Every finding on record at Troy Center for Rehabilitation and Nursing

Based on record review and interviews conducted during survey, the facility failed to ensure the resident's right to be free from neglect for one (1) (Resident #1) of three (3) residents reviewed. Specifically, Resident #1 had a pressure ulcer on the heel of their right foot known to the facility on [DATE]. There was no documented evidence the facility completed wound assessments or management from a qualified wound care provider after 09/19/2025. The designated in-house wound care provider completed rounds on days when the resident was scheduled to be out of the facility for dialysis and no alternate arrangements were made. On 10/06/2025, Resident #1 reported increased right foot pain and was transferred to the hospital from the dialysis center on 10/10/2025. The resident was diagnosed with sepsis (life-threatening reaction to an infection), a right pathological calcaneal fracture with acute osteomyelitis (heel fracture that often arises from a bone infection), and bacteremia (bacteria in the blood). Treatment included a right below-knee amputation on 10/17/2025. This resulted in actual harm and psychosocial harm to Resident #1 that was not Immediate Jeopardy. Findings include: Cross-referenced to F686: Treatment/Services to Prevent/Heal Pressure Ulcers Cross-referenced to F659: Qualified Persons Cross-referenced to F710: Resident's Care Supervised by a Physician Cross-referenced to F711: Physician Visits - Review Care/Notes/Order Facility policy and procedure titled, Abuse, revised 07/18/2025, documented the facility prohibited neglect of residents by anyone including but not limited to staff, family, friends and residents of the facility. Neglect was defined as the failure of the facility, its employees or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or distress. Facility policy and procedure titled, Wound Identification and Wound Rounds, revised 11/06/2023, documented the facility would identify, assess, and manage residents with wounds in accordance with current standards of practice. Any wound identified as worsening, defined by increase in pain, drainage, necrotic tissue, or odor would be assessed by the Registered Nurse, with physician and family notification of treatment changes as indicated. Resident #1 was admitted to the facility with diagnoses including end stage renal disease (kidneys no longer work to meet the body's needs) with dependence on renal dialysis (a treatment that filters waste and excess fluid from the blood when the kidneys are failing), diabetes (body cannot use insulin correctly and sugar builds up in the blood) with diabetic chronic kidney disease, and chronic peripheral venous insufficiency (occurs when leg veins become damaged and do not allow blood flow back to your heart). The Minimum Data Set (a resident assessment tool) dated 09/25/2025, documented the resident was cognitively intact, could make themselves understood and understood others. Record review of Admission/readmission Evaluation Part One (1) dated 09/18/2025 by Registered Nurse #2 documented an unstageable (depth of wound is unknown because devitalized tissue obscures the extent of tissue damage) pressure ulcer on the right heel of the foot that measured 2.5 centimeters long by 2.2 centimeters wide and had no depth. Registered Nurse #2 documented they were unable to visualize the wound bed, that there was 100 percent black/brown eschar (necrotic tissue-black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin), and that a treatment was in place. There is no documented evidence the wound treatments were completed as ordered 09/22/2025, 09/23/2025, 09/25/2025, and 09/29/2025. Team Meeting Note dated 09/19/2025 at 9:41 AM by Licensed Practical Nurse #1, documented the Interdisciplinary Team met on 09/19/2025 for the following reasons: High Risk Meeting. Meeting summary included Resident #1 was being referred to the in-house wound provider for a pressure ulcer on their right heel. There was no documented evidence that Resident #1's pressure ulcer on the right heel was discussed by the Interdisciplinary Team after 09/19/2025. There was no documented evidence of an assessment of the pressure ulcer on the right heel by a qualified person after the Interdisciplinary Team meeting on 09/19/2025 through 10/09/2025. Care Plan for Needs Hemodialysis, created/initiated on 09/19/2025, documented the resident was scheduled for hemodialysis (outside of the facility) related to end stage renal disease four (4) times a week on Monday, Tuesday, Thursday, and Friday, at 8:50 AM. Wound Documentation Note dated 10/02/2025 at 4:40 PM by Licensed Practical Nurse #1 documented the resident was not seen by the wound care provider due to dialysis schedule conflict. A total of three (3) wounds were assessed, including the unstageable pressure ulcer on the right heel. Notifications were made to the primary care physician and the resident's representative. Progress notes dated 10/02/2025 and 10/06/2025 documented Resident #1 was at hemodialysis when wound care provider made rounds.Nursing Progress Note dated 10/03/2025 at 8:18 AM by Registered Nurse #1 documented Resident #1 had a newly identified skin alteration according [SY3] [HM4] to POC [sic] documentation see Certified Nurse Aide for more details. Resident is out of facility at dialysis, will address when they return. There was no documented evidence in Nursing Progress Notes from 10/03/2025 at 8:18 AM to 10/06/2025 at 7:58 AM in which the newly identified skin alteration was assessed by a registered nurse. Progress Note dated 10/09/2025 at 8:47 AM by Wound Care Provider #1 documented they did not see Resident #1 as scheduled because Resident #1 was at dialysis. Nursing Progress Note dated 10/06/2025 at 7:58 AM by Registered Nurse #1, documented that on 10/06/2026 at 7:55 AM, Resident #1 reported increased right foot pain. Registered Nurse #1 documented there was an open sore on the heel. The resident was informed they would refer them to the physiatrist (physical medicine) and podiatry to look and assess them. Registered Nurse #1 documented Discussed wound doctor, yet dialysis schedule conflicts. Will also have NP see her There was no documented evidence that the facility made alternate arrangements to assess and manage the pressure ulcer by a qualified person. Podiatry Consult Note dated 10/08/2025 at 9:36 PM documented Resident #1's right heel had an intact dressing. There was no documented evidence of assessment, management or treatment for Resident #1's pressure ulcer by the Podiatrist that saw the resident on 10/08/2025. Nursing Progress Note dated 10/10/2025 at 12:00 PM by Registered Nurse #1 documented that the dialysis nurse called on 10/10/2025 at 12:00 PM to report the resident was being sent to the hospital for hypotension (low blood pressure) and lethargy (severe exhaustion, lack of energy, or mental alertness). Hospital Infectious Disease Consultation Note dated 10/11/2025 documented they were consulted for antibiotic management of a non-operative heel wound. The resident came to the hospital from the dialysis center on 10/10/2025. The resident presented with no fever and had a white blood count of 13.7 thousand (normal is 4 to 11 thousand). Blood cultures were obtained, and the resident was started on intravenous antibiotics. Magnetic resonance imaging of the right foot on 10/11/2025 had findings that were consistent with osteomyelitis of the calcaneus (heel fracture that often arises from a bone infection), and a fracture (bone break)/disruption of the infected fragment at the site of the Achilles attachment (tendon that connects the heel bone to the calf). The dressing to the right foot was taken down (removed). The wound was extensive with a large dark area of necrosis (cell injury which results in premature death of the cells) on the wound bed, and they could see and feel bones exposed by their heel. The wound had a strong odor and was draining thick brown pus material. Physical exam documented right heel with an extensive wound that probed about 1/2 (one half) inch deep. There was a large area of eschar on the wound bed, and the heel bone was exposed. Blood cultures showed mixed bacteria. Assessment was bacteremia. Hospitalist Discharge summary dated [DATE] documented the resident presented on 10/10/2025 with right foot heel pain and a draining foot ulcer. Initial assessment was consistent with a right pathological calcaneal fracture with acute osteomyelitis. A below knee amputation was completed on 10/17/2025. During an interview on 03/23/2026 at 11:55 AM, Family Member #1 stated resident was to be seen by the wound care doctor at the facility. They were told by nursing staff that the wound doctor was there on Thursday when the resident was out for dialysis treatment and could not be seen. Staff told them they could not evaluate the wound; they could only have a nurse look at it. The Infectious Disease doctor at the hospital told Resident #1 there was a hole in their heel that was infected in the bone. They told Resident #1 they needed to amputate, or they would lose their life. Resident #1 asked if they could amputate just the foot and was told it would be a below knee amputation with the possibility of an above knee amputation. They stated Resident #1 was traumatized. Resident #1 asked Family Member #1 if they should even have it amputated because if they had it amputated, It's going to affect my life so much, especially with it being the right leg and not being able to drive again. During an interview on 03/24/2026 at 2:39 PM, Licensed Practical Nurse #1 stated they helped with wounds. The wound care provider was supposed to see Resident #1, but their dialysis treatment conflicted, and they were not in the building when the wound care doctor was present. The wound care provider came one (1) day a week that they believed was Thursday. The resident's first wound evaluation would have been a week from admission, on 09/25/2025 and the wound care provider did not see the resident. When Licensed Practical Nurse #1 accompanied the wound care provider during wound rounds, they would evaluate the wound and put a note in the electronic