staff to call and notify them. Cornbread was part of the meal and Food Service Aide #3 should have called the Food Service Director. They stated Resident #112 was on double portions. Resident #57 should always get their peanut butter and jelly sandwich as they were losing weight, and it was their preference. 10NYCRR 415.14(d)(3)(4)

Based on observations, record review, and interviews during the recertification survey conducted 7/16/2025 - 7/22/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for one (1) of one (1) main kitchen. Specifically, in the main kitchen the preparation sink was leaking with a puddle underneath; the walk-in cooler had a black substance on the back wall, the cooler contained personal items, undated and/or uncovered food, and expired food; the walk-in freezer had uncovered food items; and the dry food storage area had dented cans. Additionally, the 3rd floor kitchenette had outdated bread. Findings include:The facility policy Storage of Food & Supplies, revised 2/2022, documented food and food supplies were stored to minimize exposure to splash, dust, or other contamination. Food products that were opened and not completely used; transferred from its original package to another storage container; or prepared at the facility and stored would be labeled as to its contents and used by dates. Discard food that is damaged.The facility policy Sanitation of Kitchen, Food Service Equipment & Work Surfaces, revised 2/2022 documented the frequency of cleaning foodservice equipment and surfaces that were nonfood-contact surfaces was dependent on the type of equipment and was outlined on the cleaning schedules.The July 2025 Daily Kitchen Cleaning log documented to wash the inside and outside of the refrigerator.The following observations were made in the main kitchen on 7/16/2025 between 10:08 AM and 10:42 AM:the walk-in cooler shelf contained 1 soft side employee lunch box and a 16-ounce soft drink. There were 16 uncovered four-ounce plastic dishes of pudding; a 2.5 quart of chicken noodle soup dated 7/9/2025; five pounds of undated deli turkey wrapped in plastic; 4 pounds of undated cooked pasta in a metal pan; an undated 1.5 pound plastic container of diced cooked potatoes; an undated plastic quart of sliced black olives; a plastic container of sliced oranges dated 7/2/2025 with a use by date of 7/5/2025; and 2 uncovered and undated metal pans of gelatin.the walk-in freezer contained one 12-pound cardboard box of stuffed shells, and one cardboard box of breakfast pastries open to air.the dry storage area contained one dented 4-pound can of tuna dated 6/10/2025 and one dented 7-pound can of cranberry sauce.the kitchen preparation sink was leaking from the drain with a puddle approximately 3 feet by 2 feet. A juice nozzle was on the floor approximately 4-inches from the pooling water.The following observations were made in the main kitchen on 7/17/2025 between 8:28 AM - 8:48 AM:the walk-in cooler contained 1.5 pounds of undated American cheese wrapped in plastic and 1.5 pounds of undated Swiss cheese wrapped in plastic. Additionally, the walls in the back of the walk-in cooler next to the freezer door had a black substance on the white paneling. The right-side wall had a black substance extending 24 inches in length from the floor and 6-8 inches in width. The left side had a black substance extending from the ceiling to the floor that was 6-8 inches wide.the kitchen prep sink was leaking with a 6-inch by 8-inch puddle on the floor.During an interview on 7/17/2025 at 8:52 AM, the Food Service Director stated food items should be used by the best used by date/expiration on the original package and if the food item was placed in another container, it should be used with 3 days of the item being opened to ensure food did not expire and was good quality. All food should be covered to prevent physical contamination. All staff should be checking the can goods to ensure they were not dented. Dented cans should be discarded as they posed a food safety risk. The walk-in cooler and freezers should be swept and cleaned daily. The walls should be cleaned monthly and as needed to prevent the buildup of debris. The juice nozzle should not be on the floor as it was not sanitary, and the maintenance department was made aware of the leaking sink. The equipment in the kitchen, such as the sink, should be in good repair for safety reason and was important for pest control issues as pooling water could attract pests.The following observations were made in the 3rd floor kitchenette:on 7/18/2025 at 8:33 AM there was 1 loaf of bread dated 5/22/2025.on 7/21/2025 at 9:31 AM, there was 1/4 loaf of bread dated 5/21/2025.During an interview on 7/21/2025 at 9:32 AM, Certified Nurse Aide #2 stated the loaf of bread should be discarded as it was past the best used by date. The food service staff was responsible to stock the items on the unit and remove any outdated items. During an interview on 7/21/2025 at 9:58 AM, Foodservice Aide #3 stated they made toast with the bread on the unit that morning at breakfast. They were responsible for checking the dates on the food items and discarding any items that were past their used by date. They were unaware the bread had a used by date on it.There was no documented work order for the leaking kitchen prep sink.NYCRR10 415.14(h)

Based on observations, record review, and interviews during the recertification survey conducted 7/16/2025-7/22/2025, the facility did not ensure residents maintained acceptable parameters of nutritional status for one (1) of four (4) residents (Resident #39) reviewed. Specifically, Resident #39 had weight loss not addressed by the physician or dietitian and there was no documented verification of the resident's actual weight. Findings include:The facility policy Clinical Services: Weight Policy and Procedure, revised 10/2023, documented residents were to have monthly weights obtained and recorded. Significant weight changes would have a verification of weight measurement for accuracy and documentation purposes. If verification indicated significant weight change the resident, the resident's family/representative, and the dietitian would be notified and the plan of care revised. Resident #39 had diagnoses including adjustment disorder and emphysema (progressive lung disease). The 6/26/2025 Minimum Data Set assessment documented the resident had severely impaired cognition, required substantial assistance or was dependent for all activities of daily living, weighed 113 pounds, and did not have weight loss. The Comprehensive Care Plan updated 11/13/2024 documented the resident had a nutrition diagnosis of unintended weight loss related to varied oral intake. Interventions included, monitor/evaluate weight/weight changes, monitor/record/report to physician significant weight loss, notify registered dietitian, family, and physician of significant weight changes. Physician orders documented: 8/3/2024 8 ounces Mighty Shake (nutritional supplement) 10/24/2024 weekly weights every Friday 11/13/2024 8 ounces Ensure Plus (nutritional supplement) two times a day to promote weight maintenance/adequate oral intake 3/25/2025 house diet, regular texture and thin consistency. The resident's record documented the following weights: on 5/30/2025 113 pounds on 6/2/2025 113 pounds on 6/20/2025 112.5 pounds on 7/7/2025 99 pounds (12.39 % loss x 30 days). There was no documented evidence a re-weight was obtained after significant weight loss. There was no documented evidence the family, physician, or dietitian were notified timely of the significant change in weight. During an observation on 7/17/2025 at 12:35 PM Resident #39 was assisted with eating and consumed less than 50% of their lunch meal. During an observation on 7/18/2025 at 8:37 AM Resident #39 was sitting at a dining room table being encouraged to eat but was not physically assisted. The 7/18/2025 at 1:41 PM Registered Dietitian #21 progress note documented they reviewed the resident's weights and noted a severe decline over the past month. The resident's original weight was 99 pounds on 7/7/2025 and a reweight was obtained as requested today 7/18 of 107.5 pounds (11 days after the original weight of 99 pounds). The recommendation included routine weights be done consistently in the resident's wheelchair versus standing and initiating weekly weeks. The resident's appetite remained variable at 50-100% intake at meals. During an interview on 7/18/2025 at 11:11 AM, Certified Nurse Aide #7 stated after they weighed the resident, they documented the weight in the electronic record. The weight popped up red if the resident lost weight and they would tell the nurse. They were Resident #39's aide on 7/7/2025, but they did not weight the resident. They stated a different aide weighed the resident for them that day. If they had gotten that weight, they would have told the nurse. During an interview on 7/18/2025 at 12:42 PM, Certified Nurse Aide #27 stated when they weighed a resident and the weight was low, they re-weighed the resident either the same day or the next day. They would let the nurse know the resident lost weight. They weighed Resident #39 on 7/7/2025. They looked at the old weight for the resident prior to inputting the new weight. They informed Licensed Practical Nurse #28 about the weight loss and was told that since the resident had not been eating well and was having a lot of lose stool, weight loss was expected. During an interview on 7/18/2025 at 1:27 PM, Licensed Practical Nurse #28 stated if there was a big discrepancy in weights they expected to be notified by the aides. Every nurse should check their assigned resident's weights, even if they were not told by the aides. If they noticed a big weight difference they should weigh the resident again, let the provider know, and document in the electronic record the provider was notified. Resident #39 lost weight as they were not eating a lot and had loose stools last month. They were not sure why there was not documentation a provider was notified or if the resident was reweighed. During an interview on 7/21/2025, Registered Nurse Unit Manager #5 stated last month there were a lot of residents with stomach issues with vomiting and diarrhea and they expected some weight loss to happen. The medical provider, family, and the dietitian should be notified of weight loss even if it was expected. They stated they were sure the weight loss from 7/7/2025 was reported to the provider. During an interview on 7/22/25 at 12:51 PM, Registered Dietitian #21 stated they should be notified if a resident lost 5% of their weight in 1 month or 10% of their weight in 6 months. They started running weight reports. When weight loss was noticed the resident should be reweighed to confirm accuracy. Resident #39 was experiencing weight loss, and they were following. They noticed the weight from 7/7/2025 and asked for a re-weight. They were not sure why they did not document the follow-up in the electronic record. 10NYCRR 415.12(i)1

Based on observations, record review, and interviews during the recertification survey conducted 7/16/2025-7/22/2025, the facility did not ensure the resident environment remained free of accident hazards for one (1) of two (2) residents (Resident #1) reviewed. Specifically, Resident #1 had a physician order to provide line-of-sight supervision for all intakes, and the resident was observed eating unsupervised in their room without staff in the vicinity. Findings include:The facility policy Dysphagia Management, revised 1/9/2023, documented residents who had dysphagia (difficulty swallowing) would be referred to Rehabilitation for evaluation and treatment interventions to promote adequate nutrition and hydration. Collaboration with the dietitian would determine the most appropriate diet based on nutrition assessment and dysphagia evaluation. An interdisciplinary patient-centered care plan for dysphagia would be developed.Resident #1 had diagnoses including right sided paralysis and weakness following a stroke, dysphagia, and acute respiratory failure with hypoxia (low oxygen levels). The 5/9/2025 Minimum Data Set documented the resident had severely impaired cognition, received a mechanically altered diet, did not have a swallowing disorder, and required set up for eating.The 5/15/2024 physician order documented a house diet with regular/whole texture, moderately thick consistency, follow dining strategies, staff to cut solids into bite sized pieces and open containers and condiments, and provide line-of-sight supervision for intake.The 6/6/2025 Comprehensive Care Plan documented the resident had an activities of daily living self-performance deficit related to confusion, functional limitations, neurological deficits due to frontal lobe deficit related to their stroke. Interventions included staff to cut solids into bite sized pieces, open containers and condiments, seat the resident in a chair or upright in bed at 90 degrees, alternate liquids and solids, alternate taking bites and sips at a slow rate, remain seated upright for 30-45 minutes after every meal, contact guard assistance of one for eating, and provide direct supervision, line-of-sight, while eating.The following observations of Resident #1 were made: on 7/17/2025 at 12:42 PM, sitting up in bed with their eyes closed. Their lunch was on the bedside table across their lap. There was no staff in the room or in line-of-sight.on 7/18/2025 at 12:48 PM, Certified Nurse Aide #23 brought Resident #1's lunch tray into their room. They set up the tray on the overbed table and left the room. There were no staff in the hallway or within line-of-sight of the resident. At 12:53 PM, Certified Nurse Aide #24 and the Activities Director entered the room with a tray for the resident's roommate and left the room. From 12:55 PM to 1:26 PM, the resident ate their meal without line-of-sight supervision. The resident coughed several times while drinking.During an interview on 7/22/2025 at 10:08 AM, Certified Nurse Aide #24 stated the meal ticket should document if a resident needed assistance while eating. If the resident's care plan documented to be eyeline supervision for eating, the resident should not be left alone with their meal. They stated they were unaware Resident #1 required line-of-sight supervision when they dropped off the resident's tray on 7/17/2025.During an interview on 7/22/2025 at 10:34, Licensed Practical Nurse #13 stated if a resident required eye-line supervision for eating they needed to be supervised so they did not aspirate (inhale food/drink into lungs) while eating or drinking. They assisted with serving trays on the unit and was unaware Resident #1 required eyeline supervision for their meals. The resident should not be left alone in their room with their meal tray as it was not safe, and the resident could aspirate. They stated there was not enough staff to supervise the resident while they ate in their room.During an interview on 7/22/2025 at 11:30 AM, Licensed Practical Nurse Unit Manager #18 stated if a resident was eyeline supervision for eating they had to be in sight of staff during the meal. Resident #1 should not be left alone to eat in their room if they required line-of-sight supervision. They stated there was not enough staff to watch the resident in their room if they did not want to get up for lunch. There was no excuse not to watch the resident, but it was between not feeding the resident if they did not want to get up or giving the resident their tray and not supervising them.During an interview on 7/22/2025 at 1:08 PM, Nurse Practitioner #26 stated that if a resident's orders documented the resident should be within eyeline supervision during meals they expected staff to supervise the resident. It was important to supervise the resident for aspiration precautions or choking precautions. If a resident was not supervised staff could not intervene timely if they choked. They stated they were unaware Resident #1 was eyeline supervision and was not supervised during meals. 10 NYCRR 415.12(h)(1)(2)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00368679) surveys conducted 7/16/2025-7/22/2025, 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 two (2) of five (5) residents (Residents #17 and 31) reviewed. Specifically, Resident #17 had brown debris behind long, untrimmed fingernails and Resident #31 had long, sharp fingernails and poor oral hygiene.Findings include: The facility policy Activities of Daily Living (ADL) Care and Support, issued 6/2023, documented staff provided assistance for residents who were unable to carry out care independently as documented on the person-centered care plan and included showering, toileting, dressing, and grooming. 1) Resident #31 had diagnoses including cerebral infarction (stroke), aphasia (difficulty speaking), and hemiplegia (paralysis on one side). The 6/13/2025 Minimum Data Set assessment documented the resident had severely impaired cognition, did not reject care, and was dependent for most activities of daily living.The Comprehensive Care Plan initiated 3/18/2006 and revised 12/15/2020, documented the resident required assistance with self-care and mobility related to cerebral infarction and hemiplegia. interventions included oral care daily with total dependence of one. The resident's undated care instructions (Kardex) documented the resident received showers on Tuesday and Friday on the day shift, received tube feedings for nutritional needs, had nothing to eat or drink by mouth, received oral care daily, and was dependent on one for oral care. Resident #31 was observed on 7/16/2025 at 1:51 PM, 7/17/2025 at 11:43 AM, 7/18/2025 at 9:43 AM, and 7/21/2025 at 11:02 AM with long sharp fingernails on the right hand, the left hand was contracted, and the fingernails could not be observed. The resident had foul smelling breath, and a white film on their teeth. The certified nurse aide activities of daily living log documented the resident received oral care twice daily on the day and evening shift. Certified Nurse Aide #11 documented completion of oral care on both the day and evening shift on 7/18/2025. During an interview on 7/16/2025 at 1:51 PM, Resident #31's family member stated they visited often and observed the resident’s mouth was dry, their breath smelled bad, and a white film was on their teeth. They stated the resident should get better oral hygiene. During an interview on 7/21/2025 at 2:39 PM, Certified Nurse Aide #11 stated they were responsible for bathing and grooming residents including nail care and oral care. They showered Resident #31 on 7/18/2025 and did not do nail or oral care. They believed nail care was only provided by licensed practical nurses for Resident #31 because their left hand was contracted, and they did not want to hurt the resident. They stated the resident often had bad breath, and they did not provide oral care for the resident because they thought the licensed practical nurse completed oral care because the resident received a tube feeding and they were worried the resident could choke. During an interview on 7/21/2025 at 10:53 AM, Certified Nurse Aide #12 stated their duties included assisting residents with showers and grooming. Resident #31 was on their assignment for the day, and all their care was provided. The resident did not refuse any care. Nail care should be completed on the resident’s shower day or with daily care when needed. They were responsible for cleaning and clipping nails unless the resident was a diabetic, then the licensed practical nurse was responsible. They did not clip or clean Resident #31 nails because they did not notice they were long or had sharp edges. During an interview on 7/21/2025 at 11:02 AM, Dentist #14 stated it was important for all residents to have their teeth brushed to remove plaque and decrease the chance of dental caries and for overall health. Teeth should be brushed at least daily. They stated the resident had tarter build up, bad breath, and should have their teeth brushed. During an interview on 7/21/2025 at 1:08 PM, Licensed Practical Nurse #15 stated they expected nail care and oral care to be completed by certified nurse aides assigned to the resident. If a certified nurse aide was not able or did not feel comfortable completing nail or oral care, they should notify the licensed practical nurse who would complete the care. They stated Resident #31's nails were sharp and should be clipped, the resident had bad breath, and tarter build up on their teeth. During an interview on 7/21/2025 at 1:30 PM, Registered Nurse Unit Manager #16 stated hygiene care was completed by nursing staff which included certified nurse aides and licensed practical nurses. Residents were showered twice a week and hygiene care was completed daily. Nail care should be completed on their shower day but could be done whenever needed. Certified nurse aides completed nail care for all residents unless they were diabetic, then care was completed by the licensed practical nurse. Resident #31 drooled a lot and frequently had bad breath. It was important to provide nail and oral care for dignity and self-esteem. 2) Resident #17 had diagnoses including renal abscesses (collection of pus), osteomyelitis (bone infection), and discitis (inflammation of spinal disc). The 5/12/2025 Minimum Data Set assessment documented the resident had intact cognition and required maximum assistance or was dependent for most activities of daily living. The 1/2/2025 Comprehensive Care Plan documented the resident had a deficit in self-care function. Interventions included maximum assistance of 2 for upper body dressing, showering, and set up for eating and personal hygiene. The resident’s Kardex (care card) documented the resident’s shower days were Wednesday and Saturday on the 6:00 AM to 2:00 PM shift and required set up for personal hygiene. The following observations were made of Resident #17: on 7/16/2025 at 11:40 AM with long, yellowed fingernails on both hands. The right ring, middle finger and thumb had brownish debris under the nails. The resident stated they hated having long fingernails, but they could not get anyone to trim them. on 7/17/2025 at 11:51 AM with long fingernails and brown/black debris under all nails on both the right and left hands. on 7/18/2025 at 8:43 AM in bed with long fingernails and debris under their right pointer fingernail and the thumb, pointer, middle fingers of their left hand. on 7/21/2025 at 9:38 AM their pointer, middle and ring fingers on the right hand and middle and ring finger on their left hand had visible brown/black matter under the nails. The resident’s fingernails were long and yellowed on both hands. During an interview on 7/22/2025 at 10:08 AM, Certified Nurse Aide #24 stated morning care for a resident included toileting, personal hygiene, dressing, and getting them up for breakfast or an activity. Nail care occurred on a resident’s shower day or any day a resident’s nails needed to be done. They did not perform nail care on Resident #17 during the days they were scheduled to care for the resident. They noticed Resident #17’s nails were long when they provided care. They did not know why they did not do nail care. During an interview on 7/22/2025 at 10:34 AM Licensed Practical Nurse #13 stated the certified nurse aides were responsible for nail care. Nail care should be completed on shower days and as needed. A resident should not have long nails if they did not want them. Resident #17 did not refuse nail care. They saw Resident #17’s nails that morning and their nails needed care. During an interview on 7/22/2025 at 11:30 AM, Licensed Practical Nurse Unit Manager #18 stated nail care should be done after showers and as needed but after showers was best. They were unaware of why Resident #17 did not have nail care completed. If a resident had long nails with debris under them, nail care should be completed. 10 NYCRR 415.12(a)(3)