medical record that they were seen by the wound care provider. If the wound care provider or Registered Nurse #1 was not available, they would conduct wound rounds by themselves. The initial evaluation was always done by a registered nurse. When Licensed Practical Nurse #1 documented a wound, they would write about what they saw during the evaluation. On 09/25/2025, a registered nurse was not with them when they did weekly wounds for Resident #1. They did not refer the resident to the wound care provider on 09/25/2025 because there was no change in the wound. Even if they did refer to the wound care provider on 09/25/2025, the resident would not have been seen because they were at the dialysis center. Nurse Practitioner #1 was notified on 09/25/2025 and should have seen and assessed the resident. On 10/02/2025, Licensed Practical Nurse #1 evaluated the wound and then Registered Nurse #1 went into the room and looked at the resident's wound bed that had started to separate, was still covered with eschar, was pulling away from the edges, had serosanguineous (thin and watery, with light red or pink hue caused by the presence of red blood cells) drainage that was not purulent. Registered Nurse #1 called Nurse Practitioner #1. The resident was not seen by the wound care provider on 10/02/2025 because they were at the dialysis center. During an interview on 03/25/2026 at 9:36 AM, Registered Nurse #1 stated there was a conflict between Resident #1's dialysis schedule on Thursday, and the wound care provider's schedule and the resident was unable to be seen by them. A solution to the conflict would have been to change the resident's dialysis time because it needed to align better with the wound care provider's schedule. No changes were made. They would have assessed the resident's wound in absence of the wound care provider and stated they did not do a thorough job documenting the assessments. They were with Licensed Practical Nurse #1 during wound rounds on 10/02/2025, and stated the wound started to open and the current treatment was not effective. They notified the provider and received an order for a new treatment. They reviewed a note they had written on 10/02/2025 and stated the note did not include the change in the wound and the measurements. If the medical provider saw the resident on 10/02/2025, they would have written a note. They assessed the resident's foot on 10/06/2025, when the resident reported increased pain in their right foot. They did not recall removing the dressing and assessing the status of the wound at that time. They notified the medical provider and reached out to the physiatrist who was responsible for pain management. If the medical provider saw the resident on 10/06/2025, they would have written a note. During an interview on 03/25/2026 at 11:58 AM, Director of Nursing #1 stated they were not aware of the conflict between dialysis and wound care for Resident #1. If they were made aware, they would have made sure the physician or nurse practitioner was made aware and would have looked at the wound themselves. They stated that on 09/18/2025, the resident's wound was assessed by a registered nurse, on 09/25/2025 by a licensed practical nurse, and on 10/02/2025 by a registered nurse. They did not see an assessment for 10/9/2025. They were not sure if they were aware the wound care provider had signed off on the resident on 10/09/2025. The wound care provider was coming in on Thursday when Resident #1 was not in the facility. They stated licensed practical nurses could measure but could not assess a wound and were supposed to write what they observed in a nursing progress note. They stated Physician #1's admission evaluation note for the resident did not include documentation of the pressure ulcer. During an interview on 04/01/2026 at 10:05 AM, Administrator #1 stated they were not working at the facility when Resident #1 was admitted , and that the facility conducted high-risk meetings for residents with wounds, and Resident #1 should have had weekly meetings. Director of Nursing #1 was responsible for providing oversight to all nursing staff and the Corporate Nurse Consultant provided oversight to the Director of Nursing. Administrator #1 was responsible for ensuring meetings were held to discuss the residents' needs. They stated the physician/nurse practitioner was responsible for a resident's overall care. They stated they attended Quality Assurance and Performance Improvement meetings and after reviewing the notes stated, wounds and pressure ulcers were discussed/reviewed at the meetings. During an interview on 03/26/2026 at 1:53 PM, Nurse Practitioner #1 stated they never got to see Resident #1 because they (Nurse Practitioner #1) were only in the facility on Tuesday and Friday and the resident was always at dialysis on those days. Physician #1 was in the facility on Monday and Wednesday. They did not recall being called for anything specific regarding Resident #1 and said if they were called, they would have given a verbal order and would have asked staff to ensure Physician #1 saw the resident when they came into the facility. Physician #1 did the resident's admission evaluation and there was no documentation in the note about the resident's pressure ulcer. They stated ultimately, there was a medical director that could have been notified of any concerns. They did not realize Licensed Practical Nurse #1, who was doing weekly wound assessments, was not a registered nurse. During an interview on 03/31/2026 at 2:17 PM, Wound Care Provider #1 stated they used to go into facility for weekly wound rounds on Thursdays. They had no flexibility in their schedule and could not be in the facility more than one (1) day a week. They stated if the resident was not available for them to assess due to dialysis, the resident should have been seen at a wound care center. Their wound care notes were available to all staff. They stated it was not normal and unacceptable for there to be no weekly assessment by a registered nurse when the wound care provider was not able to see the resident. They stated if the registered nurse had assessed the wound and identified that it had gotten worse; they could have sent the resident out to a wound care center at that time. During an interview on 03/27/2026 at 1:14 PM, Medical Director #1 stated they were told about what happened to Resident #1 and there was no reason why the in-house wound care provider could not see the resident virtually, when there was a conflict with the resident's dialysis schedule. They stated they wished they had known about the situation with Resident #1 because they could have called the wound care provider or the dialysis center to come up with a plan. They stated there was a reason why skin checks were done, and wound services came into the facility. They relied on weekly wound assessments and treatments done by staff. They stated during interval medical visits, the wound care notes needed to be reviewed. They stated the resident not being seen by medical or wound care because they were going to dialysis four (4) days a week was not an excuse for not having an assessment by a qualified person. 10 New York Code of Rules and Regulations 415.4(b)(1)(i)

Based on record review and interviews during a survey, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for three (3) (Resident #s 1, 6, and 7) of three (3) residents reviewed. Specifically, the facility failed to provide daily care/treatment of a pressure ulcer in accordance with professional standards of practice and care planned interventions for (a.) Resident #1's unstageable pressure ulcer on the right heel, (b.) Resident #6's stage 3 pressure ulcer on the sacrum, and (c.) Resident #7's stage 3 pressure ulcer on the sacrum, that were present upon admission. Findings include:Cross-referenced to F600: Free from Abuse and Neglect Cross-referenced to F656: Develop/Implement Comprehensive Care Plan Cross-referenced to F657: Care Plan Timing and Revision Policy and Procedure titled, Wound Identification and Wound Rounds, revised 11/06/2023, documented the facility would identify, assess, and manage residents with pressure injuries, skin alterations, impairments, or wounds in accordance with current standards of practice. For new admissions and a newly discovered pressure ulcer, the Register Nurse would complete a skin assessment including documentation of size, depth, stage if applicable and appearance of the skin impairment. The licensed nurse would notify the health care provider and obtain a treatment order utilizing the facility's wound care guidelines.Resident #1: Resident #1 was admitted to the facility with diagnoses of end stage renal disease (kidneys no longer work to meet the body's needs) with dependence on renal dialysis (a treatment that filters waste and excess fluid from the blood when the kidneys are failing), diabetes (body cannot use insulin correctly and sugar builds up in the blood) with diabetic chronic kidney disease, and chronic peripheral venous insufficiency (occurs when leg veins become damaged and do not allow blood flow back to your heart). The Minimum Data Set (an assessment tool) dated 09/25/2025, documented the resident was cognitively intact. The resident was able to make themselves understood and understood others.Care Plan for Alteration in Skin Integrity, created on 09/19/2025 and initiated on 09/30/2025, documented the resident had an actual pressure injury site to their right heel with eschar tissue (necrotic tissue-black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin). Interventions included apply treatment per order. Document titled LN: Admission/readmission Evaluation Part 1 dated 09/18/2025 by Registered Nurse #2 documented an unstageable pressure ulcer (depth of wound is unknown because devitalized tissue obscures the extent of tissue damage) on the right heel that measured two and a half (2.5) centimeters long by two and two tenths (2.2) centimeters wide and had no depth. Unable to visualize the wound bed. There was 100 percent black/brown eschar (necrotic tissue-black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin). It documented a treatment was in place. Review of the Order