Based on observations, record review, and interviews during the recertification survey conducted 7/16/2025- 7/22/2025, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for three (3) of three (3) residents (Residents #2, #6 and #50) reviewed. Specifically, Resident #6 did not have a comprehensive care plan for the use of anticoagulants (blood thinners); Resident #2 did not have a comprehensive care plan for managing their peripherally inserted central catheter (intravenous line); and Resident #50 did not have bilateral floor mats as care planned.Findings include:The facility policy Baseline/Comprehensive Person-Centered Care Plans, revised 3/2023, documented the person-centered care plan was developed to include information necessary to properly care for the resident and was reviewed and revised quarterly, following a significant change, annually, following a hospital readmission, and as needed. The care plan was kept current by all disciplines on an ongoing basis and all clinical department heads were responsible for ensuring there was a system for monitoring implementation of the resident care plans. 1) Resident #2 had diagnoses including acute osteomyelitis (bone infection) of the right ankle and foot. The 6/9/2025 Minimum Data Set assessment documented the resident was cognitively intact, had intravenous access, and received intravenous medications. Physician orders documented: on 6/12/2025 change the transparent dressing and securement device every 7 days and as needed. on 7/10/2025 cefiderocal sulfate tosylate (antibiotic) intravenous solution reconstituted. Use 0.75 gram intravenously two times a day for right ankle osteomyelitis. on 7/21/2025 change peripherally inserted central catheter line intravenous tubing one time a day for routine care; change needleless connector on peripherally inserted central catheter line every 7 days; measure external catheter length from insertion site upon admission and with each dressing change; saline flush intravenous solution use 10 milliliter intravenously two times a day for routine care and 10 milliliters before and after administration. The Comprehensive Care Plan initiated 5/16/2025 documented the resident was on antibiotic therapy. Interventions included administer antibiotic as ordered, monitor for adverse reactions to antibiotic therapy, and monitor for secondary infections related to antibiotic therapy. The Comprehensive Care Plan did not include the use of a peripherally inserted central catheter or interventions for management and monitoring of the peripherally inserted central catheter. During an observation on 7/17/2025 at 12:08 PM, Resident #2 had a peripherally inserted central catheter in their left upper arm with a dressing dated 7/6/2025. During an interview on 7/22/2025 at 10:26 AM, Licensed Practical Nurse #4 stated Resident #2 had a peripherally inserted central catheter managed by the registered nurses. They were unaware it was not in the resident's care plan but thought it should be, so all staff knew it was there and how to monitor and care for it properly. They had access to care plans but thought the registered nurses, Director of Nursing, and the Assistant Director of Nursing were responsible for reviewing and updating care plans during care plan meetings. During an interview on 7/22/2025 at 11:14 AM, Registered Nurse Manager #5 stated registered nurses initiated, reviewed, and updated care plans quarterly, when there was a change in the resident's condition. They stated they were responsible for Resident #2's care plan. Resident #2 had a peripherally inserted central catheter in their left upper arm they received medication through. They were unsure why it was not in the care plan, and it should have been added because it required ongoing assessments, care, and frequent monitoring. 2) Resident #50 had diagnoses including stroke with right side hemiplegia (paralysis) and right hemiparesis (weakness) and falls. The 6/13/2025 Minimum Data Set assessment documented the resident was cognitively intact, required partial/moderate assistance with bed mobility, toileting hygiene, showering and bathing, lower body dressing, putting on/taking off footwear, and had one fall without injury since admission or reentry. The Comprehensive Care Plan initiated 6/23/2025 documented the resident had an actual fall due to psychoactive drug use and an unwitnessed fall out of bed reaching for an item from the side stand table. Interventions included grabber tool for items out of reach, appropriate footwear when ambulating or mobilizing in wheelchair, and two bilateral floor mats. The undated resident care instructions (Kardex) documented the resident was a high risk for falls and required two bilateral floor mats. Resident #50 was observed at the following times: on 7/16/2025 at 1:58 PM, lying in bed with one gray fall mat on the left side of the bed. on 7/17/2025 at 12:23 PM, lying in bed with one gray fall mat on the left side of the bed. There was a gray fall mat standing upright between the tall dresser and the wall. The resident stated the floor mat that was standing up was not being used on the floor anymore. on 7/18/2025 at 9:07 AM and 7/21/2025 at 11:00 AM, sitting on the edge of their bed. There was a gray floor mat on the left side of the bed, and a gray fall mat standing upright between the tall dresser and the wall. During an interview on 7/22/2025 at 10:14 AM, Certified Nurse Aide #7 stated they had access to all resident care plans, and they reviewed them regularly because the care plan included everything they needed to know about a resident and how to properly care for them. They provided care to Resident #50 who was a fall risk. The resident had only one fall mat in use. They stated Resident #50 was supposed to have bilateral fall mats and the care plan should have been followed to prevent injuries if the resident had another fall out of bed. During an interview on 7/22/2025 at 10:26 AM, Licensed Practical Nurse #4 stated all nursing staff had access to care plans, and they contained everything they needed to know about a resident so they could properly care for them. Resident #50 was a fall risk and was care planned for bilateral fall mats. They were unaware the resident had one floor mat in use. The care planned should be followed because if the resident had another fall the floor mats would decrease their risk for injuries. During an interview on 7/22/2025 at 11:14 AM, Registered Nurse Manager #5 stated Resident #50 was a fall risk and was care planned for bilateral fall mats. They were unaware the resident had one fall mat in use. If Resident #50 had another fall they were at a higher risk for injuries without bilateral fall mats. 3) Resident #6 had diagnoses including atrial fibrillation (irregular heart rhythm). The 4/25/2025 Comprehensive Minimum Data Set assessment documented the resident had moderately impaired cognition and was on an anticoagulant (blood thinner). The 4/3/2025 physician order documented apixaban (anticoagulant) oral tablet 2.5 milligrams by mouth, two time a day for atrial fibrillation. The 6/30/2025 Comprehensive Care Plan did not include anticoagulant therapy with a focus on monitoring the effects of the medication.During an interview on 7/18/2025 at 9:45 AM, Licensed Practical Nurse #4 stated Resident #6 was on anticoagulant therapy and did not have risks of anticoagulant therapy included in their care plan and it should be included. During an interview on 7/18/2025 at 10:32 AM, Registered Nurse Unit Manager #5 stated anticoagulant therapy should be included in the care plan for any resident prescribed anticoagulants. It was important for the care plan to include risks for anticoagulant therapy so staff and knew how to appropriately provide care. Resident #6 was on anticoagulant therapy and did not have a care plan for its use. The care plan should include anticoagulant use, so staff were aware of signs and symptoms to look for related to anticoagulant therapy. Anticoagulant therapy and an associated diagnosis were missed when the care plan was created. The Director of Nursing, Assistant Director of Nursing or the Unit Manager were responsible for updating and ensuring accuracy of the care plan. Anticoagulant therapy and associated diagnosis were missed when the care plan was created. During an interview on 7/22/2025 at 12:51 PM, the Director of Nursing stated they and the Assistant Director of Nursing were responsible for creating and updating care plans. Care plans were reviewed and updated quarterly and with need. Care plans should include medications, central lines, and fall risk interventions. 10NYCRR 415.11(c)(1)

Based on interview and record review during the recertification survey conducted 7/16/2025-7/22/2025 the facility did not develop and implement an effective discharge planning process that focused on the resident's discharge goals for one (1) of three (3) residents (Resident #17) reviewed. Specifically, Resident #17 expressed the intention to be discharged to the community and was not updated on the status of their discharge plan.Findings include:The facility policy Admission, Discharge Policy, revised 6/2025, documented the discharge planning process began prior to admission during the pre-admission evaluation. Upon admission, the Team Based Assessment was completed by the interdisciplinary team to establish discharge plan and goals. Once the patient's goals for discharge were established and a date has been set that was amenable to the patient the social worker would coordinate necessary services, to include referrals to community resources.Resident #17 has diagnoses including renal (kidney) abscesses, osteomyelitis (infection) of vertebra, and discitis (infection and inflammation of spinal disc). The 5/12/2025 Minimum Data Set assessment documented the resident had intact cognition, had moderately severe depression, had no behavioral symptoms, required maximum assistance or was dependent for most activities of daily living, and there was no active discharge planning occurring for the resident. The 1/3/2025 Comprehensive Care Plan documented the resident had the need for a safe and appropriate discharge plan to return home. The resident's discharge goal was to discharge to the community. Interventions included to assess the discharge needs beginning on the day of admission, at the initial care plan meeting, and throughout the stay, and to assess learning needs and barriers toward discharge planning. The 1/29/2025 Team Based Assessment Weekly Discharge Plan completed by Case Manager #9 documented during a 1/2/2025 meeting it was determined the resident did not live alone and resided with their spouse, required assistance of two, needed skilled care for nephrostomy tubes (drains urine directly form the kidney), pressure wounds, and surgical wounds. The resident needed training on nephrostomy care. The resident had 5 stairs to enter their home, had durable medical equipment in the home, and required moderate assistance of two for dressing and transferring. The expected discharge location was home. The update on 1/16/2025 documented the resident required 2-person assistance and was unable to ambulate. The 1/22/2025 update documented it was unsure if the resident was able to be discharged home due to their living conditions. The 1/29/2025 update documented the resident's expected date of discharge was 2/28/2025.The 3/4/2025 Care Conference assessment documented the resident, and their family member were in attendance. The resident expressed an interest in attending therapy and wanting to be up in their chair more. There was no updated documentation regarding the resident's discharge plan The 4/8/2025 Team Based Assessment Weekly Discharge Plan completed by Case Manager #9 documented the resident required total assistance of two for transfers and dressing. The 2/19/2025 discharge plan update documented the resident's discharge plan was unclear. On 2/26/2025 the discharge plan update was unclear due to the resident's progress and the resident had a care plan meeting the next week to discuss a plan. The resident's needs did not exceed home health services and the resident's family did not verbalize discomfort with the resident's discharge timeline or resources. The resident's anticipated discharge date was 5/8/2025.The 4/9/2025 Case Manager #9 progress note documented they spoke with the Veteran's Administration social worker regarding the resident's discharge plan. They informed the Veteran's Administration social worker the resident would likely require long term care. The resident did not meet the Veteran's Administration's criteria for long term care. A plan was to be discussed at the resident's next care plan meeting.The 4/17/2025 Case Manager #9 progress note documented the resident exhausted their Medicare Part A benefit.The 4/22/2025 Social Services Director progress note documented they met with the resident per their request. The resident had inquired what their discharge plan was. The resident was receiving intravenous antibiotics three times a day and would not be able to manage them on their own at home. The resident also acknowledged they were unable to ambulate which was needed to be able to return home. The resident was agreeable to complete their intravenous therapy then see if they were able to return home.The 5/27/2025 care conference assessment documented the resident and responsible party were invited but did not document attendance. The resident had good pain management, and their nephrostomy tube was draining without difficulty. The resident was participating more in activities. The social services section documented the resident had potential for additional surgeries and did not wish to be long term care.There was no further documentation regarding discharge planning for the resident or working toward the resident's desired goal of returning home. During an interview on 7/16/2025 at 11:40 AM, Resident #17 stated things had not been going well since their Medicare ran out 3 months ago. They had no therapy since then and they needed more therapy to be able to go home. The resident stated no one was helping them to work toward their goal of going home. During an interview on 7/21/2025 at 9:38 AM, Resident #17 stated they were tired not getting physical therapy to be able to go home. During an interview on 7/21/2025 at 1:23 PM, Case Manager #9 stated if a resident wanted to discharge but needed additional services, they would look at getting the resident managed long term plan caregiving services. If a resident wanted therapy, they let the therapy and nursing department know so nursing could put in a screen and notes to support the need for therapy services. Therapy would then screen the resident to decide if the resident would benefit from a therapy program. Resident #17 wanted to be discharged but needed 24-hour care that could not be provided by the family. The resident was previously on the second and moved to the fourth floor under their caseload a couple of months ago. They did not discuss options for returning home with Resident #17. At the time of their last care conference, the resident needed to stay in the facility because they were on intravenous antibiotics. They did not follow up with the resident regarding discharge planning since then and the resident had a quarterly care plan meeting coming up. They typically waited until the quarterly care conferences to have those conversations as the resident had not asked to speak with them. During an interview on 7/22/2025 at 10:34 AM, Licensed Practical Nurse #13 stated Resident #17 was constantly asking about their discharge and about getting therapy. They did not know what the resident was told about their discharge plan, but they were aware the resident was admitted for short term rehabilitation. They told the Unit Manager about the resident's wish for therapy and discharge.During an interview on 7/22/2025 at 12:10 PM, the Director of Rehabilitation stated if a resident expressed the want for therapy services, nursing should document the rational and put in a screen for therapy to review. Therapy would screen to determine if therapy was appropriate for a resident. Therapy required a screen from nursing in to assess the resident. They did not receive a screen for Resident #11 since they came off therapy services on 4/11/2025.During an interview on 7/22/2025 at 12:23 PM, the Director of Social Services stated discharge planning started the day of admission, and the initial assessment was completed. If a resident could not fully participate due to cognition, they involved the resident's family. If a resident needed 24-hour care they would look at insurance to cover a personal aide. They were aware Resident #17 wanted to discharge from the facility, and they were working to get Medicaid in place. It was not safe for the resident to discharge home without caregivers due to their care level. The resident exhausted their Medicare A benefit. They had a care plan meeting on 5/27/2025 and the resident was to have surgeries for their nephrostomy tubes. The resident made them aware they did not want to be long term care. They stated the resident had some follow ups in the middle of June and they should have followed up with the resident after that. They should not wait until the quarterly care conference to discuss discharge planning with the resident.10NYCRR 415.11(d)(3)

Based on record review and interviews during the abbreviated survey (NY00309249), the facility failed to ensure residents were free of significant medication errors for one (1) of four (4) residents (Resident #1) reviewed. Specifically, Resident #1's hospital discharge orders included routine short acting insulin and sliding scale (the amount of insulin administered is based on the results of blood glucose finger sticks) short acting insulin. The resident's admission physician orders included long-acting insulin and blood glucose monitoring before and after meals, and at bedtime. The physician orders were not transcribed to the Medication Administration Record and the resident did not have blood glucose level readings completed for 10 days. Additionally, the resident did not have admission orders for routine short acting insulin and sliding scale short acting insulin as recommended. Subsequently, Resident #1 was hospitalized for hyperosmolar hyperglycemic state (severely high blood glucose levels with severe dehydration and confusion). This resulted in actual harm to Resident #1 that was not Immediate Jeopardy. The facility policy, Medication Requisition Worksheet, revised 2/2015, documented medication reconciliation occurred at the time of admission and within 24 hours for each new resident admitted to the facility. The first reconciliation occurred by the pharmacist upon submission of the physician orders. The second reconciliation was completed when nursing reviewed all the medications listed on the hospital discharge summary/transfer sheet by way of a medication reconciliation worksheet. Nursing would complete the medication reconciliation worksheet before notifying the physician for initial verification of orders. Nursing would carefully review medications recommended by the hospital at discharge and list medications that needed clarification. Nursing would notify the physician of any discrepancies. The servicing pharmacy would conduct their own internal reconciliation upon receipt of orders and communicate any discrepancies to the ordering physician or nursing supervisor for clarification. The facility policy, Diabetes Management Protocol, issued 6/2014 and 3/2023, documented for insulin dependent diabetic residents, the responsible nurse administered routine insulin as ordered, performed finger sticks as ordered, administered short acting insulin per sliding scale, monitored residents for symptoms of hypoglycemia/hyperglycemia (low or high blood sugar levels in the blood), documented finger stick results, dose of insulin, where administered, and re-evaluated requirements of sliding scale insulin periodically to optimized routine orders. Resident #1 had diagnoses including Type 2 diabetes (the body does not use insulin effectively or does not produce enough insulin) and multiple sclerosis (a central nervous system disease). There was no Admission Minimum Data Set assessment yet completed prior to the resident's discharge to the hospital on 1/21/2023. The hospital physician discharge summary dated 1/9/2023 at 2:42 PM documented the resident's diabetes was poorly controlled. The resident was started on Lantus (glargine, long acting insulin) 10 units twice daily, in addition to Humalog (lispro, short acting insulin) per sliding scale coverage, plus Humalog 3 units with meals. Chemstrips (fingerstick glucose readings) were improving. The 1/11/2023 at 10:59 AM hospital discharge orders documented: - Insulin glargine 100 units per milliliter injection, inject 10 units under the skin in the morning and 10 units before bedtime. - insulin lispro 100 units per milliliter injection, inject 5 units in the morning, 5 units at noon, and 5 units in the evening. Inject with meals. - insulin lispro 100 units per milliliter injection, inject 0-14 units (sliding scale,) under the skin 4 (four) times a day before meals and nightly. - stop taking glimepiride (an oral anti-diabetic medication) 4 milligrams. The facility admission physician orders documented: - on 1/11/2023 (untimed) insulin glargine solution 100 units per milliliter, inject 10 units subcutaneously (under the skin) twice a day for diabetes. - on 1/11/2023 at 5:09 PM (telephone order) accuchecks (blood glucose finger sticks) before and after meals and at bedtime for diabetes. Call medical if less than 70 milligrams/deciliter and greater than 450 milligrams/deciliter. The order was entered into the computer at 5:11 PM by Registered Nurse #22 with the order type documented as standard other. The order was signed by Nurse Practitioner #15 on 1/13/2023 at 5:46 PM. There was no documented evidence of an admission physician order for routine short acting insulin and sliding scale insulin. The Comprehensive Care Plan initiated 1/11/2023, documented the resident had diabetes mellitus. Interventions included diabetes medications as ordered, monitor/document for side effects/effectiveness, dietary consult for nutritional regimen and ongoing monitoring, finger stick blood sugars as ordered by physician, monitor/document/report as needed signs/symptoms of hyperglycemia (high blood sugar), including increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps and pain, Kussmaul's breathing (rapid breathing), acetone (fruity) breath, coma. The 1/2023 Medication Administration Record documented insulin glargine inject 10 units subcutaneously two (2) times per day for diabetes with a start date of 1/11/2023. There was no documented evidence of orders or results for accuchecks from 1/11/2023-1/21/2023. The Weight and Vital Signs Summary did not include blood sugar (accuchecks) results prior to 1/21/2023. The 1/12/2023 Nurse Practitioner #15 progress note documented they reviewed external medical records. Hospital labs and consults were reviewed. The plan was to continue with Lantus 10 units twice daily and follow accuchecks (blood glucose finger sticks). There was no documented evidence Nurse Practitioner #15 reviewed accuchecks or the hospital discharge summary which included routine short acting insulin and sliding scale insulin. The 1/16/2023 Physician #14 History and Physical documented hospital labs and consults were noted and reviewed. The resident had controlled type 2 diabetes. The plan was to continue with Lantus 10 units twice daily and follow. There was no documented evidence Physician #14 reviewed accuchecks or the hospital discharge summary which included routine short acting insulin and sliding scale insulin. The 1/19/2023 at 8:26 PM progress note by Licensed Practical Nurse #33 documented the resident was alert and oriented and able to make needs known. No complaints of pain or discomfort voiced. Licensed Practical Nurse #23 progress notes documented: - on 1/21/2023 at 11:53 AM the resident followed verbal directions but did not respond verbally. The resident had an elevated heart rate of 128 beats per minute (normal 60-100 beats per minute), and neurological checks were within normal limits. The resident had no signs of distress. Director of Nursing #20 and on-call Physician #31 were notified. There was no documented evidence the resident's blood glucose level was checked. - on 1/21/2023 at 12:38 PM Physician #31 ordered labs including a complete blood count, comprehensive metabolic panel, ammonia level, and a urinalysis with culture and sensitivity (determines possible presence of a urinary tract infection). Continue neurological checks and monitor the resident's vital signs in 1-2 hours. If the resident's heart rate did not come down, the provider would order medication. The resident responded verbally and denied pain or discomfort. The resident's heart rate was 122 beats per minute. - on 1/21/2023 at 1:38 PM the resident had a heart rate of 124 beats per minute. Physician #31 was updated and ordered the resident be sent to the emergency room for evaluation. An ambulance was called, and a message was left for the family representative. - on 1/21/2023 at 1:53 PM the resident was admitted to the hospital for hyperkalemia (high blood potassium levels). The Weights and Vital Signs Report documented on 1/21/2023 the resident's blood glucose results were 118 milligrams/deciliter at 11:33 AM and 118 milligrams/deciliter at 11:34 AM. The 1/21/2023 at 6:42 PM hospital physician progress note documented Resident #1 presented to the emergency room with an increased heart rate and mental status changes. The resident had an elevated blood sugar level of 1192 milligrams/deciliter (drawn at 2:45 PM, normal for non-diabetics 75-115 milligrams per deciliter) and an elevated potassium level (7.0 milliequivalents/liter, normal 3.5-5.2 milliequivalents/liter). The resident was administered an insulin drip via intravenous (into a vein) route and was started on medication to reduce their elevated potassium levels. The resident would be admitted into the Intensive Care Unit. Repeat blood work showed the resident continued with elevated blood sugar levels. The 1/26/2025 at 10:37 AM hospital discharge summary documented the resident's discharge diagnosis was hyperosmolar hyperglycemic state. The resident had poorly controlled diabetes with a Hemoglobin A1C of 10.7% (a blood test that measures average blood glucose levels over the past 2-3 months, normal is less than 5.7%). The plan was to follow up with endocrinology as an outpatient. The 1/24/2023 at 9:55 AM Facility accident/incident investigation summary completed by the Administrator documented: - On 1//11/2023 Resident #1 was admitted to the facility and their physician orders for blood glucose monitoring did not transcribe to the Medication Administration Record. The order was inputted as a standard order instead of a MAR order. - On 1/21/2023 at 1:55 PM, Resident #1 had increased pulse, lethargy (tiredness), and confusion and was sent to the hospital and was found to have hyperglycemia. - On 1/23/2023 at 8:00 AM, the hospital updated the Administrator. Resident #1 was admitted with a high blood glucose level, hyperkalemia, and hypernatremia (high blood sodium levels). The resident's blood glucose level was 1192. The Health Care Proxy was at bedside and stated they did not believe the resident had received blood glucose finger sticks or insulin since their admission to the facility. - On 1/23/2023 at 8:30 AM, the facility became aware Resident #1 had a blood glucose level of 1192. The resident's blood glucose prior to transfer was 118. The facility verified a care plan violation had occurred, and the resident's blood glucose monitoring did not transcribe and reflect on the medication or treatment administration records. The allegedly responsible employee (unidentified) was issued a disciplinary notice and re-educated on transcription of orders and secondary verification by a second nurse. During an interview on 1/27/2025 at 1:39 PM, Licensed Practical Nurse #2 stated registered nurses, and licensed practical nurses were responsible for entering provider orders into the computer system once the provider had issued an order. Nursing input the order and scheduled the time of administration based on the physician order. An order for a blood glucose (sugar) fingerstick would be entered into the computer to be done before and after meals, did not require a specific time, and nursing was trained to know what before and after meals indicated. Nursing had one hour before or after the scheduled time to administer medications. Licensed Practical Nurse #2 was unsure if additional boxes needed to be checked when the order was entered into the computer. During an interview on 1/28/2025 at 11:58 AM, Licensed Practical Nurse # 26 stated physician orders were entered into the computer. If an order for a blood glucose fingerstick was before and after meals and at bedtime, it was entered as a new order. They ensured the category standard medication-electronic medical record box was checked. This allowed nursing to see the order on the resident's electronic medication administration record. If the correct box was not checked, the physician order would only show up under general physician orders in the medical chart and would not transfer to the medication administration records and the fingerstick would be missed. The Director of Nursing was interviewed: - on 1/31/2025 at 1:50 PM, they stated orders were issued on paper by the nurse practitioner or physician and licensed nurses were responsible for putting the orders into the computer. A blood glucose monitoring fingerstick order would need to be placed under the category standard-electronic medical record, or electronic medication administration record order, for it to show on the medication administration record. - on 2/3/2025 at 8:23 AM, they stated they or the Assistant Director of Nursing reviewed hospital discharge orders. The current second check system occurred when they entered orders, and a second person checked them. They did not check their own entries. Another second check occurred the next day by the nurse practitioner. Once orders were entered, the after-visit summary which included the resident's discharge medications, would be scanned into the resident's electronic medical record under the miscellaneous tab. This was completed by 5:00 PM each day. It was rare that a nursing supervisor or off-shift nurse entered orders. If they did, the Director of Nursing or Assistant Director of Nursing would do the second check the following day. The only way to know if an order was transcribed incorrectly would be during a second check the following day. It was important for residents with diabetes to have their orders transcribed appropriately and receive their accuchecks and insulin or it could pose a serious health risk to the resident. It was considered a medication error if the orders were not transcribed correctly. During an interview on 2/6/2025 at 9:47 AM, Licensed Practical Nurse #28 stated Resident #1 was a bad diabetic. They stated they did not recall monitoring the resident's blood sugars from admission. Their nursing judgement would be to check the resident's blood glucose level before they administered insulin and call the physician for an order. Resident #1's blood sugars could have been low if they received insulin without their blood sugar being monitored. Licensed Practical Nurse #28 stated if Resident #1's physician order for finger sticks did not show up on the medication records then whomever placed the order made an error. The medication administration record would issue a reminder at least 1/2 half an hour before the fingerstick was due. Nurse Practitioner #15 was interviewed: - on 2/6/2025 at 10:17 AM, they stated all newly admitted diabetic residents received orders to monitor their blood sugars. Blood sugars (finger sticks) were monitored for at least five (5) days to evaluate whether the resident was stable and needed higher or lower doses of insulin or less frequent blood sugar monitoring. They expected nursing to enter the orders and check them for accuracy and review the resident's results with the provider after 5 days. Nurse Practitioner #15 stated they were Resident #1's primary care provider before admission, and the resident had uncontrolled diabetes for many years. They should have had blood glucose monitoring every day per their order. They were not aware the resident's finger sticks were not being obtained and did not know Resident #1 was hospitalized for a blood sugar of 1192. They stated the resident's emergency room diagnosis was a direct result of their finger sticks not being obtained. Hyperosmolar hyperglycemic state was a life-threatening condition caused from prolonged high blood sugars. Resident #1 not having their blood sugar monitored could have led to their death if they were not hospitalized . - on 2/19/2025 at 10:49 AM, they stated hospital discharge orders were initially reviewed by staff who approved the admission and then forwarded to nursing. Nursing reviewed the orders, and verbal orders were given by the providers until they could see the resident, typically within 48-72 hours of their arrival. Nursing would initially review orders and call with any discrepancies, and they would review orders and labs when they arrived. They were not aware if Resident #1 had orders for short-acting insulin as it was two years ago. They stated hospitals often prescribed short-acting insulin for diabetics but that became problematic if the resident did not eat. Nurse Practitioner #15 stated they would have kept the order for short-acting insulin for Resident #1 due to their history of uncontrolled diabetes and their lab value A1C level of 10.7%. This clearly showed Resident #1's diabetes was not under control and needed close monitoring. It was important to monitor Resident #1's blood glucose levels and administer insulin. If blood glucose levels were too high, kidney disease, ketoacidosis, cardiac or vascular disorders such as stroke could occur. - on 2/20/2025 at 9:48 AM, they stated Resident #1's blood glucose level of 118 decimeters per milliliter prior to their emergency room transfer could have been altered if nursing did not wait for alcohol to dry on their finger before obtaining the fingerstick reading. A blood glucose level of 1192 decimeters per milliliter could only result from a lab draw because glucometers did not read above 600. The facility glucometers were checked monthly for calibration and controls. During an interview on 2/7/2025 at 12:39 PM, Registered Nurse #20 stated licensed nurses were trained during orientation on how to put physician orders into the computer. They had an extra day during training to learn the various types of orders. The facility had a two-person check system. When a new physician order was entered into the computer it would go into a queue and a second nurse would sign into the computer to verify the order. The second nurse's username and password would time stamp and sign their name and that indicated the order had been checked. During an interview on 2/20/2025 at 9:18 AM, Medical Director #14 stated hospital discharge/admission orders were first reviewed by nursing and then the nurse practitioners. They saw newly admitted residents in the first week. They reviewed records the best they could but had to check records on three different computer systems that were not connected to one another. Residents with diabetes should be monitored for their blood sugars and receive short or long-acting insulin if ordered. They could not recall Resident #1 or if they had active blood glucose or insulin orders. They stated hyperosmolar hyperactive state was a complication of diabetes and could happen if a resident's blood sugars were not being monitored or insulin was not administered. 10NYCRR 415.12 (m)(2)