Recap Report for order date 09/01/2025 to 10/31/2025 and the Treatment Administration Record dated September 2025, did not document a treatment order for the unstageable pressure ulcer on the right heel on 09/18/2025. There was no treatment order until 09/20/2025: Treatment Administration Record dated September 2025, documented TheraHoney Gel (wound dressings), apply to right heel topically every dayshift for wound care; cleanse with normal saline solution, apply gel to wound bed only and cover pressure area with optifoam (highly absorbent foam dressing). The start date was 09/20/2025. The treatment was not documented as being administered on 09/22/2025, 09/23/2025, 09/25/2025, and 09/29/2025. On 09/26/2025, 09/27/2025, 09/30/2025, 10/01/2025, and 10/02/2025, location of administration documented the treatment was administered to both heels. There was no documented evidence that the resident had a wound on their left heel. Order Recap Report dated 09/01/2025 to 10/31/2025, documented an order dated 10/02/2025 for Anasept Antimicrobial External Gel 0.057% (sodium hypochlorite, a broad-spectrum antimicrobial), apply to right heel every day shift for wound care, cleanse with wound cleanser, apply collagen powder (specialized wound care product promotes wound healing and tissue regeneration) and anasept to wound bed, cover with island dressing (sterile, bordered gauze dressing for wounds with light to moderate drainage). Start date was 10/03/2025 at 7:00 AM and was discontinued on 10/10/2025. Treatment Administration Record documented that the treatment was not administered until 10/04/2025 and was not administered on 10/06/2025. On 10/04/2025, 10/05/2025, 10/07/2025, 10/08/2025, and 10/09/2025, location of administration documented not recorded. Resident #6: Resident #6 was admitted to the facility with diagnoses of orthopedic surgery of right tibia/fibula (bones in lower leg) aftercare, diabetes, and chronic kidney disease stage 3A (kidney function is between 45-59 %). The Minimum Data Set, dated [DATE], documented the resident was cognitively intact. The resident was able to make themselves understood and understood others. Care Plan for Nutritional Problem or Potential Nutritional Problem, created/initiated 02/27/2026, documented the resident had a pressure injury on the sacrum. Document titled LN: Admission/readmission Evaluation Part 1 dated 02/24/2026 by Registered Nurse #1 documented a stage three (3) pressure ulcer (serious skin injury that involves full-thickness skin loss and exposure of the fatty tissue) on the sacrum that measured two (2) centimeters long by two (2) centimeters wide by 0.1 centimeters deep. There was no treatment order for the stage three (3) pressure ulcer on the sacrum that was identified on 02/24/2026 until 02/27/2026. Order Summary Report for active orders as of 03/01/2026, documented an order dated 02/26/2026 for Calcium Alginate - Silver External Pad two (2) inch by two (2) inch, apply to sacrum topically every dayshift for wound care, cleanse with normal saline and pat dry, cut calcium alginate silver to size of wound bed and apply, cover with border gauze. Start date was 02/27/2026. Treatment Administration Record dated March 2026, documented Calcium Alginate - Silver External Pad two (2)-inch x two (2) inch, apply to sacrum topically every dayshift for wound care, cleanse with normal saline and pat dry, cut calcium alginate silver to size of wound bed and apply, cover with border gauze. Start date was 02/27/2026 at 7:00 AM. The treatment was scheduled to be done at 7:00 AM. The order was discontinued on 03/18/2026 at 10:58 AM. The treatment was not documented as being administered on 03/03/2026, 03/08/2026, and 03/18/2026. The record was blank. Resident #7: Resident #7 was admitted to the facility with diagnoses of cirrhosis of liver (late stage of liver disease characterized by scarring in the liver tissue), diabetes, and hypokalemia (low amount of potassium in the blood). The Minimum Data Set, dated [DATE], documented the resident had moderate cognitive impairment. The resident usually made themselves understood and understood others. Care Plan for Alteration in Skin Integrity, initiated 02/19/2026, documented the resident had a stage three (3) pressure ulcer on the sacrum. Interventions included apply treatment per order. Nursing admission Evaluation Note dated 02/18/2026 at 2:48 PM by Registered Nurse Manager #1, documented a stage three (3) pressure ulcer on the sacrum that measured two and a half (2.5) centimeters long by two and a half (2.5) centimeters wide, by two tenths (0.2) centimeters deep. Treatment Administration Record dated March 2026, documented Santyl External Ointment 250 unit/gram (collagenase), apply to sacrum topically every shift for wound care, cleanse with normal saline, apply nickel thick layer of Santyl to wound, cover with normal saline moistened gauze and island dressing. Start date was 03/06/2026 at 7:00 AM. The treatment was scheduled to be done at 7:00 AM. The order was discontinued on 03/12/2026 at 12:27 PM. The treatment was not documented as being administered on 03/08/2026 and 03/12/2026. The record was blank. During an interview on 03/25/2026 at 9:36 AM, Registered Nurse Manager #1 stated Resident #1 had a pressure ulcer on their right heel that was assessed on admission by the registered nurse supervisor on 09/18/2025. They recalled the treatment being skin prep or Medihoney. The registered nurse who completed the admission was to ensure treatment was in place when a wound was identified and would call physician for the order. They were not aware there was no order for Resident #1 until 09/20/2025. The medication cart nurse was responsible for doing the treatment during their assigned shift and should complete it by shift change. If there were blanks on the Treatment Administration Record, the treatment was not done. They were not aware treatments were not done and stated the protocol was to report any missed treatment to Registered Nurse Manager #1 and the physician. During an interview on 03/25/2026 at 11:58 AM, Director of Nursing #1 stated they believed they were the director in September and October 2025. When Resident #1 was admitted on [DATE], there was an unstageable pressure ulcer with eschar on the wound bed and was documented on the assessment. They reviewed the electronic medical record and did not see an order for treatment until 09/20/2025. They reviewed the Treatment Administration Record and saw missing treatments. Treatments were scheduled for all three (3) shifts, day, evening, night. The day nurse had the whole shift to do the treatments that were usually done in between medication passes. If unable to do a treatment, they were to notify the physician, Director of Nursing, and nurse manager, or ask other licensed staff for help. It should also be written on the 24-hour report, which was on paper back then. During an interview on 03/26/2026 at 11:15 AM, Licensed Practical Nurse #4 stated they completed assigned wound care during the 3:00 PM to 11:00 PM shift, towards the end of the shift. When the wound care was completed, it was documented on the Treatment Administration Record in the electronic medical record. If they could not complete the wound care, they would document in the computer system and on the 24-hour shift report and would tell the oncoming nurse. During an interview on 03/26/2026 at 11:23 AM, Licensed Practical Nurse #5 stated they usually worked the 7:00 AM to 3:00 PM shift and would complete assigned wound care in between medication passes throughout the shift. They document in the computer system when wound the care was complete. If they could not complete the wound care, they would write a nursing note in the computer system and on the 24-hour shift report. If a resident refused treatment, they would leave the resident and reapproach. They stated wound care was important and they would let Registered Nurse #1 know if they continued to refuse. During an interview on 03/26/2026 at 3:09 PM, Registered Nurse #1 stated a treatment was supposed to be in place when a wound was identified. There should never be a blank entry on the Treatment Administration Record, which indicated the treatment was not done. If treatment could not be done, there needed to be communication to Registered Nurse #1, and to the oncoming nurse. During an interview on 03/27/2026 at 1:14 PM, Medical Director #1 stated they relied on weekly wound assessments and treatments done by staff. 10 New York Code of Rules and Regulations 415.12(c)(1)

Based on record review and interviews conducted during a survey, the facility failed to ensure that comprehensive care plans were revised and updated according to professional standards for one (1) (Resident # 1) of three (3) residents reviewed. Specifically, for Resident #1, the comprehensive care plan was not updated (a.) to reflect weekly wound assessments were not done by the wound care provider when the resident was out for dialysis treatment on 09/25/2025, 10/02/2025, and 10/09/2025, and (b.) when there was a significant change in the pressure ulcer on 10/02/2025 and had deteriorated. Findings include: Cross-referenced to F686: Treatment/Services to Prevent/Heal Pressure UlcersResident #1: Resident #1 was admitted to the facility with diagnoses of end stage renal disease (kidneys no longer work to meet the body's needs) with dependence on renal dialysis (a treatment that filters waste and excess fluid from the blood when the kidneys are failing), diabetes (body cannot use insulin correctly and sugar builds up in the blood) with diabetic chronic kidney disease, and chronic peripheral venous insufficiency (occurs when leg veins become damaged and do not allow blood flow back to your heart). The Minimum Data Set (an assessment tool) dated 09/25/2025, documented the resident was cognitively intact. The resident was able to make themselves understood and understood others. The Policy and Procedure titled, Care - Plans Comprehensive, revised 10/2019, documented assessments were ongoing, and care plans were revised as information about the residents' condition changed. The Interdisciplinary Team reviewed and updated the care plan when