Based on record review and interviews during the abbreviated survey (NY00309249) the facility did not ensure the physician reviewed the total program of care, including medications and treatments, for one (1) of four (4) residents (Resident #1) reviewed. Specifically, Resident #1's hospital discharge orders included routine short-acting insulin and sliding scale (the amount of insulin administered was based on the results of blood glucose finger sticks) short-acting insulin. The resident did not have admission orders for routine short-acting insulin and sliding scale short-acting insulin as recommended. Subsequently, Resident #1 was hospitalized for hyperosmolar hyperglycemic state (severely high blood glucose levels with severe dehydration and confusion). This resulted in actual harm to Resident #1 that was not Immediate Jeopardy. Findings include: The facility policy, Transcription of Orders, was issued 1/2024, after the incident. There were no transcription policies available for 2023. Resident #1 had diagnoses including type 2 diabetes (the body does not use insulin effectively or does not produce enough insulin) and multiple sclerosis (a central nervous system disease). The admission Minimum Data Set assessment was not completed prior to the resident's discharge to the hospital on 1/21/2023. The hospital physician discharge summary dated 1/9/2023 at 2:42 PM, documented the resident's diabetes was poorly controlled. The resident was started on Lantus (glargine, long acting insulin) 10 units twice daily, in addition to Humalog (lispro, short-acting insulin) per sliding scale coverage, plus Humalog 3 units with meals. Chemstrips (fingerstick glucose readings) were improving. The 1/11/2023 at 10:59 AM Hospital discharge summary physician orders documented: - insulin glargine (a long-acting insulin) 100 units per milliliter injection, inject 10 units under the skin in the morning and 10 units before bedtime. - insulin lispro (a short-acting insulin) 100 units per milliliter injection, inject 5 units in the morning, 5 units at noon and 5 units in the evening. Inject with meals. - insulin lispro 100 units per milliliter injection, inject 0-14 units (sliding scale) under the skin four times a day before meals and nightly. - stop taking glimepiride (an oral anti-diabetic medication) 4 milligrams. The facility admission physician orders documented: - on 1/11/2023 (untimed) insulin glargine (Lantus, a long-acting insulin) solution 100 units per milliliter, inject 10 units subcutaneously (under the skin) twice a day for diabetes. - on 1/11/2023 at 5:09 PM (telephone order) documented accuchecks (finger sticks) before and after meals and at bedtime for diabetes. Call medical if less than 70 milligrams/deciliter and greater than 450 milligrams/deciliter. The order was entered into the computer at 5:11 PM by Registered Nurse #22 with the order type documented as standard other. The order was signed by Nurse Practitioner #15 on 1/13/2023 at 5:46 PM. There was no documented evidence of a facility admission physician order for routine short acting insulin and sliding scale insulin per the hospital discharge orders. The Weight and Vital Signs Summary did not include blood sugar (accuchecks) results prior to 1/21/2023. The 1/12/2023 Nurse Practitioner #15 progress note documented they reviewed external medical records. Hospital labs and consults were reviewed. The plan was to continue with Lantus 10 units twice daily and follow accuchecks (blood glucose finger sticks). There was no documented evidence Nurse Practitioner #15 reviewed accuchecks or the hospital discharge summary which included routine short acting insulin and sliding insulin scale. The 1/16/2023 Physician #14 History and Physical documented hospital labs and consults were noted and reviewed. The resident had controlled type 2 diabetes. The plan was to continue with Lantus 10 units twice daily and follow. There was no documented evidence Physician #14 reviewed accuchecks or the hospital discharge summary which included routine short-acting insulin and sliding insulin scale. The 1/21/2023 at 1:38 PM nursing progress note by Licensed Practical Nurse #23, documented the resident had a heart rate of 124 beats per minute. Physician #31 was updated on the resident's status and ordered the resident be sent to the emergency room for evaluation. An ambulance was called, and a message was left for the family representative. Licensed Practical Nurse #23 documented at 1:53 PM, the resident was admitted to the hospital for hyperkalemia (high blood potassium levels). The 1/21/2023 at 6:42 PM hospital physician progress note documented Resident #1 presented to the emergency room with an increased heart rate and mental status changes. They were found to have an elevated blood sugar level of 1192 milligrams/deciliter (drawn at 2:45 PM, normal for non-diabetic 75-115) and an elevated potassium level (7.0 milliequivalents/liter, normal 3.5-5.2). The resident was administered an insulin drip via intravenous (by vein) route and was started on medication to reduce their elevated potassium levels. Physician #29 documented the resident would be admitted into the Intensive Care Unit. Repeat blood work showed the resident continued with elevated blood sugar levels. The 1/25/2023 at 2:47 PM facility Physician #14 progress note documented Resident #1 was seen for a history and physical on 1/16/2023, medications and medication administration records were reviewed, and plan was to continue insulin glargine 10 units twice a day for type 2 diabetes. The progress note did not identify the instructions from the 1/11/2023 hospital discharge summary or identify Resident #1 had no accuchecks or short-acting insulin since admission. The 1/26/2023 at 10:37 AM hospital discharge summary documented the resident's discharge diagnosis was hyperosmolar hyperglycemic state (severely high blood glucose levels and other high level of substances in the blood). The resident had poorly controlled diabetes with a Hemoglobin A1C of 10.7% (a blood test that measures average blood glucose levels over the past 2-3 months, normal is less than 5.7%). The plan was to follow up with endocrinology as an outpatient. During an interview on 2/19/2025 at 10:49 AM with Nurse Practitioner #15, they stated hospital discharge orders were initially reviewed by staff who approved the admission and then forwarded to nursing. Nursing reviewed the orders, and verbal orders were given by the providers until they could see the resident, typically within 48-72 hours of their arrival. Nursing would initially review orders and call with any discrepancies, and they would review orders and labs when they arrived. They were not aware if Resident #1 had orders for short-acting insulin as it was two years ago. They stated hospitals often prescribed short-acting insulin for diabetics but became problematic if the resident did not eat. Nurse Practitioner #15 stated they would have kept the order for short-acting insulin for Resident #1 due to their history of uncontrolled diabetes and their A1C lab value (a lab value that measures blood glucose levels over time) of 10.7%. This clearly showed Resident #1's diabetes was not under control and they needed close monitoring. Anytime a resident with diabetes had complications including hospitalization , they always required glucose monitoring to determine how stable their blood glucose levels were. It was important to monitor Resident #1's blood glucose levels and administer appropriate insulin. They stated progress notes written by them were signed within two (2) days and reflected the resident's current plan of care. During an interview on 2/20/2025 at 9:18 AM, Physician #14 stated they had been the Medical Director of the facility for the past two years. They oversaw all residents in the facility. They stated hospital discharge/admission orders were first reviewed by nursing and then the nurse practitioners. They would not see newly admitted residents for a week. They stated they reviewed records the best they could but had to check records on three different computer systems that were not connected to one another. Residents with diabetes should have their blood glucose monitored and receive short or long-acting insulin if ordered. They could not recall Resident #1 or if they had active blood glucose or insulin orders. They stated hyperosmolar hyperactive state was a complication of diabetes and could happen if a resident's blood sugars were not monitored or insulin was not administered. Progress notes written by them were not signed or dated on the same day, but within two (2) days and reflected the Resident's current plan of care. 10NYCRR 415.15(b)(2)(iii)

Based on record review and interviews during the abbreviated survey (NY00308422), the facility did not ensure the residents' environment remained free of accident hazards and residents received adequate supervision to prevent accidents for 1 of 1 resident (Resident #2) reviewed. Specifically, Resident #2 had an unwitnessed fall and complained of pain the following morning. The medical provider was not notified until 2 days after the fall, an x-ray was not completed until 2 days and 17 hours after the resident complained of pain, and an investigation was not initiated timely to rule out abuse. Subsequently, the resident was hospitalized and was diagnosed with a left hip fracture. Findings include: The facility policy, Fall Prevention Program, revised 9/2017, documented residents at risk for falls were identified on the certified nurse aide assignment sheet. Residents were assessed for fall risks on admission, re-admission, change in condition, and quarterly thereafter. Interventions included assess environment for lighting, floor, bathroom, bed height, appropriate chair, and accessible storage. Monitor staff compliance with fall prevention measures including assistance with transfers, ambulation and other activities as needed and followed directions for Resident care as indicated on the Resident care flow sheets. The facility policy, Accident/Incident Policy and Procedure, revised 12/2018, documented it was the responsibility of staff to report all incidents and accidents that occurred at the facility. The accident/incident form would be filled out by the person with knowledge of the situation. The Registered Nurse Supervisor would complete the document and document the assessment of the resident's condition and notify the attending physician and family representative. The accident/incident report must be completed on the shift the incident occurred; the nursing supervisor was responsible for starting an investigation and obtaining witness statements. The investigation must be completed within 72 hours. If the injury was unknown from a fall, statements were obtained going back 24-48 hours to determine the cause of the injury. The Director of Nursing reviewed all accident/incident reports for accuracy and completed documentation of the incident to determine if there was credible evidence to substantiate an allegation of abuse, neglect, or mistreatment. Resident #2 had diagnoses of dementia, history of falls, and unsteady balance. The 11/24/2022 Minimum Data Set assessment documented the resident had severely impaired cognition, required extensive assistance of 2 for bed mobility and transfers, was dependent for bathing, toileting and personal hygiene, had no functional limitations in either upper and lower extremities, and used a wheelchair. The Comprehensive Care Plan initiated 9/22/2021 documented the resident had a history of falls with/without injury. Interventions included continue interventions on the at-risk plan, encourage rest periods in-between meals, floor mats next to bed on both sides, if noted to be near edge of bed during 1-2 hour rounds, re-position to middle of bed, low bed, rounding every 1-2 hours to anticipate needs, non-skid socks on while in bed, offer to put resident to bed between 9:00-10:00 PM unless resident appeared tired, send to emergency room for evaluation for any falls with head injury, keep resident in area where staff could monitor while awake, neuro checks per facility policy, monitor/document/report to physician as needed any signs/symptoms of pain, bruising, change in mental status, new onset, confusion, inability to maintain posture, agitation. The 1/3/2023 at 9:15 PM Registered Nurse Supervisor #6 progress note documented they were called to the resident's unit for a fall. Resident #2 was found on the floor next to their bed. An assessment was completed, the resident's hips were palpated (felt) and pelvis was pressed on, no injuries were noted. The resident was assisted back to bed via a lift sheet. The resident's family representative was made aware of the fall. There was no documented evidence if the fall was witnessed, the medical provider was notified, or an investigation was initiated to rule out abuse, neglect, or mistreatment. The 1/4/2023 at 6:18 PM nursing progress note by Registered Nurse #6 documented they were made aware of the resident experiencing pain to their left hip, the resident was a poor historian, could have Tylenol (pain reliever) 650 milligrams for pain, and the family representative was aware x-rays could be completed if needed. There was no documented evidence the medical provider was notified of the resident's increased complaints of pain. The 1/4/2023 at 6:30 PM Licensed Practical Nurse #21 progress note documented the resident was given 650 milligrams of Tylenol for pain. At 7:28 PM Licensed Practical Nurse #21 documented the pain medication administration was effective with a follow-up pain level of 2 (on a 1-10 pain scale). The 1/6/2023 at 1:08 PM nursing progress note by Registered Nurse Unit Manager #3 documented the resident representative was concerned about the unwitnessed fall 2 days prior. The resident was transferred to bed for an assessment. Swelling was noted to the left upper thigh/hip area with some shortening in comparison to the right leg. The resident complained of discomfort with touch around the hip area. Nurse Practitioner #15 was updated on the condition, an x-ray was requested, and an order obtained. The X-ray report returned with a result of acute displaced and slightly impacted intertrochanteric fracture of the left hip (a bone break to the hip joint where the bone ends were slightly pushed into each other). The resident representative was notified and pending transfer to the emergency room . Resident left the facility by ambulance at 12:40 (did not include AM or PM). The 1/6/2023 at 11:10 AM X-ray report results documented Resident #2 had an acute displaced and slightly impacted intertrochanteric fracture of the left hip. The 1/6/2023 at 1:53 PM hospital emergency room progress note documented Resident #2 arrived for evaluation, had sustained a fall 2 days prior and x-rays prior to arrival documented a fracture to the left hip. The 1/9/2023 at 9:00 PM nursing progress note by Registered Nurse Supervisor #6 documented the resident returned to the facility from the hospital and had a left hip fracture repair. Surgical dressing was intact, and the resident was to follow up with the orthopedic surgeon. The 1/10/2023 at 3:51 PM facility Accident/Incident report and Investigation Summary completed by Registered Nurse #20 (7 days after the resident's unwitnessed fall) documented Resident #2 had a fall out of bed on 1/3/2023. The investigation determined the resident was left in a high position in the bed by Certified Nurse Aide #8 and a care plan violation had occurred. Resident #2 fell out of bed from the high position and sustained a left hip fracture. Medical was notified on 1/6/2023, X-rays obtained, and the Resident was sent to the emergency room for evaluation. Certified Nurse Aide #8 was issued a disciplinary notice for a care plan violation and Registered Nurse Supervisor #6 was issued a disciplinary notice for not notifying medical and had not initiated an investigation. The Accident/Incident Report did not include witness statements. There was no documented evidence how the facility determined abuse, neglect, or mistreatment did not occur from 1/3/2023-1/6/2023. During an interview on 1/27/2025 Certified Nurse Aide #1 stated during resident care, the aides would often raise the beds up to their waist level, perform care and then lower the bed back down when finished. If a bed malfunctioned, they would never leave the resident alone. They were expected to put the call light on or yell for help for another staff member. They stated Resident #2 required total care and assistance of 2 staff. Certified Nurse Aide #1 stated they had been out on medical leave for a period so were unaware if the resident had a fall. During an interview on 1/27/2025 at 1:23 PM, Registered Nurse Unit Manager #3 stated assessments and neurological checks were completed when a resident sustained an unwitnessed fall, and the medical provider and family representative were called. Certified nurse aides knew how to care for residents by the resident Kardex, and a shift huddle at the beginning of shifts by the nurses was done to verbalize any reports to the aides. Residents should never be left in bed in a high position, if a bed was not working properly then staff should yell for help or put the call light on. Registered Nurse Unit Manager #3 stated they did not recall the incident with Resident #2. During an interview on 1/27/2025 at 1:39 PM, Licensed Practical Nurse #2 stated they thought Resident #2 had a fall but was unsure of the incident. A Supervisor should be called to the Unit if a resident had a fall. They recalled hearing the resident had a fractured hip but did not recall details. They stated a resident should never be left in a bed left in a high position. Certified nurse aides knew how to care for residents by looking at the Kardex. During an interview on 1/28/2025 at 3:30 PM, Certified Nurse Aide #9 stated they were working on the evening Resident #2 fell out of bed. They stated they helped transfer Resident #2 to bed with Certified Nurse Aide #8 and left the room. They stated they told Certified Nurse Aide #8 to please make sure the resident's bed was put in the low position before they exited the room. Certified Nurse Aide #9 stated approximately 10 minutes later they returned to the hall outside of the resident's room to retrieve linen and saw the resident on the floor next to the bed in their room. The bed was in a high position. During an interview on 1/28/2025 at 3:35 PM, Registered Nurse Supervisor #6 stated they were called to the resident's Unit for a fall. Resident #2 was found lying on the floor next to the bed on a floor mat and when they entered the room, the bed was in the low position. They stated staff did not advise them the resident's bed was in a high position when the resident was found on the floor. They completed an assessment and did not observe any injuries. They stated Resident #2's son was aware of the incident, but they did not notify the medical provider and did not initiate an investigation. They stated they did not initiate an investigation due to staff not advising them the bed was high, and their assessment might have changed with that knowledge. Registered Nurse Supervisor #6 stated the resident had previously falls, and agency certified nurse aides received training on resident safety. They stated Certified Nurse Aide #8 was terminated. They stated they received a disciplinary notice for not reporting the incident, not notifying medical or completing an investigation. WHEN? During an interview on 1/29/2025 at 9:23 AM, Licensed Practical Nurse #7 stated they were on duty the evening Resident #2 had a fall. They were alerted to the fall and when they entered Resident #2's room, the resident was on the floor and the bed was in a high position, approximately chest level- above waist level but below shoulder level. They stated they alerted Registered Nurse Supervisor #6 of the fall, obtained vital signs on Resident #2 and contacted the family representative. Resident #2 was care planned for a low bed and fall mats, and interventions carried over to the Kardex. Licensed Practical Nurse #7 stated the resident fell from a high bed after the certified nurse aide left the room, facility protocol was one certified nurse aide always remained with a resident during care, and you never left a resident alone in a high bed. Agency certified nurse aides received the same training as regular staff. During a telephone interview on 1/29/2025 at 11:52 AM, Certified Nurse Aide #8 stated they worked for the facility's agency company and worked the evening of Resident #2's fall. Resident #2 was on their assignment. They stated they had raised the bed up to change and wash Resident #2 and when they finished, they could not lower the bed. They stated they left Resident #2 in the bed in a high position approximately at their hip level and exited the room to tell a nurse. They stated they were not aware they could not leave a resident in a high bed position alone. They stated the resident's bed malfunctioned, and they did not know to unplug or re-plug it into the wall to make it work. During an interview on 1/29/2025 at 2:26 PM, Registered Nurse #20 stated they were the former Director of Nursing at the facility, was not alerted to Resident #2's fall until they reviewed a 24-hour report 3 days later. They immediately initiated an investigation and obtained witness statements. They determined Registered Nurse Supervisor #6 did not initiate an investigation to rule out abuse and Certified Nurse Aide #8 had a care plan violation for leaving Resident #2 unattended in a high bed position. Both staff members were issued disciplinary notices. Registered Nurse #20 stated protocol was to always notify medical and a family representative of a resident's fall even if they did not present with injuries. An accident/incident report should be initiated as well as an investigation to rule out abuse. The accident/incident report guided staff on how to conduct the investigation. Registered Nurse Supervisor #6 should have initiated an investigation into the fall and ruled out abuse and should have notified medical. Staff involved in the Resident's care should be suspended until abuse was ruled out. If Resident #2 complained of pain the following day, Registered Nurse #6 should have called medical and obtained an X-ray order then. It was unacceptable to not follow through with an investigation and reporting. During a telephone interview on 1/31/2024 at 1:50 PM, Director of Nursing #21 stated the Kardex determined how to care for a resident. If a Resident was in bed in a high position, it was unacceptable for a certified nurse aide to leave the room. Aides were trained raise a Resident ' s bed during care and to immediately lower it when care was completed. If a resident had a fall, protocol was to call a Registered Nurse Supervisor to the unit. The Registered Nurse Supervisor was responsible for conducting a resident assessment and notifying medical and the family representative. Medical should be notified whether or not the resident had an injury. The accident/incident form, which included a full investigation to rule out abuse or neglect, should be initiated by the Supervisor and witness statements should be obtained. It was important to notify medical and investigate to ensure an injury or other situation was not missed. If a resident was in a bed in a high position, it was unacceptable for a certified nurse aide to leave the room. Aides were trained raise a resident's bed during care and to immediately lower it when care was completed. 10NYCRR 415.12(h)(I)

Based on observation, interview, and record review during the recertification survey conducted 1/8/2024- 1/12/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Specifically, the main kitchen walk-in cooler had a foul odor and food debris on the floor; and steam table pans were stacked wet inside one another and not air dried as required. Findings include: The facility policy Sanitation of Kitchen, Food Service Equipment & Work Surfaces revised 2/2022 documented food service equipment and surfaces are cleaned. Food contact surfaces of stationary food service equipment and work surfaces are cleaned and sanitized to minimize the risk of pathogen and chemical contamination. Food-contact surfaces and equipment were to be washed with the appropriate cleaning solution with approved cleaning tools, rinse the surface, and allow surface or equipment to air dry. During an observation of the main kitchen on 1/8/2024 at 9:52 AM, the walk-in cooler had a foul odor and unclean floor sections with food debris under the storage racks. During an interview on 1/8/2024 at 9:52 AM, the Food Service Director stated they were not sure when deep cleaning or the floors were cleaned because they had only been there a week. They stated they expected deep cleaning to be done weekly, or at least once a month. All equipment should be moved and cleaned including the equipment in the walk-in coolers. During an observation on 1/9/2024 at 11:34 AM the main kitchen had multiple stainless-steel containers ranging from 2-6 inches deep stacked approximately 6 pans deep for 8 stacks on the rack next to the cook line. When separated the pans were still wet inside. At 11:37 AM, the walk-in cooler floors were unclean with food debris. During an interview on 1/9/2024 at 11:37 AM, the Food Service Director stated the pans should not be wet and they expected the dish machine staff to air dry them before storing and stacking them on the rack. 10NYCRR 415.14(h)

Based on observation, interview, and record review during the recertification survey conducted from 1/8/2024-1/12/2024, the facility did not ensure each resident received food that accommodated resident allergies, intolerances, and preferences for 2 of 4 residents (Residents #1 and #54) reviewed. Specifically, Resident #1 did not receive gluten free (a protein found in some grain products) options as ordered; and Resident #54 was not provided their food preference for 2 meals. Findings include: The facility policy Food Preparation and Production revised 2/2022 documented food was prepared and produced by methods that conserve nutritive value, flavor, appearance, and maintain food safety; The facility would utilize production report/menu tally to identify the number of servings needed for each food item that was to be served for a specific meal for regular, mechanically altered, and therapeutic diets. Production quantities would be adjusted based on the current census, diet tally, food preferences, allergies, intolerances, and employee and guest meals. 1) Resident #1 was admitted to the facility with diagnoses including moderate protein-calorie malnutrition, and depression. The 12/27/2023 Minimum Data Set assessment documented the resident had moderately impaired cognition, was independent with eating, and received a mechanically altered, therapeutic diet. Physician orders dated 9/20/2023 documented the resident was to receive a mechanical soft gluten free diet and thin liquids. The undated comprehensive care plan documented an unintended weight loss related to poor dentition and varied oral intakes. Interventions included diet per physician order gluten restricted, mechanical soft solids, and thin liquids. Obtain/provide/honor and monitor the resident's food/beverage preferences/eating patterns. The care instructions (Kardex) as of 1/12/2024 documented special instructions of gluten free. The diet per physician order was gluten restricted, mechanical soft solids, thin liquids. Meal tickets dated 1/8/2024-1/10/2024 documented the resident was to receive a gluten restricted diet, mechanical soft texture, with thin liquids. Allergies were listed as wheat and grapefruit, no dislikes, and other: gluten free. The following observations were made: - on 1/8/2024 at 12:42 PM the resident's lunch meal ticket listed ground beef patty with gravy, vegetables, gluten free spaghetti as a side, gluten free garlic bread, and fruit for dessert. The resident's tray included ground beef and vegetables. There was no gravy, gluten free spaghetti, gluten free garlic bread or fruit for dessert on the meal tray. The resident stated the food was cold. - on 1/9/2024 at 12:28 PM the resident's lunch meal ticket listed ground chicken, mashed potatoes, vegetables, 1 slice of gluten free bread, and fruit for dessert. There was no gluten free bread on the meal tray. - on 1/10/2024 at 12:28 PM the resident's lunch meal ticket listed the ground beef cubes with broth, and gluten free noodles. The resident was served ground (mechanical soft) beef stroganoff, peas, drinks, and fruit for dessert. There were no gluten free noodles provided. The kitchen production sheet for lunch on 1/10/2024 documented ground beef cubes with broth, and gluten free buttered noodles. During an interview on 1/10/24 at 1:30 PM, dietary aide #19 stated their job duties were to serve breakfast and lunch on the unit. Some of the residents on the unit had special diets. All diet information was listed on the meal ticket. There were 2 pans of beef stroganoff today, one was regular and the other was ground consistency. The noodles were either regular or pureed consistency. There were not any ground beef cubes in broth, and they thought the beef stroganoff was gluten free. There were no gluten free noodles. They stated they did not give noodles to the resident as the noodles they had on the unit were not gluten free. They were supposed to call the kitchen for any missing items to get the item or a substitute. They did not do that today for the gluten free noodles. The dietitian puts the information on the meal tickets, and the food service director prints them out. During an interview on 1/10/2024 at 2:12 PM, the Food Service Director stated different diets were needed to accommodate the residents' ability to swallow, or allergies. The registered dietitian made out the meal tickets based on dietary needs. A food allergy would be listed on the resident's meal ticket. There were alternates for each meal service there were special products for lactose intolerance or gluten free diets. The department needed to expand the gluten free menu. Currently there was no gluten free pasta or gluten free bread available. The recipe for beef stroganoff contained a little flour, so it was not gluten free. The production sheet for the cook documented foods needed for each resident for each meal. If a resident's diet was not followed it could be a risk. During an interview on 1/10/2024 at 2:39 PM, cook #21 stated they used the production sheets to know what to cook for meals. They did not have gluten free noodles available to make today. They should tell the supervisor if they were missing food items. They stated they missed the need for beef with no gravy and did not make it. The beef stroganoff was prepared per the recipe, so it was not gluten free. The residents needed to have the prepared food as ordered. During an interview on 1/10/2024 at 4:40 PM, registered dietitian #22 stated they assessed residents for dietary needs and preferences. They made sure the residents' menus reflected allergies, preferences, and modifications per medical orders. Meal tickets were generated by the computer software after they entered the information into the computer. A production sheet was printed for cooks using the same software. The production sheets had the needed foods and beverages to be prepared. Dietary aides plated the food using the meal ticket and staff on the floor double checked that the ticket and tray matched. A gluten restricted diet meant no gluten and no wheat. Ground beef cubes with beef broth was the gluten free entree today. A lack of menu items that met residents' needs may contribute to weight loss. 2) Resident #54 was admitted to the facility with diagnoses including cerebral infarction (stroke), dementia, and anxiety. The 12/12/2023 Minimum Data Set assessment documented the resident had moderately impaired cognition, was dependent on staff for most activities of daily living and required set-up assistance with eating. Physician orders dated 3/3/2022 included general diet, regular texture, thin consistency liquids. The 12/8/2023, registered dietitian nutrition evaluation documented the resident was on a general/house diet with regular solid food, thin liquids, and required a Kennedy cup (spillproof cup with a lid) for cold drinks. The resident was not to receive salad, hard bread, bagels, English muffins, pizza, Brussels sprouts, cauliflower, or broccoli on their tray. Their food preferences/dislikes were coffee, oatmeal, and eggs. The resident required set-up assistance including encouragement to sit upright at 90 degrees, alternate liquids with foods, and to take small bites and sips at a slow rate. The resident's meal tickets dated 1/8/2024-1/10/2024 documented house (general) diet, regular texture with thin liquids. Resident dislikes were listed as coffee, oatmeal, and eggs. The following meal observations of Resident #54 were made: - on 1/9/2024 at 9:08 AM the resident was in bed in a gown with their breakfast tray on an overbed table. There was a bowl of oatmeal untouched on the tray. The meal ticket documented the resident was to receive choice of hot or cold cereal, and their dislike was listed as oatmeal. - on 1/10/24 at 9:24 AM the resident's breakfast tray was in their room. The resident ate 2 slices of toast, did not eat the hash browns, and the bowl of oatmeal was untouched. Oatmeal was listed as a dislike on their meal ticket. The resident stated they did not like oatmeal. During an interview on 1/10/2024 at 4:56 PM registered dietitian #22 stated that preferences were assessed on admission. Care plan meetings were held quarterly, annually, and as needed when preferences were reviewed. If a food item was listed as a dislike, it should not be provided on the meal tray. Resident #54's meal ticket had a choice of hot or cold cereal, and oatmeal was listed as a dislike. Servers should check dislikes when serving the food, and make sure residents were getting preferred foods. During an interview on 1/11/2024 at 11:33 AM, registered nurse Unit Manager # 12 stated staff delivering meal trays were responsible to double check that the tray and ticket matched. A resident should not be served food items they did not like. During an interview on 1/11/2024 at 1:26 PM, certified nurse aide #23 stated one of their job duties was to deliver meal trays to residents. They were to make sure if the resident did not want the meal, they were offered a substitute. They were supposed to check to make sure the items on the tray matched the meal ticket. If they did not match, they should tell the dietary aide or call the kitchen. They also need to check meal ticket and food to ensure diet texture, liquid consistency, allergies, and resident likes/dislikes were correct. 10NYCRR 415.14(d)(3)(4) 48675

Based on observation, record review, and interview during the recertification survey conducted 1/8/2024-1/12/2024, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 2 residents (Resident #77) reviewed. Specifically, Resident #77 did not receive a magnetic resonance imaging (a test to view images of the anatomy) to their left heel as ordered to rule out osteomyelitis (bone infection). Findings include: Resident #77 was admitted to the facility with diagnoses including sepsis (system wide infection), diabetes, and difficulty walking. The 10/13/2023 Minimum Data Set assessment documented the resident had intact cognition, was dependent putting on and taking off footwear, and with transfers. The resident had a stage 2 pressure ulcer (partial thickness loss of top layer of skin), a stage 3 pressure ulcer (full thickness tissue loss), a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle), and had open lesion(s) on their foot, received pressure ulcer care, applications of dressings to feet (with or without topical medications), and antibiotic medications. The 10/16/2023, Nursing Admission Assessment, completed by licensed practical nurse Assistant Unit Manager #1 documented the resident had a wound to their left lower extremity, had activity of daily living impairments due to left foot wounds, was non-weight bearing on their left foot, and had pressure ulcers to left heel and left toe(s). The 10/16/2023, comprehensive care plan documented the resident had a stage 4 pressure ulcer on the left heel. Interventions included if dressing falls off report to nurse, monitor site for signs and symptoms of infection, treatments as ordered, and weekly wound rounds. A 11/1/2023 wound care physician #6 progress note documented the left heel wound was a Stage 4 pressure ulcer, measured 4.6 centimeters by 3 centimeters by 0.2 centimeters, 60% viable (living) tissue (tendon), and the progress of the wound and context of surrounding the progress were considered in greater depth today. Relevant conditions including infection considered and addressed through treatment changes. A 11/3/2023 nurse practitioner #5 progress note documented nursing staff asked them to follow up with the patient as there was some exposed bone on the left heel and to start a workup for osteomyelitis. The plan included to obtain magnetic resonance imaging of the left heel. The 11/3/2023, physician order documented magnetic resonance imaging to the left heel to rule out osteomyelitis (an infection in a bone). There was no documented evidence the magnetic resonance imaging was scheduled or completed as ordered. A 12/19/2023 licensed practical nurse (LPN) #13 progress note documented the resident's left lower extremity was reddened, warm to the touch, and sore. The wound had foul purulent (containing pus) drainage and a note was placed in the medical book for evaluation. A 12/20/2023 nurse practitioner #5 progress note documented they were asked to see the resident by nursing staff. The resident had a left lower extremity wound with exposed bone and was supposed to have magnetic resonance imaging that had not been completed at this time. There was no documented evidence the magnetic resonance imaging was re-ordered or scheduled. A 12/29/2023 nurse practitioner #5 progress note documented the resident was supposed to have magnetic resonance imaging and they had not seen that this had been completed at this time. The resident had a left lower extremity wound with exposed bone. The treatment plan included to start 100 milligrams of antibiotics twice daily for 10 days. There was no documented evidence the magnetic resonance imaging was re-ordered or scheduled. A 1/1/2024 registered nurse #15 progress note documented antibiotic usage, the resident had cellulitis, soft tissue or wound infection, and there was new or increasing presence of redness in the left heel. A 1/2/2024 nurse practitioner #5 progress note documented the resident was supposed to have magnetic resonance imaging and they had not seen that it had been completed at this time. The resident had left lower extremity wound with exposed bone. There was no documented evidence the magnetic resonance imaging was re-ordered or scheduled. During an observation on 1/10/2024 at 9:01 AM, the resident was in their room working with therapy staff. At 9:08 AM, the resident stated the wound care team would be in to see them today. During an interview on 1/11/2024 at 10:28 AM licensed practical nurse Assistant Unit Manager #1 stated the physician or nurse practitioner would relay new orders to the nursing staff either verbally or they would write the orders in the medical book. It was the responsibility of the nurse on duty to ensure the new orders were entered into the medical record system. If a resident had a new order for a consult, such as a magnetic resonance imaging, they entered the order into the medical record and contacted the transport scheduler by telephone or email to let them know a consult had been ordered and needed to be scheduled. It was the responsibility of the transport scheduler to set up the appointment and let nursing staff know if any additional paperwork was needed. They stated Resident #77 did have an order dated 11/3/2023 for magnetic resonance imaging to rule out osteomyelitis, the order was entered into the medical record system by licensed practical nurse #8. They did not see that this appointment had occurred yet. It was important for the magnetic resonance imaging to be completed to ensure there was no infection. They stated the registered nurse Unit Manager should ensure all medical orders were completed as ordered. During an interview on 1/11/2024 at 11:15 AM registered nurse Unit Manager #7 stated the physician or nurse practitioner relayed new orders to the nursing staff either verbally or they would write the orders in the medical book. It was the responsibility of the nurse on duty to ensure the new orders were entered into the medical record system. If a resident had a new order for a consult, such as magnetic resonance imaging, they entered the order into the medical record and contacted the transport scheduler by telephone or email to let them know a consult had been ordered and needed to be set up. Resident #77's medical orders included magnetic resonance imaging ordered on 11/3/2023. They were unsure if it had been completed at this time, but it should have been as it was a long time to wait. They stated they were made aware the magnetic resonance imaging was not completed as ordered on 12/26/2023 when they were asked to provide additional paperwork. They had not followed up with anyone regarding the status of the magnetic resonance imaging at this time. It was important for the magnetic resonance imaging to be completed as ordered to ensure the resident did not have an infection. During a telephone interview on 1/11/2024 at 12:42 PM nurse practitioner #5 stated new orders were communicated either verbally or written in the medical book. They expected orders to be completed including consults. Once the consult was completed, they expected to be made aware of the results when they came in. They had ordered magnetic resonance imaging to rule out osteomyelitis for Resident #77 on 11/3/2023. The magnetic resonance imaging had not been completed at this time. They were aware there was a previous delay due to the need for no contrast (an injection of a dye that highlights soft tissues, so they show up more clearly to determine a diagnosis) to be used during the magnetic resonance imaging, as they resident had kidney issues. They had not been made aware of any other issues that would delay the consult. They stated they discussed the need for the magnetic resonance imaging with registered nurse Unit Manager #7 about 2 weeks ago. They felt the resident needed the magnetic resonance imaging completed to rule out possible infection and stated imaging could see more than the eye. During an interview on 1/11/2024 at 1:05 PM licensed practical nurse #8 stated the physician or nurse practitioner relayed new orders to the nursing staff either verbally or they would write the orders in the medical book. It was the responsibility of the nurse on duty to ensure the new orders were entered into the medical record system. If a resident had a new order for a consult, such as magnetic resonance imaging, they entered the order into the medical record and contacted the transport scheduler by telephone or email to let them know a consult had been ordered and needed to be set up. It was the responsibility of the transport scheduler to set up the appointment and let nursing staff know if any additional paperwork was needed. They stated they entered the order into the medical record system for Resident #77's magnetic resonance imaging on 11/3/2023 and let the transport scheduler know there was an order. They thought the Unit Manager was responsible to ensure the consult was completed as ordered. During a telephone interview on 1/11/2024 at 1:28 PM transport scheduler #9 stated they scheduled the consults and set up transportation when they were notified. If there was an issue with scheduling, they would let the Nurse Manager know. They let previous registered nurse Unit Manager #10 they had sent the information over for the resident's magnetic resonance imaging consult in November 2023 and additional paperwork was needed. Licensed practical nurse Assistant Unit Manager #1 asked about the consult and they provided them with the additional paperwork requested by the imaging center. They had not heard anything else about the consult. They thought it was important for the consult to be completed to ensure the resident was taken care of. They were not sure why the resident had not had the consult completed at this time. During an interview on 1/11/2024 at 1:55 PM the Director of Nursing stated when nursing staff was notified of new orders for a consult, they should enter it into the medical record and let the transport scheduler know so the consult could be set up. They stated it was some back and forth with the facility and the imaging center regarding the resident's ordered magnetic resonance imaging. Former registered nurse Unit Manager #10 did not pass the information along to the new Unit Manager and there was a break in communication. The magnetic resonance imaging should have been completed to rule out osteomyelitis. During an interview on 1/11/2024 at 2:23 PM registered nurse Unit Manager #10 stated they were the previous Unit Manager on the resident's unit. They communicated with the transport scheduler on 11/7/2023 to let them know the need for the magnetic resonance imaging. They left the position as Nurse Manager and started another position, so they were unaware the magnetic resonance imaging was not completed, and they had not been asked about the magnetic resonance imaging. It was important for the magnetic resonance imaging to completed to ensure the resident had no negative outcomes. 10NYCRR 415.12