there was a significant change in the resident's condition, when the desired outcome was not met, when the resident had been readmitted to the facility from a hospital stay, and at least quarterly with scheduled quarterly Minimum Data Set. The Policy and Procedure titled, Wound Identification and Wound Rounds, revised 11/06/2023, documented the Registered Nurse/Interdisciplinary Team would develop a care plan for the new skin impairment. The Registered Nurse would initiate a care plan including prevention interventions as necessary. Care Plan for Alteration in Skin Integrity, created on 09/19/2025 and initiated on 09/30/2025, documented the resident had an actual pressure injury site to their right heel of the foot with eschar tissue (a thick, dry, black or brown layer of dead tissue). Interventions included apply treatment per order, refer to Physical Therapy/Occupational Therapy as needed for position evaluation, and refer to wound care specialist as needed. Wound Evaluation (Weekly) dated 10/02/2025 at 4:40 PM by Licensed Practical Nurse #1, documented an unstageable pressure ulcer on the right heel that measured four (4) centimeters long by four (4) centimeters wide and depth was unable to determine. There was 100% black/brown eschar, with a scant amount of serous (clear to yellow fluid that leaks out of a wound), and no odor. Treatment was in place. Response to treatment documented deteriorated. Interventions/action plan: treatment re-evaluated or changed. Additional comments: wound care provider unable to see due to dialysis schedule conflict. The comprehensive care plan did not have evidence of an update/revision when the resident was not seen by the wound care provider for weekly wound assessment of the pressure ulcer on 09/25/2025, 10/02/2025, and 10/09/2025, when the resident was out of the facility for scheduled dialysis treatment. The comprehensive care plan did not have evidence of an update/revision when there was a significant change in the pressure ulcer on 10/02/2025 and had deteriorated. During an interview on 03/25/2026 at 11:58 AM, Director of Nursing #1 stated care plans were initiated by a registered nurse and updated/revised as things changed. The care plan was updated when a wound was identified. During an interview on 03/26/2026 at 3:09 PM, Registered Nurse Manager #1 stated care plans were initiated by the Interdisciplinary Team and updated/revised when the resident's status changed. 10 New York Code of Rules and Regulations 415.11(c)(2)(i-iii)

Based on record review and interviews conducted during a survey, the facility failed to ensure the physician reviewed the resident's total program of care, including medications and treatments at each visit for one (1) (Resident #1) of three (3) residents reviewed. Specifically, the Attending Physician saw Resident #1 on 09/24/2025 for admission evaluation and their progress note did not include a plan for care and treatment of an unstageable pressure ulcer on the right heel. Findings include: Cross-referenced to F600: Free from Abuse and NeglectResident #1: Resident #1 was admitted to the facility with diagnoses of end stage renal disease (when the kidneys no longer work to meet the body's needs) with dependence on renal dialysis (a treatment that filters waste and excess fluid from the blood when the kidneys are failing), diabetes (body cannot use insulin correctly and sugar builds up in the blood) with diabetic chronic kidney disease, and chronic peripheral venous insufficiency (occurs when leg veins become damaged and do not allow blood flow back to your heart). The Minimum Data Set (an assessment tool) dated 09/25/2025, documented the resident was cognitively intact, was able to make themselves understood and understood others. The Policy and Procedure titled, Physician Visits, revised 05/2019, documented the Attending Physician must perform relevant tasks at the time of each visit, including a review of the resident's total program of care and appropriate documentation. Document titled Admission/readmission Evaluation Part 1 dated 09/18/2025 by Registered Nurse #2 documented an unstageable pressure ulcer (depth of wound is unknown because devitalized tissue obscures the extent of tissue damage) on the right heel that measured 2.5 centimeters long by 2.2 centimeters wide and had no depth. Unable to visualize the wound bed. There was 100% black/brown eschar (necrotic tissue-black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin). It documented a treatment was in place. Team Meeting Note dated 09/19/2025 at 9:41 AM by Licensed Practical Nurse #1, documented the Interdisciplinary Team met on 09/19/2025 regarding Resident #1 for the following reason: High Risk Meeting. Meeting attendees included Nursing, Social Services, Rehab/Therapy, Dietary, Administration, and Nurse Practitioner #1. The resident was invited but declined to attend. Meeting summary documented Resident #1 had a pressure ulcer on the right heel and would be referred to the in-house wound provider. Encounter Note dated 09/24/2025 at 1:00 AM by Physician #1, documented initial History and Physical. Review of systems skin/breast documented no rashes or skin breakdown. Physical exam of the skin documented warm and dry. The note did not include documentation of the pressure ulcer on the right heel and there was no documented plan for treatment of the pressure ulcer. During an interview on 03/27/2026 at 1:14 PM, Medical Director #1 stated that when Resident #1 was in the facility, Physician #1 was getting ready to retire, was frustrated and did not always write notes about all the resident's concerns. Physician #1 has since retired and was out of the country. They stated it was difficult to find qualified persons to work in nursing homes, including physicians. They stated they did speak with Nurse Practitioner #1 and discussed opportunities to improve as a medical team. The medical team needed to be aware of a resident's wound status and needed to open/read the notes from the wound care provider. They stated during interval medical visits the wound care notes needed to be reviewed. During an interview on 04/1/2026 at 10:05 AM, Administrator #1 statedthe physician/nurse practitioner was responsible for a resident's overall care. Physician #1 retired. They stated Physician #1 was not resident centered. 10 New York Code of Rules and Regulations 415(b)(2)(iii)

Based on record review and interviews conducted during a survey, the facility failed to ensure services provided or arranged by the facility as outlined by the comprehensive care plan were provided by qualified persons in accordance with each resident's written plan of care for one (1) (Resident #1) of three (3) residents reviewed. Specifically, Resident #1's unstageable pressure ulcer on the right heel was assessed on 9/25/2025 by a Licensed Practical Nurse who was not qualified to do so within their scope of practice. Findings include: Resident #1: Resident #1 was admitted to the facility with diagnoses of end stage renal disease (kidneys no longer work to meet the body's needs) with dependence on renal dialysis (a treatment that filters waste and excess fluid from the blood when the kidneys are failing), diabetes (body cannot use insulin correctly and sugar builds up in the blood) with diabetic chronic kidney disease, and chronic peripheral venous insufficiency (occurs when leg veins become damaged and do not allow blood flow back to your heart). The Minimum Data Set (an assessment tool) dated 9/25/2025, documented the resident was cognitively intact. The resident was able to make themselves understood and understood others. Policy and Procedure titled, Wound Identification and Wound Rounds, revised 11/6/2023, documented the facility would identify, assess, and manage residents with pressure injuries, skin alterations, impairments, or wounds in accordance with current standards of practice. The Wound Nurse/Designee, Wound Care Provider and Registered Dietician were notified of pressure ulcer or skin impairment, and the resident was scheduled for weekly wound rounds. For weekly wound rounds, the Designated Wound Nurse or Licensed Nurse would complete weekly wound rounds with the wound provider and other members of the Interdisciplinary Team (as necessary). Care Plan for Alteration in Skin Integrity, created on 9/19/2025 and initiated on 9/30/2025, documented the resident had an actual pressure injury site to their right heel with eschar (necrotic tissue-black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin). Interventions documented apply treatment per order, refer to Physical Therapy/Occupational Therapy as needed for position evaluation, and refer to wound care specialist as needed. Document titled LN: Admission/readmission Evaluation Part 1 dated 9/18/2025 by Registered Nurse #2 documented an unstageable pressure ulcer (depth of wound is unknown because devitalized tissue obscures the extent of tissue damage) on the right heel that measured 2.5 centimeters long by 2.2 centimeters wide and had no depth. Unable to visualize the wound bed. There was 100% black/brown eschar. It documented a treatment was in place. Team Meeting Note dated 9/19/2025 at 9:41 AM by Licensed Practical Nurse #1, documented the Interdisciplinary Team met on 9/19/2025 regarding Resident #1 for the following reason: High Risk Meeting. Meeting attendees included Nursing, Social Services, Rehab/Therapy, Dietary, Administration, and Nurse Practitioner #1. The resident was invited but declined to attend. Meeting summary documented Resident #1 had a pressure ulcer on the right heel and would be referred to the in-house wound provider. Document titled LN: Wound Evaluation (Weekly) dated 09/25/2025 at 11:50 AM by Licensed Practical Nurse #1, documented an unstageable pressure ulcer on the right heel that measured 2.5 centimeters long by 2.2 centimeters wide and the depth was UTD (unable to determine). There was 100% black/brown eschar, with no exudate (drainage) and no odor. Treatment was in place and response to treatment was improved. Additional comments: refer to wound care provider. There was no documented evidence that the in-house wound care provider or a qualified person assessed