Based on observation, record review, and interview during the recertification and abbreviated (NY00320208 and NY00323561) surveys conducted 1/8/2024-1/12/2024, 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 1 of 4 residents (Resident #54) reviewed. Specifically, Resident #54 was not provided assistance with bed mobility, incontinence care, and oral and personal hygiene. Findings include: The facility policy Activities of Daily Living issued 6/2023 documented activities of daily living are the essential tasks each person needs to perform, on a regular basis, to sustain basic survival and well-being. Staff were to provide assistance to complete activities of daily living per the person centered evaluation and care plan. Resident #54 was admitted to the facility with diagnoses including cerebral infarction (stroke), malignant neoplasm (cancer) of the lung, and dementia. The 12/12/2023 Minimum Data Set assessment documented the resident had moderately impaired cognition, did not reject care, was dependent on staff for most activities of daily living, and required set-up assistance for eating. The comprehensive care plan initiated 3/4/2022 documented the resident had a self-care performance deficit related to lung cancer, compression fracture, and kyphoplasty (surgery to treat compression fractures in the spine). Interventions included extensive assistance to turn and reposition in bed, for dressing, personal hygiene, oral care, and toileting care. The comprehensive care plan initiated 8/17/2022, documented the resident was at risk for oral/dental health problems related to metastatic lung cancer. Interventions included provide mouth care as per activity of daily living personal hygiene task. The resident had increased potential for skin breakdown related to decreased mobility, metastatic lung cancer, and incontinence. Interventions included encourage to reposition every 3-4 hours, provide incontinence care as needed, and a special air mattress set to current weight. The care instructions as of 1/12/2024, documented encourage to turn and reposition every 3-4 hours, bed mobility with extensive assistance of 1 to turn and reposition in bed, supporting roll to posterior bilateral knees, pillow between knees, and heel protection boots. The resident required set-up assistance with eating and encourage to take small bites. The following observations of the resident were made: - on 1/8/2024 at 2:42 PM, in bed in a hospital gown, positioned on their right side with knees bent. - on 1/9/2024 at 9:08 AM, in bed in a gown, positioned on their right side with knees bent. The resident stated they were in pain. At 12:38 PM, lying flat in bed on their right side with both knees bent up. The resident's lunch tray was on the overbed table, and the resident was attempting to feed themself. At 1:14 PM, the resident had eaten their mashed potatoes and drank fluids. They remained lying flat in bed on their right side with their knees bent. - on 1/9/2024 at 1:28 PM, a wound treatment was observed with licensed practical nurse #2. The resident's incontinence brief was completely saturated, and the resident was wet all the way up their back. The incontinence pad under the resident was wet. The resident stated the last time their brief was changed was before breakfast, and they had not been offered any assistance with repositioning, eating, oral hygiene, or personal hygiene that day. The January 2024 task schedule for care provided to the resident documented toileting care was provided on 1/9/2024 at 2:20 AM, and not again until 1/9/2024 at 7:50 PM. There was no documented refusal of care, and no progress notes of refusal of care on 1/9/2024. During an interview on 1/9/2024 at 2:04 PM, certified nurse aide #3 stated they had been working since 6:00 AM that morning. First thing in the morning they checked the assignment list and Resident #54 was on their list today. They stated the resident had not been changed or repositioned since they came on duty. Resident care information was found in the care plan in the computer. They were told by other staff the resident sometimes refused care, but they should always be offered assistance anyway. The certified nurse aide stated they did not provide incontinence care, repositioning, personal hygiene at all since they came on at 6 AM. They offered no explanation why the resident's care was not completed. They stated if they were unable to complete their assignment, they should notify a supervisor and ask for help. Residents should be checked, changed if needed, and repositioned every 2 hours. Oral care and personal hygiene were to be performed with morning care. If care was not done, the risk to the resident could be rashes or pressure sores, and they would not be comfortable. During an interview on 1/9/2024 at 2:07 PM, licensed practical nurse #2 stated that certified nurse aides were responsible for resident care which included incontinence care, turning and positioning, and oral hygiene. The care information was found in the computer. Residents should be checked, changed if needed, and repositioned every 2 hours to prevent skin breakdown. Any skin changes should be reported to the supervisor. The licensed practical nurses and Unit Manager oversaw certified nurse aides. Licensed practical nurse #2 stated they were not aware that Resident #54 had not received care on this day. If a resident was not changed and repositioned, they could have skin breakdown, discomfort, and moisture to the skin. During an interview on 1/9/2024 at 2:15 PM, registered nurse Unit Manager #12 stated incontinence care and repositioning was the responsibility of the certified nurse aides. The care information was found in the Kardex in the computer. Residents should be checked, changed if needed, and repositioned every 2-4 hours. This would reduce the potential for skin breakdown from pressure or moisture. Any change in a resident's skin should be reported to a nurse for assessment. They were not aware that Resident #54 did not receive any care during this shift. If a resident refused care, staff were to report it to the nurse. During an interview on 1/12/2024 at 12:11 PM, the Director of Nursing stated staff found resident care information in the computer. A resident should be checked and changed and repositioned every 2-4 hours. If this was not done the risk to residents could be skin breakdown and it could contribute to new or worsening pressure areas. It would not be comfortable for a resident to be wet for an extended period. Nurse Managers were responsible for oversight of their units and staff were expected to report refusals of care. 10NYCRR 415.12(a)(3)

Based on observation, interview, and record review during the recertification and abbreviated (NY 580) surveys conducted 9/27/21-9/30/21, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 3 units (Unit 3) observed. Specifically, areas were in disrepair, and equipment was not clean or working properly and insulated dome plate covers were observed to be unclean. Findings include: During an observation in the Unit 3 dining room on 9/27/21 at 11:06 AM, there were 3 stacks of green dome plate covers on the counter with food side up, and a stack near the coffee pot. One green cover near the coffee pot had a black sticky substance on the outside of the dome and one had a white flaky substance. When observed on 9/27/21 at 4:26 PM, there was a scraped section on the bottom of the bathroom door and the adjacent inside wall with black marks 3 feet long with some joint compound repair in resident room 305. When observed on 9/27/21 at 4:33 PM, the Packaged Terminal Air Conditioner (PTAC) unit in resident room 318 was leaking and there were 2 bed pans and a clear storage bin under the unit collecting water. All bins were sitting on a soiled gray pressure mat on the floor with white discoloration showing. When interviewed on 9/27/21 at 4:33 PM, Resident #50 stated their PTAC unit had been leaking during the summer and the facility staff came in and used a vacuum to suck out the water and it seemed to be okay after that for a while. They stated a staff member had slipped on the water on one occasion. When observed on 9/28/21 at 10:14 AM, the wanderguard panel (receiving unit that reads wanderguard and causes the device to alarm) in elevator number 2 was cracked and broken on the back side. During an observation on 9/29/21 at 10:48 AM, in the 3rd floor dining room had two stacks of green domes plate covers sitting on the counter with food debris and a white substance dried on the inside (food side). When interviewed on 9/28/21 at 10:30 AM, the Director of Maintenance stated the wanderguard panel would get banged into and the facility wanted to replace it or move the location, but the company vendor wanted it to remain in that location. They stated the facility would have to replace the case. When interviewed on 9/28/21 at 10:50 AM, the maintenance technician stated the PTAC unit in resident room 318 had been leaking that summer and they believed the pitch (position) was wrong and the water was able to come back into the room versus run out to the outside. They had to fix other units in the building that leaked inside due to improper pitch. They would drill in a condensation line to run outside. When interviewed on 9/28/21 at 11:00 AM, the Director of Maintenance stated when they worked at the facility a few years ago there were units that were pitched wrong. They would pitch inside versus outside which allowed for the condensation to come inside the room. They recalled at that time they would install drain lines and route them outside to take the water to the exterior. During an interview with the Food Service Director on 9/29/21 at 11:13 AM, they stated the green dome plate covers were considered clean and were to be used for lunch. When observed in the presence of the surveyor they stated the dome plate covers needed to be washed again and the dome plate covers were not brought back to the kitchen to be cleaned as required. 10NYCRR 415.29

Based on observation, record review, and interview during the recertification and abbreviated (NY 508, NY 730, NY 556 and NY 580) surveys conducted from 9/27/21-9/30/21, the facility failed to ensure residents who are unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal hygiene for 5 of 8 residents (Residents #10, 25, 36, 45, and 50) reviewed. Specifically, Residents #10 and 36 were not assisted with grooming according to their preferences; Resident #25 was not assisted with incontinence care timely; Resident #45 did not receive oral hygiene as care planned; and Resident #50 was not showered as care planned. Findings include: 1) Resident #25 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/6/21 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance of two with toileting, transferring, bed mobility, and personal hygiene. Bowel and bladder continence was not rated. The comprehensive care plan (CCP) initiated 3/26/21 documented the resident had an activities of daily living (ADL) self-care deficit with interventions including assistance of 2 staff for toileting. The resident was admitted with pressure injuries/sacral wound. Interventions revised on 9/3/21 included incontinence care as needed. The care instructions, active on 9/29/21, documented the resident required the assistance of 2 staff for toileting, and staff were to provide incontinence care as needed. During an interview with the resident on 9/27/21 at 4:13 PM, the resident stated they rang their call bell to request incontinence care. Staff had responded, turned off the call bell, but did not change the resident's wet brief. The resident stated this took place about 20 minutes prior to the interview. The resident then rang the call bell again to request assistance with incontinence care. The resident was observed continuously on 9/27/21 from 4:13 PM through 5:04 PM from outside the door of the room. At 4:39 certified nurse aide (CNA) #2 went into the resident's room, the door was left open, and the CNA was observed leaving the room without providing personal care to the resident. The resident continued to be observed by the surveyor through 5:04 PM and did not receive incontinence care as needed and requested. During a follow up interview with the resident on 9/28/21 at 10:21 AM, they stated they did not receive incontinence care the evening of 9/27/21 until after dinner. During an interview with licensed practical nurse (LPN) Unit Manager #10 on 9/30/21 at 12:42 PM, they stated the resident required the assistance of 2 staff for bed mobility and incontinence care. When a staff member answered the call bell they had to get a second person to help provide care. Call bells should be answered within minutes, but could take longer related to emergencies or staff shortage. If a resident remained in a wet brief this could lead to skin breakdown and discomfort. The resident already had a wound on their buttocks, and remaining wet could worsen the wound or cause discomfort. During an interview with LPN #11 on 9/30/21 at 1:00 PM, they stated they had worked on 9/27/21 PM. They stated they were unaware the resident's care needs were unmet. If needed, the nurses could help with care. The LPN stated that delay in incontinence care could lead to skin issues or the resident being uncomfortable. 2) Resident #10 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/16/21 Minimum Data Set (MDS) documented the resident had moderately impaired cognition and required extensive assistance of 2 staff for hygiene. The comprehensive care plan (CCP), updated 9/10/21, documented the resident had an activities of daily living (ADLs) self-care deficit. The resident required moderate assistance for hygiene and showering. The resident received showers on Sundays and Wednesdays. The CCP did not include a preference for facial grooming. The resident was observed on 9/27/21 at 10:52 AM, with quarter inch length facial hair from the jawline to the upper lip and back to the base of the neck. The resident stated they preferred to be clean shaven. The resident was observed with the same facial hair growth on 9/28/21 at 8:41 AM and 11:29 AM; on 9/29/21 at 8:29 AM, 10:20 AM, and 12:45 PM; and on 9/30/21 at 8:55 AM. The ADL record documented the resident received personal hygiene at least twice a day and was showered twice a week through 9/2021. There was no documentation in the ADL record the resident had refused or declined shaving/personal hygiene. There was no documentation in nursing progress notes in 9/2021 the resident had refused or declined assistance with shaving or hygiene. When interviewed on 9/30/21 at 11:13 AM, certified nurse aide (CNA) #7 stated resident hygiene was supposed to be done by noon depending on staffing. The resident was scheduled for showers on Mondays and Thursdays on the evening shift. Residents should be shaved daily, but at least on every shower day. The resident had not been shaved in awhile, The CNA stated the resident liked to be shaved, and the CNA did not know why they were not. The CNA stated they performed hygiene on the resident that morning, but had not shaved the resident. When interviewed on 9/30/21 at 11:32 AM, licensed practical nurse (LPN) Unit Manager #5 stated all residents should be cleaned and up by 10:00 AM. The nurse covering that side of the unit was responsible for ensuring all resident care was done as planned unless the resident refused. The nurse was responsible for entering a progress note if a resident refused any care after re-approaching the resident. The LPN Unit Manager stated all men should be shaved at least every other day. Shaving was implied when staff signed for hygiene and bathing. The LPN Unit Manager stated they did not know why the resident was unshaven, did not believe the resident refused bathing or showering within the past 2 weeks, and they would have entered a progress note if the resident did refuse. 3) Resident #45 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/29/21 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance of one or two staff for most activities of daily living (ADLs) including personal hygiene, and was totally dependent for bathing. The 1/22/20 dental consult documented the resident was evaluated and they recommended staff to help clean the resident's teeth daily. The comprehensive care plan (CCP), reviewed 8/19/21, documented the resident had a self-care performance deficit and staff were to provide total assistance with personal hygiene/oral care and with bathing and showers on Tuesdays and Fridays on the 6:00 AM-2:00 PM shift. The resident had oral/dental problems related to missing teeth and staff were to provide oral care per ADL personal hygiene plan. There was no documentation in the 9/2021 nursing progress notes the resident refused or declined assistance with oral care or personal hygiene. The care instructions, active 9/24/21, documented the resident was to received showers on Tuesdays and Fridays on the 6:00 AM-2:00 PM shifts. Staff provided bathing, personal care, and oral hygiene with total assistance of 1. The ADL record documented personal hygiene was completed daily between 9/27-9/30/21 by staff. During an observation on 9/28/21 at 9:19 AM, the resident was seated in their geri chair (reclining chair). The resident had food debris stuck in the front of their teeth and food in the corner of their mouth. At 3:40 PM, the resident was in bed and had received a shower. There was food debris stuck in the front of the resident's teeth. The resident was observed with food debris in their front teeth on 9/29/21 at 2:20 PM, and on 9/30/21 at 9:40 AM. When interviewed on 9/30/21 at 9:57 AM, CNA #12 stated personal hygiene included oral care. On 9/28/21, they had provided oral care to the resident using a swab. They noticed the food in the resident's teeth and some was removed with a swab. They had brushed the resident's teeth in the past and the resident had bled. The CNA stated they had mentioned it to another CNA, but had not told the nurse and they should have. When interviewed on 9/30/21 at 10:51 AM, CNA #24 stated the resident allowed staff to provide oral care. At times the resident told the CNA the toothbrush hurt, so the CNA would use a tooth swab instead. When interviewed on 9/30/21 at 11:19 AM, licensed practical nurse (LPN) #14 stated they had never been told that the resident refused oral care and had not noticed if there was food stuck in the resident's teeth. LPN #14 had not been told the resident bled with brushing and expected the CNAs to notify them if a resident bled. When interviewed on 9/30/21 at 11:29 AM, registered nurse (RN) Unit Manager #15 stated personal hygiene included mouthcare. They had not seen the resident's mouth and had not been told the resident had pain or bleeding when mouth care was completed. They expected staff to notify them of this and would have made a referral for the resident to be seen by the dentist if they had been aware. On 9/30/21 at 12:33 PM, Resident #45 was resting in their chair. The resident stated they liked to have their teeth brushed, and their teeth did not hurt at present. The resident stated their teeth bled when they were brushed. 10NYCRR 415.12(a)(3)