the resident's pressure ulcer on the right heel on 09/25/2025. An email dated 04/10/2026 at 9:43 AM from the New York State Education Department, Nursing Board Office, documented general information about the scope of practice of New York State licensed professionals. It was not within the scope of practice of a Licensed Professional Nurse to (a) practice nursing independently or provide nursing care that they are not competent to perform and (b) perform nursing assessments, determine nursing diagnoses, or develop or change nursing care plans. A competent, trained Licensed Practical Nurse may measure, document and report their findings to a Registered Nurse once an assessment of each patient and the wound is performed prior to and after as indicated, any wound care or measurements a patient may require. A Licensed Practical Nurse was accountable to make observations and report their findings to the directing Registered Nurse, who performed the assessment and formulated a care plan. The Registered Nurse was responsible for reassessing the patient and formulating a plan of care, evaluating and amending that plan based on the assessments. Licensed Practical Nurses may collect clinical data (wound size, color, drainage, etc.) and report it to a Registered Nurse. The Registered Nurse was responsible for determining/interpreting that clinical data. The Registered Nurse makes a determination of effectiveness of the nursing and/or medical regimen and makes a decision regarding the plan of care. During an interview on 03/24/2026 at 2:39 PM, Licensed Practical Nurse #1 stated they were a travel resource nurse and worked at the facility in September and October 2025, as the Assistant Director of Nursing duties, while the position was vacant. They helped with wounds, infection control, education, and other assignments. The wound care provider was supposed to see the resident, but their dialysis treatment conflicted, and they were not in the building when the wound care doctor was present. The wound care provider came one day a week that they believed was Thursday. The resident's first wound evaluation would have been a week from admission, on 09/25/2025 and the wound care provider did not see the resident. They stated the resident was not at high risk. When Licensed Practical Nurse #1 accompanied the wound care provider during wound rounds, they would evaluate the wound and put a note in the electronic medical record that they were seen by the wound care provider. If the wound care provider or Registered Nurse Manager #1 was available, they would conduct wound rounds by themselves. The initial evaluation was always done by a registered nurse. When Licensed Practical Nurse #1 documented a wound, they would write about what they saw during the evaluation. On 09/25/2025, a registered nurse was not with them when they did weekly wounds for Resident #1. There was 100% eschar on the wound bed and there was no way to see the depth of the wound. There was no worsening or significant change and would have let the registered nurse know. They did not refer the resident to the wound care provider on 09/25/2025 because there was no change in the wound. Even if they did refer to the wound care provider on 09/25/2025, the resident would not have been seen because they were at the dialysis center. Nurse Practitioner #1 was notified on 09/25/2025 and should have seen and assessed the resident. During an interview on 03/25/2026 at 9:36 AM, Registered Nurse #1 stated Resident #1 had a pressure ulcer on their right heel upon admission on [DATE] and was assessed by the registered nurse supervisor. They did not know if they attended the high-risk meeting on 09/19/2025. The weekly wound assessment scheduled for 09/25/2025 was done by Licensed Practical Nurse #1 who was the corporate regional clinical nurse manager and was the facility's acting Assistant Director of Nursing. Registered Nurse #1 usually accompanied Licensed Practical Nurse #1 and the wound care provider on weekly wound rounds and stated on 09/25/2025 they were most likely assigned to a medication cart and passed medications or just did not document the assessment. If they were assigned to a medication cart and had to pass medications, they would not have attended wound rounds. During an interview on 03/25/2026 at 11:58 AM, Director of Nursing #1 stated they believed they were the director in September and October 2025. When Resident #1 was admitted on [DATE], there was an unstageable pressure ulcer with eschar on the wound bed and was documented on the assessment. They were not aware of conflict between dialysis and wound care. If they were made aware they would have made sure the physician or Nurse Practitioner was made aware and would have looked at the wound themselves. They stated that on 09/18/2025, the resident's wound was assessed by a registered nurse, and on 09/25/2025 by a licensed practical nurse. Licensed Practical Nurse #1 was a corporate resource nurse who went to each facility when they needed help. They stated licensed practical nurses could measure but could not assess a wound and were supposed to write what they observed in a nursing progress note. During an interview on 03/26/2026 at 1:53 PM, Nurse Practitioner #1 stated they did not realize Licensed Practical Nurse #1 who was doing weekly wound assessments was not a registered nurse. During an interview on 03/31/2026 at 2:17 PM, Wound Care Provider #1 stated it was not normal and unacceptable for there to be no weekly assessment by a registered nurse when the wound care provider was not able to see the resident. 10 New York Code of Rules and Regulations 415.11(c)(3)(ii)

Based on record reviews and interviews conducted during a survey, the facility failed to ensure residents were afforded the right to formulate advanced directives including having a physician order related to their code status (level of medical interventions a person wishes to have started if their breathing stopped such as cardiopulmonary resuscitation or do not resuscitate), and establishing mechanisms for documentation and communicating the residents' choices to staff responsible for their care for one (1) (Resident #1) of three (3) residents reviewed. Specifically, when the resident no longer wanted cardiopulmonary resuscitation on [DATE], there was no physician order for the change in code status and advance directive until [DATE]. Findings include: Resident #1: Resident #1 was admitted to the facility with diagnoses of end stage renal disease (kidneys no longer work to meet the body's needs) with dependence on renal dialysis (a treatment that filters waste and excess fluid from the blood when the kidneys are failing), diabetes (body cannot use insulin correctly and sugar builds up in the blood) with diabetic chronic kidney disease, and chronic peripheral venous insufficiency (occurs when leg veins become damaged and do not allow blood flow back to your heart). The Minimum Data Set (an assessment tool) dated [DATE], documented the resident was cognitively intact. The resident was able to make themselves understood and understood others. The Policy and Procedure titled, Advance Directives and State Specific Medical Orders for Life-Sustaining Treatment - NY, revised [DATE], documented residents had the right to formulate an advance directive and to modify or revoke their advance directives and/or MOLST (Medical Orders for Life-Sustaining Treatment) at any time and the modifications and/or revocation would be acknowledged and honored by the facility. The facility would follow Federal and State requirements in the acknowledgement of existing and execution of new or revised advance directives and MOLSTs when delivering care to residents. Policy implementation documented the resident could initiate an advance directive, and/or change determinations on their advance directive at any time. The Social Worker or designee would review the resident's advance directive, provide education to the resident regarding the advance directive, and ensure the resident's advance directive was reflected in the clinical record. Medical orders would be documented in the electronic health record to reflect the resident's code status and any restrictions to intubation and hospitalization, based on the resident's MOLST. Care Plan for Advance Directive - Health Care Proxy, created/initiated [DATE], documented the resident had Medical Orders for Life-Sustaining Treatment. Goal documented the resident's advance directive and Medical Orders for Life-Sustaining Treatment would be regarded and respected. Interventions documented review and revise advance directive/Medical Orders for Life-Sustaining Treatment quarterly and as needed. Encounter Note dated [DATE] at 1:00 AM, signed [DATE] at 8:02 AM by Physician #1, documented initial History and Physical. Advance Care Planning documented consent: do not resuscitate. Advance directives were voluntarily discussed with the resident. The resident was alert and oriented and competent to make the decision for themselves. When the resident was admitted to the facility they indicated they wanted to be fully resuscitated but now indicated they changed their mind and did not want to be resuscitated in case of cardiorespiratory arrest even if there was a chance for recovery. The resident understood the consequences of the decision. There was no documented evidence that the resident's code status was changed until [DATE]: Order Recap Report for order date [DATE] to [DATE], documented: CPR (cardiopulmonary resuscitation) order: attempt cardiopulmonary resuscitation. Order date was [DATE] and end date was [DATE]. Review of Pre Dialysis Notes dated [DATE], [DATE] and [DATE], documented the resident's code status was cardiopulmonary resuscitation order: attempt cardiopulmonary resuscitation. Please see Medical Orders for Life-Sustaining Treatment. Review of Order Recap Report for order date [DATE] to [DATE], documented: Do not resuscitate order: do not attempt resuscitation (allow natural death). Order date was [DATE] and end date was [DATE]. Medical Orders for Life-Sustaining Treatment form signed on [DATE] by the resident and Physician #1, documented do not resuscitate order: do not