Based on observation and interview during the recertification and abbreviated surveys (NY 580) conducted 9/27/21-9/30/21, the facility failed to provide residents with a safe, clean, comfortable, and homelike environment for 3 of 3 resident units (Units 2, 3, and 4) reviewed. Specifically, there were unclean floors in unit dining rooms, unclean door handles, baseboards, unclean fall mats in resident room 220, the window sills in the unit dining rooms were unclean with bugs, dining tables in unit dining rooms were unclean, food carts were unclean with uncovered food items, light fixtures within the unit dining rooms were unclean and contained bugs, dining room floors and resident floors were unclean with food debris and spills, and there was unclean resident equipment including bedframes, commodes, and IV (intravenous) poles. Findings include: There was no documentation the facility had a policy addressing equipment and environmental cleaning procedures. The following observations were made on Unit 2: - On 9/27/21 at 11:30 AM, the right-side elevator had handprints inside the elevator door and streaks of dried debris under the button/control panel. - On 9/27/21 at 11:56 AM, in room 211 the bathroom floor was sticky, and the bathroom door had a sticky substance around the door handle. Resident #78 stated they had not seen a housekeeper in their room since 9/24/21. - On 9/27/21 at 12:50 PM, in room 206 Resident #308's bed frame had dried-on yellow-brown debris. The resident stated it had been there when they were admitted to the facility a week ago. - On 9/28/21 at 10:16 AM, the Unit 2 dining room had cobwebs and dead bugs along the window side baseboard. - On 9/28/21 at 10:19 AM, Resident room 220 on the window side, fall mattresses on each side of the bed were soiled and stained with food debris and white discoloration. - On 9/29/21 at 8:05 AM, in room 211 there were seven plastic tabs from fingerstick lancets discarded on the floor and a nebulizer face mask was laying on the floor underneath Resident #101's nightstand. - On 9/29/21 at 2:28 PM, Resident #308's bed frame had dried-on yellow-brown debris as on 9/27/21. - On 9/29/21 at 3:00 PM, the right-side elevator had handprints inside the elevator door and streaks of dried debris under the button/control panel as on 9/27/21. The following observations were made on Unit 3: - On 9/27/21 at 12:13 PM, the windowsills in the Unit 3 dining room had spider webs and were dirty. The tables had dried food and a sticky substance on them. The rolling carts used to distribute food had food crumbs and fluid rings on them. The light fixture screens/coverings were full of dead bugs. The doorway had dried red colored food or juice splatters on the door jam. - On 9/27/21 at 4:26 PM, the commode in resident room 305 bathroom was soiled with feces. The bottom of the bathroom door had a scraped section with black marks 3 feet long and an adjacent 3-foot-long section of the wall had joint compound repair. - On 9/27/21 at 4:31 PM, there were dead flies and bugs in the screening guards around the overhead light fixtures in the dining room. There were cobwebs and dead bugs on the floor at the window side baseboards and in the windowsill tracks. The dining room floors were sticky to walk on. The walls and doors on the opposite side of the room for the storage closets had old sticky red and black splatters. The same observations were made on 9/28/21 at 10:16 AM. - On 9/27/21 at 12:46 PM, 9/28/21 at 8:44 AM, 9/28/21 at 2:25 PM, 9/29/21 at 7:40 AM and 9/30/21 at 10:24 AM, room 317, the pole where the tube feeding formula was hung and the floor underneath the pole had a brownish dried on substance. During an observation on 9/28/21 at 10:07 AM the Unit 4 dining room had sticky floors with black spots. There were 3 live fruit flies over the coffee machine and 2 live fruit flies over the cabinets. When interviewed on 9/29/21 at 2:31 PM, the Director of Maintenance stated that terminal cleaning of resident rooms was handled by housekeeping. Terminal cleaning was a deep clean that was done at least monthly. One room was chosen and cleaned, and the rooms rotated. The Director stated they expected the floor mattresses to be cleaned or at least checked daily and cleaned if needed. When interviewed on 9/30/21 at 10:12 AM, housekeeper #17 stated they had sanitizing spray they used to clean mats or mattresses on the ground. The housekeeper stated that was done daily each time they went into a room on routine rounds. When interviewed on 9/30/21 at 10:17 AM, housekeeper #18 stated they were responsible for cleaning fall mats and mattresses on the ground in resident rooms. The housekeeper stated the mats and mattresses should be sprayed and wiped down each time they were in a room, which was almost daily. During an interview with certified nurse aide (CNA) #39 on 9/30/21 at 10:29 AM, they stated if there was a spill, the tube feeding equipment was to be cleaned. The CNA observed the tube feeding pole in room 317 and stated that it was dirty. They stated CNAs were not allowed to touch the poles and the licensed practical nurses (LPN) were to clean the poles. During an interview with LPN #34 on 9/30/21 at 10:32 AM, they stated if a tube feeding pole was unclean, they would clean it themself. Some of the housekeepers also cleaned the poles. They were not sure who specifically was assigned to clean the pole. They stated room 317's tube feeding pole was unclean and should have been cleaned. Dirty equipment could lead to an infection control issues and was undignified. During an interview with registered nurse (RN) Unit Manager #15 on 9/30/21 at 11:07 AM, they stated nursing or housekeeping should clean tube feeding equipment. The RN expected the pole to be clean and could be an infection control and dignity issue if it were not. When interviewed on 9/30/21 at 2:50 PM, the Director of Maintenance stated they oversaw the housekeeping department. The Director stated there were specific duties for the housekeepers on each floor, which included refilling toilet paper, picking up spills in rooms, wiping over-bed tables, sweeping, and mopping resident room floors and emptying garbage. There had been a shortage of housekeepers but currently there were enough to cover each floor in the facility. 10NYCRR 415.29(j)(1)

Based on observations, record reviews, and resident and staff interviews conducted during the partially extended abbreviated survey (NY 702), it was determined the facility's administration (including Administrators and the Director of Nurses) failed to administer the facility in a manner that protected the health and safety of its residents, in accordance with accepted professional standards. Specifically, the facility failed to ensure there were policies and procedures inplace to assess 10 residents who were at risk for falling and/or who were on anticoagulant therapy (used to prevent blood clotting) for changes in condition, and provide timely interventions. The facility failed to ensure staff monitoring of resident condition following falls, particularly those with a head injury and/or those on anticoagulant therapy; adequately train staff to perform neurological checks following a fall; and conduct thorough investigations following falls, particularly those with head injuries. This resulted in Immediate Jeopardy, Substandard Quality of Care, and actual harm to the health and safety of Residents #1 and 3, and the potential for serious harm that is Immediate Jeopardy to the health and safety of Residents #6, 10, 11, 12, 13, 14, 15, and 16. Findings include: F 309 - Quality of professional care - the facility's administration, including the Administrator and Director of Nurses, failed to have a system in place to assess residents for changes in condition, including neuro checks for resident falls; communicate the changes to the interdisciplinary team; notify physicians of the changes; and provide timely interventions. A surveyor interviewed the Administrator at 12:25 PM on July 27, 2011. He stated: - the facility did not develop new policies and procedures following Resident #1's significant change in condition and subsequent death; - he was unaware staff did not consistently follow existing policies for neurological checks following a head injury, and physician notification for changes in resident condition; - within the past year, the facility did not conduct audits and evaluate trends related to changes in resident condition and falls. During an interview with the DON at 12:00 PM on July 27, 2011, she stated: - she was unaware the facility lacked a policy and procedure for neurological assessment of a resident after an unwitnessed fall; -she would expect staff to have a heightened awareness of residents who fall and are on anticoagulant therapy though the facility does not have a policy on this. - she was unsure how long the facility policy, "Resident Assessment Procedure, Post Fall," lacked specific components of neurological checks and time intervals for completion of the checks; - she was unaware nurses did not consistently follow the facility procedure to monitor "neuro signs" for 48 hours and document their observations when a head injury was suspected; and - she became aware the facility required no hands-on training and demonstration of competency to perform neurological checks when the Director of Staff Development informed her of this on July 22, 2011. 10NYCRR 415.26(a)