attempt resuscitation (allow natural death). During an interview on [DATE] at 12:51 PM, Registered Nurse #1 reviewed the progress notes and stated a change in the resident's code status for do not resuscitate was documented in Physician #1's note dated [DATE]. They did not recall an order for the change in code status. Typically, when Physician #1 wanted an order entered into the electronic medical record, they would communicate with the nurses by writing the order in a nurse book. Physician #1 would either hand the book to Registered Nurse #1, Licensed Practical Nurse #6, Director of Nursing #1, or Medical Records Staff #1 who worked in the same office as Physician #1. They reviewed physician orders and stated the order for cardiopulmonary resuscitation was discontinued on [DATE]. The staff person notified of the change in code was responsible for entering the order into the electronic medical record. If a code status changed it would be entered immediately at the time of the change. There should never be a delay of seven days for a code status change. During an interview on [DATE] at 2:36 PM, Medical Director #1 stated medical staff had a process in place for writing physician orders, placing them in a book and then handing them to nursing staff. This enabled the physician to physically show the order to the nurse and then nurse had the ability to ask questions about the order. They stated that aside from the written order, a verbal order was valid for a code status change since it needed to be entered at the time of the change. Some nursing homes were under the misconception that code status was not official until the Medical Orders for Life-Sustaining Treatment was completed and signed by the physician and stated that was not true. The facility should not have waited to enter the code status order because Physician #1 was only at facility two (2) days per week. 10 New York Code of Rules and Regulations 415.3(e)(1)(ii)

Based on observation, interview and record review conducted during a Survey, the facility failed to report the results of all investigations to his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within five (5) working days of the incident, and if the alleged violation is verified appropriate corrective action was taken for one (1) of one (1) residents reviewed. Specifically on 10/14/2025, Resident #3 threw objects including a chair that resulted in the chair hitting Resident #5's right foot. Resident #3 also climbed on top of Resident #4's bed while Resident #4 was laying in their bed. There was no documented evidence this incident involving Resident #3 was reported to the State Survey Agency as required. Findings include: Facility policy titled, Abuse Policy, reviewed 07/18/2025, documented the facility prohibited the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone, including staff, family, friends, or other residents. The Administrator and Director of Nursing would be responsible for investigating and reporting to the appropriate State Agency(s) immediately (no later than two (2) hours after allegation/identification of allegation) after identifying the alleged/suspected incident. The policy further defines abuse as the willful infliction of injury or intimidation resulting in physical harm, pain, or mental anguish. Resident #3 was admitted to the facility with diagnoses of vascular dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life caused by decreased blood flow to the brain), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety (a feeling of fear, dread, and uneasiness that acts as a natural reaction to stress). The Minimum Data Set (an assessment tool) dated 01/12/2026, documented the resident could be understood, could understand others, and had moderate cognitive impairment. Facility Investigation Summary documented the date and time of incident as 10/14/2025 at 8:30 PM. During this time, Resident #3 had escalated behaviors and a psychotic episode. Resident #3 threw soda cans and an object at a nurse in their room while the nurse administered medication to the roommate (Resident #4). Resident #3 was escorted back to bed. Resident #3 began swinging their walker at staff. Staff attempted to redirect the resident without success, and the resident was at significant risk of harm to others. Staff placed Resident #3 on a one to one (1:1) (when a dedicated caregiver was assigned exclusively to one resident to provide personalized attention). Resident #3 stood up from the bed they were in and got into the bed where Resident #4 was laying. Resident #3 was removed from this bed and placed in another bed. Resident #4 was also assisted out of the bed and brought to another room. Resident #3 continued to be aggressive and went across the hall into Resident #5's room. Resident #3 pushed a tray table out of their way and Resident #5 tried to push it back. While doing this, Resident #5 hit their elbow. Resident #3 picked up a chair and threw the chair down. The chair hit Resident #5's right foot. There were two (2) Certified Nurse Aides in the room at this time and they escorted Resident #3 out of the room. Medical Director #1 was notified and orders were given to send Resident #3 to the hospital. A Registered Nurse skin assessment was completed for both Resident #4 and Resident #5. It further documented that there was no evidence of abuse, neglect, exploitation, mistreatment, or intentional misconduct by staff. The event was determined to be the result of an episode of an acute psychosis event of Resident #3, where they became belligerent, aggressive, violent and exhibited physical behavior. Resident #3 was at very high risk of harm to others. There was no alternative but to attempt to pharmacologically intervene and transfer to the hospital for further evaluation. There was no documented evidence that the facility submitted a report of the resident-to-resident abuse to the New York State Department of Health. During an interview on 03/26/2026 at 2:08 PM, Director of Nursing #1 stated they were not in the facility at the time of this incident, but they received a phone call from Registered Nurse #1 regarding the incident. Director of Nursing #1 stated they did not believe this incident was reportable to the State Agency because Resident #3 did not hurt anyone. Director of Nursing #1 stated they completed the facility investigations and Administrator #1 was the person to report incidents to the State Agency. During an interview on 03/26/2026 at 2:22 PM, Administrator #1 stated they had been working in the facility for about three (3) months and heard about the incident that occurred on 10/14/2025. Administrator #1 stated if any incident occurred, a facility investigation would be started and completed by Director of Nursing #1. 10 New York Codes, Rules, and Regulations 415.4(b)(2)

Based on record review and interviews conducted during a survey, the facility failed to ensure comprehensive care plans were developed and implemented for residents according to professional standards for one (1) (Resident #6) of three (3) residents reviewed. Specifically, Resident #6's comprehensive care plan did not contain measurable goals and interventions for the care and treatment of the stage three (3) pressure ulcer on the sacrum (triangular bone at the base of the spine). Findings include: Cross-referenced to F686: Treatment/Services to Prevent/Heal Pressure Ulcers Resident #6: Resident #6 was admitted to the facility with diagnoses of orthopedic surgery of right tibia/fibula (bones in lower leg) aftercare, diabetes, and chronic kidney disease stage 3A (where kidney function is between 45-59 percent). The Minimum Data Set (an assessment tool) dated 02/28/2026, documented the resident was cognitively intact. The resident was able to make themselves understood and understood others. The Policy and Procedure titled, Care - Plans Comprehensive, revised 10/2019, documented a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs was developed and implemented for each resident. The Interdisciplinary Team, in conjunction with the resident and representative, developed and implemented a comprehensive, person-centered care plan for each resident. The care plan would describe services that were furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Areas of concern that were identified during the resident assessment would be evaluated before interventions were added to the care plan. The Policy and Procedure titled, Wound Identification and Wound Rounds, revised 11/06/2023, documented the Registered Nurse/Interdisciplinary Team would develop a care plan for the new skin impairment. The Registered Nurse would initiate a care plan including prevention interventions as necessary. Document titled LN: Admission/readmission Evaluation Part 1 dated 02/24/2026 by Registered Nurse #1 documented a stage three (3) pressure ulcer (serious skin injury that involves full-thickness skin loss and exposure of the fatty tissue) on the sacrum that measured two (2) centimeters long by two (2) centimeters wide by 0.1 centimeters deep. Care Plan for Nutritional Problem or Potential Nutritional Problem, created/initiated 02/27/2026, documented the resident had a pressure injury on the sacrum. The comprehensive care plan did not have evidence of measurable goals and interventions for the care/treatment of the stage three (3) pressure ulcer on the sacrum, to promote healing and prevent infection. During an interview on 03/25/2026 at 11:58 AM, Director of Nursing #1 stated care plans were initiated by a registered nurse and updated/revised as things changed. The care plan was updated when a wound was identified. During an interview on 03/26/2026 at 3:09 PM, Registered Nurse #1 stated care plans were initiated by the Interdisciplinary Team and updated/revised when the resident's status changed. 10 New York Code of Rules and Regulations 415.11(c)(1)

Based on observation, record review, and interviews during the recertification survey from 2/05/2024 to 2/12/2024, the facility did not adequately provide for residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area on one (1) of 2 units. Specifically, the facility nurse call system did not function in resident room #s 5, 7, and 11 on the North Unit. This is evidenced by: During observations on 2/08/2024 at 9:33 AM, the call bell did not activate when tested in resident room # 5 for beds A and B. Additionally, room [ROOM NUMBER] was utilizing tap bells and did not have nurse cords to activate the nurse call system. room [ROOM NUMBER] was utilizing a tap bell and did not have a nurse call cord to activate the nurse call system. During an interview on 2/08/2024 at 9:37 AM, Resident #8 stated that they would press the nurse call cord if one were provided. Record review of [NAME] Center Repair Requisitions, dated 12/26/2023, documented that the nurse call system in room [ROOM NUMBER] and room [ROOM NUMBER] were in disrepair. Record review of [NAME] Center Repair Requisition, dated 12/30/2023, documented that the nurse call system in room [ROOM NUMBER] was in disrepair. The document titled [vendor] Quote documented that the facility obtained a quote to affect repairs to the call bell system on 1/09/2024. During an interview on 2/08/2024 at 9:44 AM, Maintenance Life Safety Consultant #1 stated that the facility had contracted with a vendor to repair the nurse call systems in 3 resident rooms and was presently awaiting to schedule a starting date once the vendor had all the replacement parts. During an interview on 2/12/2024 at 10:33 AM, Administrator #1 stated that the repairs to the call bell system were completed. 10 New York Codes, Rules and Regulations 713-1.3(b)

Based on observation, record review, and interviews during a recertification and abbreviated survey (Case # NY00327311 and NY00315143) from 2/05/2024 to 2/12/2024, the facility did not ensure sufficient nursing staff to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for all residents in the facility. Specifically, there was not sufficient staff to meet resident needs in activities of daily living; multiple residents stated there were long waits for call lights showers were not given, not gotten out of bed and dressed until late morning, long waits to return to bed, and not enough staff to provide care. This is evidenced by: The facility's staffing policy revised on 11/2023, documented staffing numbers and skills requirements of direct care staff were determined by the needs of the resident's care plan. The number of nursing staff on duty would be sufficient to ensure nursing care needs of each resident were met. The facility's Call Light System - Resident Response policy dated 12/2017, documented the purpose was to provide timely response to residents in need of assistance to ensure high quality resident outcomes; be sure call light was within easy reach of the resident; answer call light as soon as possible and check on resident frequently who may not be able to use call their call light. Resident #2 The resident was admitted to the facility with the diagnoses of urinary tract infection, diabetes mellitus type 2, hypertension, hypothyroidism (underactive thyroid), and obesity. The Minimum Data Set (an assessment tool) dated 11/28/2023 documented the resident could understand and be understood by others and was cognitively intact. The comprehensive care plan initiated 9/22/2023 documented the resident required assistance with Activities of Daily Living related to limited mobility, Diabetes Mellitus, obesity, and inability to complete Activity of Daily Living tasks; Interventions included a total mechanical lift with assistance of 2 or more staff for transfers. The following observations of Resident #2 were made: On 2/05/2024 at 10:40 AM, resident was in bed wearing hospital gown. On 2/06/2024 at 11:00 AM, resident was in bed wearing hospital gown. Both resident and roommate stated they were waiting for Certified Nurse Aide to assist with morning care. Resident was noted to have left over breakfast on overbed table, face with crumbs and hair was disheveled. On 2/6/2024 at 11:10 AM, resident turned on call light, staff responded in 13 minutes and told resident they would be back. On 2/07/2024 at 10:13 AM, resident was in bed wearing hospital gown and stated they are waiting for assistance to get washed up. During an interview on 2/6/2024 at 11:15 AM, the resident stated staff only provided care to them once a day if that. Resident stated they waited a very long time for care. Resident stated they had a foley catheter secondary to urinary incontinence and required assistance after soiling briefs. Resident # 32 The resident was admitted to the facility with the diagnoses of osteoarthritis, difficulty walking, chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), weakness, and depression. The Minimum Data Set, dated dated dated [DATE] documented the resident could understand and be understood by others and was cognitively intact. The comprehensive care plan initiated 3/17/2017 and revised 11/2/2024 documented the resident required assistance with Activity of Daily Living tasks related to limited mobility, osteoarthritis, chronic left shoulder pain, and inability to complete Activity of Daily Living tasks. Resident was a partial assist with 1 staff helper, and the resident was to be encouraged to use a call light for assistance. Resident did not have a comprehensive care plan to self-administer hearing aids. Record review of grievances revealed the resident filed a grievance with the facility on 7/21/2023 for help during the night, and that they wait an hour and half for assistance. During an observation on 2/05/2024 at 12:59 PM, the resident's call light remained on for 20 minutes. It was noted that there were 6 staff in the vicinity of the resident's room that did not answer light, and that the staff instead went about other duties. During an interview on 2/05/2024 at 11:45 AM, the resident was observed in their room sitting in a chair. Resident observed to be extremely hard of hearing. The resident did not have hearing aids applied, and hearing aides were seen in the resident's closet. Resident stated they asked for assistance in applying hearing aids, but staff would not assist. Resident was wearing a hospital gown, and stated they were wearing a hospital gown as it was all the clean clothing available to them. Their laundry was taken and not returned. Resident stated they would wait for hours on the toilet for assistance, and at times they would not receive a shower or overnight care. During an interview on 2/05/2024 at 11:50 AM, Licensed Practical Nurse #6 stated the resident refused their hearing aids. Licensed Practical Nurse #6 then walked to resident's room, located the hearing aids in resident's closet, and placed them on Resident #32. At the time of the observation, Resident #32 was very receptive and thankful to have hearing aids placed. During an interview on 2/07/2024 at 10:48 AM, Registered Nurse #1 stated there were typically 4-5 Certified Nurse Aides on day shift, 3-4 on evening shift and, 1-2 overnights. Registered Nurse #1 further stated that there were missed showers at times, and sometimes residents refused. They stated that it would be documented in their electronic charting system; that only a few residents consented to getting up on the 11 PM - 7 AM shift. They stated that most residents preferred to get up between 7:00 AM - 8:00 AM which was not always doable. Registered Nurse #1 further stated that on the rehabilitation unit, physical therapy would send a list of who needed to get up first, and residents needing physical therapy would be prioritized to get up first. During an interview on 2/07/2024 at 02:15 PM, Administrator #1 stated they were gradually reducing agency staff; had a recent Town Hall meeting and addressed staff answering call lights timely. They further stated that management had been working on individual units to address concerns, specifically answering call lights. Administrator #1 stated that, at times, staff on orientation were counted as regular staff, depending on their progress during orientation. Resident #327 The resident was admitted to the facility with the diagnoses of metabolic encephalopathy (a series of neurological disorders not caused by primary structural abnormalities), severe sepsis with septic shock (a condition in which the body responds improperly to an infection including possible organ failure), and cirrhosis of the liver (a condition where scar tissue gradually replaces liver tissue). The Minimum Data Set, dated dated dated [DATE] documented the resident could understand and be understood by others and was cognitively intact. The Kardex Report (list of certified nurse aide tasks) dated 2/28/2023 documented the resident was to receive a shower or bath every Tuesday and Thursday on the day shift. The Kardex Report documented the resident required the physical assistance of one staff member with bathing activity. The document titled Bathing for the dates 2/13/2023-2/28/2023 documented that no bath or shower was given to resident. On 2/21/2023 and 2/28/2023, the bathing activity was documented as NA or not applicable. During an interview on 2/12/2024 at 11:20 AM, Certified Nurse Aide #3 stated residents should receive showers according to their Kardex. They stated they check the Kardex for changes at the start of each shift. They stated if a resident refused a shower, they would inform the nurse and re-approach. During an interview on 2/12/2024 at 11:23 AM, Licensed Practical Nurse #5 stated that at the end of the shift, the nurse should check to make sure Certified Nurse Aide tasks were completed; this would include showers and bathing. Licensed Practical Nurse #5 stated they would expect the Certified Nurse Aide to inform the nurse if a resident refused a shower. During an interview on 2/12/2024 at 11:40 AM, Director of Nursing #1 stated audits should be performed at the end of the shift to ensure the Certified Nurse Aide accountability was complete and resident care had been completed. They stated they expected the Certified Nurse Aide and floor nurse (Licensed Practical Nurse or Registered Nurse) to communicate about any issues with resident care including if a resident refused care. During an interview in Resident Council meeting on 2/05/2024 at 1:40 PM, - Resident #s 61, 44 and 36 stated average wait time for call light was between 