Based upon observations, medical record reviews, a review of facility policies and procedures, and family and staff interviews conducted during the partially extended abbreviated survey (Complaint #NY 702), it was determined the facility failed to have a system in place to ensure appropriate treatment and services were provided for residents who experienced a change in condition. This concern affected 10 residents (Residents #1, 3, 6, 10, 11, 12, 13, 14, 15, and 16) who had a history of [REDACTED].#1's health and safety, as she sustained a head injury after 1 of multiple falls. She later developed a severe cerebral hemorrhage and expired after staff failed to recognize significant changes in her condition, and failed to provide timely interventions. Resident #3 sustained a head injury after an unwitnessed fall, and later developed a stroke after staff failed to recognize a significant change in his condition in a timely manner. For Resident #14, who had a history of [REDACTED]. For residents #6, 10, 11, 12, 13, and 15, all of whom received anticoagulants, staff did not complete neurological assessment/monitoring after falls, some of which were unwitnessed and/or involved possible head injury. Resident #16, who did not receive anticoagulant medications, sustained a fall with head injury, and staff did not assess/monitor her neurological status per facility policy and procedure. Additionally, the facility did not have a procedure for staff training and demonstration of competency to perform neurological assessments and monitoring. This resulted in actual harm that is Immediate Jeopardy and Substandard Quality of Care to the health and safety of Residents #1 and 3, and the potential for serious harm that is Immediate Jeopardy and Substandard Quality of Care for Residents #6, 10, 11, 12, 13, 14, 15, and 16. Findings include: The undated facility policy, Physician Notification - Change of Condition, documents staff are to consult the physician for a significant change in a resident's physical, mental, or psychosocial condition, including "behavioral changes - agitation, confusion, and neurological changes - level of consciousness." The facility does not have a policy regarding neurological assessments. The facility has a form titled, "Neurological/Vital Sign Check," dated [DATE], that documents for residents who require neurological monitoring: -vital signs(temperature, pulse, respirations, and blood pressure) and "neuro(logical)" checks are to be done every 4 hours for 24 hours, then every 8 hours for 24 hours; -neurological checks consist of documentation of the condition of each pupil, including comparison of size and reaction to light; level of consciousness ("alert, cooperative, lethargic, stupeous, comatose"); movement and grip strength of hands; and quality of speech; and -residents on anticoagulant therapy are to be monitored every 2 hours for 24 hours. The facility policy, "Resident Assessment Procedure, Post Fall," dated [DATE], documents: - a new intervention is to be initiated after each fall or injury as appropriate. All interventions will be updated on the CNA (certified nurse aide) assignment and Resident Care Plan. - if a head injury is suspected, staff are to complete and document "neuro signs" every shift for 48 hours. 1) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Nursing Admission Assessment/Note, dated [DATE], documented the resident was alert and oriented to person, place, time, and situation; both pupils were equal and reactive to light; and she was at high risk for falls. physician's orders [REDACTED]. The admission Minimum Data Set (MDS) assessment, dated [DATE], documented the resident had moderate cognitive impairment; required limited assistance for ambulation, bed mobility, and transfer; ate and drank independently with set up help; was steady at all times; had no history of falls in the last 1 to 6 months prior to admission and since admission; and received anticoagulant medication. A nurse's note, written by a registered nurse (RN) supervisor at 2:15 AM on [DATE], documented the resident had an unwitnessed fall near the door in her room. She was assessed to have 2 lacerations on the back of her head; her physician and family were notified, and she was sent to the hospital. Hospital emergency department records, dated [DATE], documented: - the resident had a single laceration on the back of her head, which was closed with 5 skin staples; the resident had an "underlying bleeding tendency due to [MEDICATION NAME];" the resident was alert and oriented to person, place, and time; pupils were equal; speech was normal; hand grips were strong and symmetric; and no muscle weakness was observed; a head CT (radiologic study) showed no abnormality; discharge instructions were for the resident to seek immediate medical care if she felt confused, dizzy, weak, or unsteady on her feet. Nurses notes on [DATE], documented the following: - during the evening shift, a licensed practical nurse (LPN #7) documented the resident received neuro(logical) checks every 2 hours, and at 4:00 PM her left pupil was slightly sluggish; at 6:15 PM, the resident's left pupil was more sluggish, she complained of dizziness and weakness when ambulating from the dining room, and the nursing supervisor was called; and at 6:30 PM, the resident's pupil size was unequal. The Accident/Incident Report, dated [DATE], was signed by the RN supervisor on [DATE], and by the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on [DATE]. Attached to the report, were: - Fall Investigation - the Evaluation/Intervention by the Clinical Management Team as to the cause of the fall and recommendation to prevent further falls was blank; - Summary of Investigative Report - the resident ambulated out of the bathroom unassisted; had weakness secondary [MEDICAL CONDITION] right knee replacement; had history of right knee giving out; and no changes were made to the resident's plan of care ("all in place"). Review of Nurses Notes between [DATE] and [DATE], revealed the following: - [DATE] during the day shift - the resident returned from the hospital at 10:00 AM. There was no documentation that neurological checks were done during the day and evening shifts; - [DATE] at 6:15 AM - "neuro checks in place for 24 hours;" - [DATE] during the evening shift - a note written at 4:00 PM documented the resident's left pupil was "slightly sluggish," and she was "awake, alert, grips equal, speech clear." At 6:15 PM, the resident complained of dizziness when ambulating; her left pupil was more sluggish; and the nursing supervisor was notified of the resident's status. At 8:10 PM, the resident was awake and alert with equal grips, clear speech, and the left pupil reacted less to light in comparison to the right pupil - both pupils measured 5 mm (millimeters), and when light was shined on them, the right pupil measured 2 mm, in comparison to the left pupil, which measured 3 mm. - [DATE] during the night shift - "vital signs and neuro checks q 2h (every 2 hours) WNL." There was no documented evidence that neurological monitoring was completed during the day shift; - [DATE] during the evening shift - at 2:00 PM, the resident was alert and oriented, and "neuro checks WNL;" at 9:00 PM, "neuro checks WNL;" and - [DATE] during the night shift - "neuro checks as ordered. PEARL (pupils equal and react to light)." The resident's [DATE] Treatment Sheet documented "neuro checks" were to be done for 48 hours: -there were no documented neurological checks on [DATE]; -beginning at 12:00 AM on [DATE], staff initialed the form every 30 minutes until 3 AM, then every hour until 11:00 PM that day; -on [DATE], staff initialed the form on 12:00 AM, 2:00 AM, 4:00 AM, 6:00 AM, 10:00 AM, and 2:00 PM: -on [DATE], staff initialed the form every 30 minutes from 12:00 AM to 3:00 AM, then every hour for the next 3 hours (until 6:00 AM). An Accident/Incident Report, dated [DATE], documented the resident had an unwitnessed fall in her room at 7:00 AM that day. The report documented the resident was alert, oriented with some short term memory loss, and denied hitting her head. The report documented the resident's "Neuro Check" as "hand grips equal." The facility investigation included written statements from 2 staff members: CNA #9 documented she called a nurse after finding the resident lying on the floor. LPN #7 documented she responded to the resident's room and found her sitting in front of her dresser, between the bed and the wall. Bruises were observed on the resident's right shoulder and right hip, and the resident told staff the bruises were caused by her previous fall on [DATE]. The physician was notified. Review of Nurses Notes from [DATE] through [DATE] did not reveal documented evidence that staff completed neurological checks after the resident's unwitnessed fall on [DATE]. The comprehensive care plan (CCP), last updated on [DATE], documented the resident was at high risk for falls related to unsteady gait, loss of peripheral vision, early dementia, and history of [MEDICAL CONDITION]; the resident fell on [DATE], 16, and 22, 2011; and interventions included use of a bed alarm at family request ([DATE]). After the last 3 falls in [DATE], the CCP did not specify additional interventions, including ongoing assessment of the resident's condition and risk for bleeding in light of her anticoagulant medication status. Review of the resident's ADL (activities of daily living) Flow Sheets, used by certified nurse aides (CNAs) to document the level of assistance needed by the resident, revealed the following: - between [DATE] and 28, 2011, the resident required little to no assistance for moving throughout the facility, choosing clothing, dressing, and personal hygiene; - on [DATE] and [DATE], the resident required total assistance for personal hygiene; - between [DATE] and [DATE], the resident required total assistance to button/tie/zip clothing, put on socks and shoes; and - on [DATE], the resident required total assistance to move throughout the facility, dress, eat and drink, and receive incontinence care. A nursing progress note on [DATE], on the day shift, documented the resident had dark bloody drainage from the stapled laceration on the back of her head; the resident complained of pain in her buttocks; and a "large very dark ecchymotic (discoloration due to bleeding under the skin) area" was observed on the resident's right buttock; A progress note, written by the nurse practitioner (NP) on [DATE], documented the resident was alert, understood where she was, and complained of pain in her right lower buttock. Nurses' notes between [DATE] and [DATE], documented the following changes in the resident's condition: - [DATE] during the day shift - the resident complained of pain with the intensity of ,[DATE] in her lower right back/buttock region and was given [MEDICATION NAME] (narcotic [MEDICATION NAME]) with minimal effect; the resident had a "dizzy episode after breakfast while walking back to her room;" and the resident had a poor appetite for breakfast and lunch; - [DATE] during the day shift - the resident complained of dizziness, her oxygen saturation level decreased, and staff applied oxygen; the resident received [MEDICATION NAME] for right lower back/buttock with "some effect;" and the resident had poor appetite and fluid intake; - [DATE] at 6:40 PM - a licensed practical nurse (LPN #1) spoke to the resident's family member/heath care proxy (HCP), who asked that the resident "be sent to the hospital if her condition is not any better by tomorrow. Obtained neuro(logical) checks, grips equal, speech clear, confused, thinks she is in a (local) hospital. Does not know day or time. Supervisor made aware." A progress note written by the NP on [DATE], documented he was asked to evaluate the resident for symptoms of "lightheadedness and dizziness." The NP changed the dosage of the resident's antihypertensive medication and ordered oxygen, nebulizer treatments "as needed," and a chest x-ray (negative). Nurses' notes between [DATE] and [DATE], documented the following changes in the resident's condition: - [DATE] at 3:00 PM - LPN #6 documented the resident was confused, trying to scoop up her napkin with a fork and eat the napkin; - [DATE] at 7:00 PM - LPN #6 documented staff assisted the resident with her meal, as she had "difficulty eating - missing (her) mouth with the spoon;" - [DATE] at 9:15 AM - the RN Unit Manager (RN #1) documented the resident had a change in condition; was alert but unable to follow verbal commands; was unable to focus her eyes; and the family telephoned RN #1, requesting that the resident be sent to the hospital. The Patient Transfer Form, completed by LPN #1 on [DATE], documented the resident was disoriented; unable to focus with her eyes; unable to eat, drink, or hold her head up; and the family requested she be sent to the hospital emergency department. A head CT performed at the hospital, dated [DATE] at 10:01 AM, documented the finding of a large hemorrhage on the right side of the resident's brain, measuring 62 mm x 28 mm x 35 mm. Two old infarcts (changes in the brain following [MEDICAL CONDITION]) were unchanged. Hospital emergency department records, dated [DATE] at 4:00 PM, documented the resident had a slight left sided facial droop; was flaccid on her left side; was able to grip with her right hand, and not with her left hand; was lethargic, had garbled speech at times; her right pupil was larger than the left pupil (4 mm and 3 mm respectively); and her right pupil reacted more sluggishly than the left pupil. At 5:30 PM that day, the resident was admitted to the intensive care unit with a [DIAGNOSES REDACTED]. A palliative care consultation, dated [DATE], documented the resident was non-functional, with dense left paresis (weakness), and there was no indication that the resident "would return to any substantial neurologic function within a reasonable amount of time." The hospital discharge summary documented the resident had a very poor prognosis; her family requested comfort care; and she expired on [DATE]. Surveyor interviews regarding staff observations of the change in the resident's condition in June and [DATE] were conducted on [DATE] and [DATE]. They revealed: - [DATE] at 10:30 AM - RN #3, the Manager of Unit #3, where the resident formerly resided, stated she was not in the facility between [DATE] and [DATE]. She stated the resident did not require oxygen prior to [DATE], and was alert, oriented, and walked independently with a walker. She stated staff should have notified the physician when the resident tried to eat her napkin. After reviewing the resident's medical record, she stated there was no documentation that the physician was contacted. She stated that resident falls were discussed daily in the facility's morning report. She stated that for suspected head injury, neurological checks, consisting of vital signs, assessment of pain, pupils, and level of consciousness were documented on the Neurological/Vital Sign Check form and in the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - [DATE] at 11:10 AM - LPN #1, assigned to Unit #3, stated that after the resident's fall on [DATE], she "would look off to the side when you talked to her." LPN #1 stated that on [DATE], the resident's HCP noticed the left side of the resident's face was drooping, and wanted the resident to be sent to the hospital if her condition had not improved by [DATE]. LPN #1 stated she informed the nursing supervisor, RN #6, about what the resident's HCP said. LPN #1 stated she was not scheduled to work on [DATE] and 3, 2011, and when she returned on [DATE], she was "shocked to see the resident was still there. She seemed worse - she was staring to the right." LPN #1 stated the resident normally walked with a walker, and staff had to bring her to the dining room in a wheelchair that morning. LPN #1 stated she told a family member, who was employed by the facility, about the change in the resident's condition. The family member telephoned the resident's HCP, who then telephoned the facility and directed that the resident be sent to the hospital. - [DATE] at 2:10 PM - CNA #4 stated she worked on Units 2 and 3, and was assigned to care for the resident on [DATE]. She stated the resident was leaning to the left when she got her out of bed that morning; she had to ask the resident to wash her face several times, and the resident began reaching as if she was removing her glasses; when walking back to her bed, the resident kept reaching forward instead of holding her walker; the resident continued to lean to the left at breakfast; the resident was not as talkative as usual; and her mouth was drooping on the left. CNA #4 stated these were all new changes, and she informed LPN #1 about them. - [DATE] at 3:40 PM - LPN #5 stated she worked double shifts (day/evening) on the resident's unit on [DATE] and [DATE]. She stated that during that time, her oxygen saturation would drop when she walked. LPN #5 stated, "Once in a while, she (the resident) said she couldn't see." - [DATE] at 10:45 AM - CNA #8 stated she was assigned to care for the resident on [DATE]. She stated the resident was lying in bed with her eyes open, and "she didn't look like she could see." The resident was unable to sit or stand up, and assisted by another CNA, CNA #8 pulled her up and transferred her to a wheelchair. - [DATE] at 4:30 PM - RN #6, the nursing supervisor who assessed the resident at 10:30 PM on [DATE], stated she was aware on that day that the resident's HCP wanted the resident to be sent to the hospital if her condition did not approve. RN #6 stated she did not work at the facility on [DATE] and 3, 2011. At 2:35 PM on [DATE], a surveyor interviewed RN #4, the Director of Staff Development. She stated that staff orientation does not include neurological checks. She stated that staff received lectures about accidents, injuries, and completion of the Neurological /Vital Sign Check sheet. RN #4 stated staff received no hands-on training, and were not required to demonstrate competency to do neurological checks. A surveyor interviewed the Director of Nursing (DON) on [DATE] at 12 PM. The DON stated: -she was unaware the facility lacked a policy and procedure for neurological assessment of a resident after an unwitnessed fall; -she was unsure how long the facility policy, "Resident Assessment Procedure, Post Fall," lacked specific components of neurological checks and time intervals for completion of the checks; -she was unaware nurses did not consistently follow the facility procedure to monitor "neuro signs" for 48 hours and document their observations when a head injury was suspected; -she became aware the facility required no hands-on training and demonstration of competency to perform neurological checks when the Director of Staff Development informed her of this on [DATE]; - the resident's CCP should have reflected the increased risk of bleeding with falls due to anticoagulants; and - the condition of the resident was waxing and waning, and staff may not recognized her overall condition had changed. During an interview with the resident's physician at 11:30 AM on [DATE], he stated staff should have notified him of the changes in the resident's condition between [DATE] and [DATE]. He stated he would have expected staff to call him about the resident's facial droop. In summary, the facility failed to protect Resident #1's health and safety, as she sustained a head injury after 1 of multiple falls, and later developed a severe cerebral hemorrhage after staff failed to recognize significant changes in the resident's condition, and failed to provide timely interventions. The facility failed to ensure: - policies and procedures were consistently implemented for physician notification of change in resident condition, monitoring/assessment of resident's after falls including unwitnessed falls, and for residents with the potential for serious injury due to anticoagulation medication; -staff did not consistently assess the resident after falls, including neuro checks, according to the existing facility policies/forms, and document the findings; - interdisciplinary communication and timely interventions for neurological changes and signs and symptoms of bleeding; -staff were adequately trained and demonstrated competency to monitor and assess residents after falls; -compliance with the hospital's directive that the resident be sent back to the hospital for confusion, weakness, dizziness or unsteadiness; -development and implementation of comprehensive care planning for Resident #1, whose risk of significant injury from falls was increased by use of anticoagulant medication. 2) Resident #3 was admitted to the facility on [DATE], 2011 with [DIAGNOSES REDACTED]. The Nursing Admission Assessment Note, dated [DATE], documented the resident was alert with confusion; had a history of [REDACTED]. The resident's risk to fall score was 17 (with a score above 10 meaning high fall risk). A Nurses Note, dated [DATE] at 2:25 PM, documented the resident attempted to walk to the bathroom "this AM" and fell . Bed alarm sounded - resident was found sitting on the floor." The note did not document that neurological monitoring/assessment was begun at the time of the fall, nor did subsequent notes contain this documentation through [DATE]. The LPN documented range of motion and notified the physician. The 30 day Minimum Data Set (MDS) assessment, dated [DATE], documented the resident had moderate cognitive impairment; had a short term memory deficit; required extensive assistance for all activities of daily living except eating and drinking; and utilized a walker or wheelchair for mobility. physician's orders [REDACTED]. On [DATE], the physician increased the [MEDICATION NAME] dose to 6 mg daily. An Accident/Incident Report, dated [DATE], documented the resident had an unwitnessed fall in his room at 7:20 PM that evening. The resident was "observed lying on his side with an oxygen tank (which had fallen over in the holder) under his head." The registered nurse (RN #6) nursing supervisor documented her assessment, including observation of a small skin tag avulsed (torn) from the top of the resident's head, and a small abrasion on his left elbow. RN #6 documented the resident's "Neuro(logical) check" as "PERRLA (pupils round and reactive to light and accomodation- able to focus near and far); (hand) grips =; tongue midline." The physician was notified of the fall. There is no documented evidence that the physician responded to the information. A Nurses' Note, written by RN #2 at 6:00 AM on [DATE], documented the resident's "neuro" check was WNL (within normal limits); PEARLA (pupils equal and reactive to light and accommodation); and the resident was "awake with normal confusion." review of the resident's medical record revealed [REDACTED]. A Nurses Note, dated [DATE] at 11:20 AM, written by RN #1, the Manager of Unit 2 where the resident resided, documented the resident was brought back to the unit from therapy. RN #1 was told the resident was unable to follow commands in therapy, and unable to tell the therapist what was wrong. RN #1 documented the resident was unable to "verbalize anything but grunting;" his pupils were equal and reactive (to light), but he was "not able to follow pen light." The physician was notified, and ordered that the resident be sent to the hospital emergency department. The hospital discharge summary, dated [DATE], documented the discharge [DIAGNOSES REDACTED]. The Readmission Nursing Assessment Note, completed by RN #1 on [DATE], documented the resident returned to the facility on that day with [DIAGNOSES REDACTED]. The resident was assessed to be confused and at high risk to fall The comprehensive care plan (CCP), initiated on [DATE] and updated on [DATE], documented the resident had a history of [REDACTED]. The resident's history [MEDICAL CONDITION](stroke) was crossed out. Interventions included observation for signs and symptoms of TIA, including change in mental status, changes in speech, and facial drooping. The CCP documented the resident had impaired communication related to TIA, and did not address the resident's [MEDICAL CONDITION]. The CCP did not include an intervention to monitor the resident for changes in condition related to falls in the context of anticoagulant use. The CCP documented the resident fell on [DATE], and did not include his fall on [DATE]. RN #1 was interviewed at 12:15 PM on [DATE]. After reviewing the resident's medical record, she was unable to find any Neurological/Vital Sign check forms, nor documentation of neurologic checks on the resident's medication administration records (MARs) and treatment administration records (TARs) for the falls on [DATE] and [DATE]. At 2:35 PM on [DATE], a surveyor interviewed the certified occupational therapy assistant (COTA) regarding the resident's condition on the morning of [DATE]. She stated the resident was "definitely different. He was more confused than usual. He couldn't follow commands and couldn't pick up his feet. His oxygen sats (saturation - level of oxygen in the blood steam) were dropping into the 80s. I told the nurses about the change in his condition." At 12:00 PM on [DATE], a surveyor interviewed the Director of Nursing (DON). She stated she would expect staff to have an increased level of awareness to look for a change in condition with residents on anticoagulant therapy who sustain falls. She also stated the facility did not have a policy regarding this. She stated this resident should have been on neurological checks and the possibility of head injury should have been identified. At 3:30 PM on [DATE], a surveyor interviewed the Medical Director via telephone. He stated for a resident receiving anticoagulant therapy, whether a fall is witnessed or unwitnessed, staff should perform neurological checks every 15 minutes for 2 hours, then every 30 minutes for 2 hours, then every hour for 4 hours, then every shift for ,[DATE] hours. In summary, the facility failed to protect Resident #3's health and safety, as he sustained a head injury after an unwitnessed fall, and later developed a stroke after staff failed to recognize a significant change in the resident's condition in a timely manner. The facility failed to ensure: -staff did not consistently assess/monitor, including neuro checks, the resident who had falls with a head injury and document the findings; -staff did not consistently investigate each fall and implement measures to decrease the likelihood of future falls; - interdisciplinary communication and timely interventions for neurological changes and signs and symptoms of intracranial bleeding after a fall; - development and implementation of accurate comprehensive care planning for the increased risk of significant injury from falls related to use of anticoagulant medication. 3) Resident #14 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated [DATE], documented the resident was understood and was able to understand others. The resident scored 12 out of 15 on the Brief Interview for Mental Status, meaning moderate cognitive impairment. The comprehensive care plan (CCP), originally dated [DATE] and updated [DATE], documented the resident was independent in decision making abilities. The certified nurse aide (CNA) care card (used when providing care), updated [DATE], documented the resident required the assistance of one with rolling walker. The [DATE] Accident/Incident Report documented the resident was standing in the hallway, and when he began to sit in his wheelchair, he fell , striking his face on the floor. Ice was applied to his right eye and the physician was contacted. A small bump was observed over the resident's right eye, and the resident was noted to be "alert, oriented, and awake." The "Neuro(logical) Check" area, used to describe the resident's neurological status after the incident, was blank. The resident's Patient Transfer Form, dated [DATE] (attached to [DATE] Hospital Admission and Discharge records), documented the resident was sent to the hospital for a change in mentation and [MEDICAL CONDITION]. Specifically, the resident "has had multiple falls lately, has also begun drooling - speech more and more garbled; slapping and swearing at staff - increasing in intensity." Review of nursing progress notes from [DATE] to [DATE] documented the resident's falls: -[DATE] the resident had 2 falls on this date: one when "he attempted to ambulate to the bathroom," and another when reaching for a towel on his dresser "when he became unstable." The resident sustained [REDACTED]. -[DATE] the resident "was found on the floor in room, states he slid out of his chair, PERL (pupils equal and reactive to light), did not hit head." The note further documented the resident had an "abrasion 2 cm by 2 cm to back and shin tear at base of abrasion;" -The Accident/Incident Report, dated [DATE], documented the resident had an unwitnessed fall, and was "found on the floor at the foot of his bed." The resident was reported to state, "I was fixing my bed and I fell and hit my head." The resident was noted to be alert and oriented and the "Neuro Check" described the resident to have PERLA, and (hand) grips were equal and strong;" -[DATE] nursing progress note documented "Neuro's checked, found no lumps, bumps or red areas on head;" - [DATE], the resident was continually getting up unassisted, with some confusion noted;" - [DATE], the resident was found on the floor next to his bed. sitting on a pillow. The resident stated that he "wanted to go to the bathroom himself," and said he "did not need help." Fifteen minute checks were initiated "due to resident's noncompliance with calling for assistance;" -[DATE], the resident was found naked and sitting on the floor next to his bed. The resident stated he "was reaching for the urinal;" and "fifteen minute checks on resident continued, grips equal;" - [DATE], the resident was found next to his bed sitting on the floor. The resident stated that he "slid off the bed," and the physician was notified; -[DATE],