15 to 20 minutes during the day, with overnights taking more time and staff did not help each other out, it is like nobody there. If a certified nurse aide is assigned to you, the other certified nurse aides would not touch you. - Resident # 61 stated they had sat on toilet until legs went numb. - Resident # 36 stated they had sat in wet pads for hours. During an interview on 2/06/2024 at 11:38 AM, Resident #67 stated at about 4:00 AM on 2/05/2024, they activated their call light and called out for help because of extreme pain and needed a pain pill. They stated that as they were crying out in pain, they heard staff outside in hallway talking and laughing, and no one came to answer the active call bell light until the day shift arrived. In an observation at this time, Resident #67's status was noted to include post amputation of left lower extremity. During an interview on 2/09/2024 at 10:56 AM, Resident # 11 stated their call light was on for 35 minutes, Certified Nurse Aide #4 came in and shut light off. Resident #11 stated Certified Nurse Aide #4 told the resident that there were only three aides on the floor and were assisting other residents, so Resident #11 would have to wait. During an interview on 2/09/2024 at 12:43 PM, Certified Nurse Aide # 2 stated there were only 3 certified nurse aides on the floor at the time Resident #11 turned their light on to facilitate their return to bed. Certified Nurse Aide #1 further stated that 1 Certified Nurse Aide was giving a shower, and the other was providing patient care. Certified Nurse Aide #1 stated the resident was told they would have to wait as no certified nurse aide was available immediately to put them back in bed. During an interview on 2/09/2024 at 1:54 PM, Administrator #1 stated all staff assist each other on the floor, including supervisors and managers. They further stated that the supervisor went to the floor to assist staff and Resident #11, and an investigation was initiated. The facility's daily staffing schedule dated 2/02/2024 - 2/05/2024 documented the following: 02/02/2024 North Unit, Day shift (7:00 AM - 3:00 PM) - 1 Licensed Practical Nurse and 4 Certified Nurse Aides for 39 residents. South Unit 2 Licensed Practical Nurses, 1 Registered Nurse on orientation, and 4 Certified Nurse Aide for 39 residents. 02/02/2024 North Unit, Evening shift (3:00 PM - 11:00 PM) - 1 Licensed Practical Nurse and 4 Certified Nurse Aides, 1 Certified Nurse Aide on orientation for 39 residents. South Unit 2 Licensed Practical Nurses, and 5 Certified Nurse Aide for 39 residents. 02/02/2024 North Unit, Night shift (11:00 PM - 07:00 AM) - 1 Licensed Practical Nurse on orientation and 3 Certified Nurse Aides, for 39 residents. South Unit 1 Licensed Practical Nurse, and 2 Certified Nurse Aide for 39 residents. 02/03/2024 North Unit, Day shift (7:00 AM - 3:00 PM) - 2 Licensed Practical Nurses, 4 Certified Nurse Aides and 1 Certified Nurse Aide on orientation, for 39 residents. South Unit 3 Licensed Practical Nurses, and 3 Certified Nurse Aides for 39 residents. 02/03/2024 North Unit, Evening shift (3:00 PM - 11:00 PM) - 2 Licensed Practical Nurses and 4 Certified Nurse Aides, for 39 residents. South Unit 2 Licensed Practical Nurses, 1 Licensed Practical Nurse on orientation and 4 Certified Nurse Aide for 39 residents. 02/03/2024 North Unit, Night shift (11:00 PM - 07:00 AM) - 1 Licensed Practical Nurse on orientation and 2 Certified Nurse Aides, for 39 residents. South Unit 1 Licensed Practical Nurse, 2 Certified Nurse Aide and 1 Certified Nurse Aide on orientation for 39 residents. 02/04/2024 North Unit, Day shift (7:00 AM - 3:00 PM) - 2 Licensed Practical Nurses, 4 Certified Nurse Aides and 1 Certified Nurse Aide on orientation, for 39 residents. South Unit 2 Licensed Practical Nurses, and 3 Certified Nurse Aides for 39 residents. 02/04/2024 North Unit, Evening shift (3:00 PM - 11:00 PM) - 2 Licensed Practical Nurses and 3 Certified Nurse Aides, for 39 residents. South Unit 2 Licensed Practical Nurses, 1 Licensed Practical Nurse on orientation and 4 Certified Nurse Aide for 39 residents. 02/04/2024 North Unit, Night shift (11:00 PM - 07:00 AM) - 1 Licensed Practical Nurse on orientation and 2 Certified Nurse Aides, for 39 residents. South Unit 1 Licensed Practical Nurse, 2 Certified Nurse Aide and 1 Certified Nurse Aide on orientation for 39 residents. 02/05/2024 North Unit, Day shift (7:00 AM - 3:00 PM) - 2 Licensed Practical Nurses, 4 Certified Nurse Aides and 2 Certified Nurse Aides on orientation, for 39 residents. South Unit 1 Licensed Practical Nurses, 1 Registered Nurse on orientation, and 5 Certified Nurse Aides for 39 residents. 02/05/2024 North Unit, Evening shift (3:00 PM - 11:00 PM) - 2 Licensed Practical Nurses and 3 Certified Nurse Aides, for 39 residents. South Unit 1 Licensed Practical Nurse, 1 Licensed Practical Nurse on orientation and 4 Certified Nurse Aide for 39 residents. 02/05/2024 North Unit, Night shift (11:00 PM - 07:00 AM) - 1 Licensed Practical Nurse on orientation and 2 Certified Nurse Aides, for 39 residents. South Unit 1 Licensed Practical Nurse, 1 Certified Nurse Aide for 39 residents. 10NYCRR 415. (a)(1) (i-iii)

Based on observations, interviews, and record review during the recertification survey from 2/05/2024 to 2/12/2024, the facility did not ensure treatment with respect, dignity, and care for each resident in a manner and in an environment that promoted maintenance or enhancement of their quality of life, recognizing each resident's individuality. Specifically, residents were observed to wear hospital gowns instead of personalized clothing; and staff entered resident rooms without knocking or conducting themselves in a way of dignified care and respect to the residents on 2 of 2 units. This is evidenced by: A facility policy titled Resident Rights dated 2/2020, documented residents had a right to a dignified existence; to be treated with respect, kindness and dignity; to have self-determination, and be free from abuse, neglect, misappropriation of property and exploitation. A facility policy titled Personal Property, last revised 8/2019 documented that the residents were permitted to retain and use personal possessions and appropriate clothing as space and safety regulations permit. A facility policy titled Resident Rights, last revised 2/2020, documented that the residents were permitted to retain and use personal possession to the maximum extent that space and safety permit. During observations on the North and South units on 2/07/2024 from 9:30 AM to 1:30 PM, roughly a third of residents were noted to be wearing hospital gowns instead of personalized clothing. Residents wearing hospital gowns were seen in their rooms - both in bed and not - the unit hallways, as well as the dining areas and lounges on both units. During an observation in the main entryway of the facility on 2/07/2024 at 3:00 PM, Resident #6 was walking near the entrance while dressed in a hospital gown that opened in the back untied, causing the resident's naked back and back side to be visible to anyone in the hallway. Additionally, the resident was not wearing socks or shoes and had a wander guard ankle monitor on their leg. In an interview at this time, Registered Nurse #2 saw that the survey team was observing Resident #6 and stated that the resident was care planned not to have to wear socks. Registered Nurse #2 then tried to redirect the resident to return to their unit and get clothing. The resident stated they refused to wear the ugly clothing the facility supplied. Registered Nurse #2 was observed to have tied the back of the hospital gown during the engagement with the resident. During observations on 2/08/2024 at 11:01 AM, 11:06 AM, and 11:45 AM, Certified Nursing Aides walked into resident rooms without knocking and announcing themselves to occupants within the room. During an observation in the North unit hallway on 2/09/2024 at 10:41 AM, Laundry Deliverer #1 walked into a resident's room without knocking and announced, as they walked in, that they were from laundry and had articles of clothing for the resident in the room. Resident #2 Resident #2 was admitted to the facility on [DATE] with diagnoses including hypothyroidism (underactive thyroid), diabetes mellitus type 2, obesity, and chronic urinary tract infection. The resident was cognitively intact and required 2-person physical assistance for personal hygiene. The resident required a two-person mechanical lift to transfer from/to the bed. During an interview on 2/06/2024 at 10:54 AM, Resident #2 stated Certified Nurse Aides provided care only once a day, if that. They stated that they would wait several hours before receiving any care. The resident stated they wore 3 extra-large incontinence briefs that the facility would supply, and that nursing staff took 3 extra-large incontinence briefs from their drawer for other residents. Resident #2 stated that when it was time for their care, they were told by staff that there were no 3 extra-large incontinence briefs available. They further stated that the resident's family member had brought in a personal supply of briefs. During an observation in Resident #2's room on 2/07/2024 at 10:13 AM, the resident was noted to still be in bed, not yet having had any personal care for the day. During an interview on 2/08/2024 at 9:34 AM, the Medical Records/Supply Officer #1 stated Certified Nurse Aides were to come to them and request 3 extra-large incontinence briefs. They stated 3 extra-large incontinence briefs were only provided to residents based on who needed them and that 3 extra-large incontinence briefs were kept locked in a secure location and rationed out on as needed. They further stated that otherwise, Certified Nurse Aides would use them for residents who did not require large incontinence briefs, and all other sizes were stocked on the units. Resident #11 Resident #11 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, type 2 diabetes, and chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). The Minimum Data Set (an assessment tool) dated 11/14/2023 assessed that the resident had a Brief Interview for Mental Status score of 15/15, indicating that the resident was fully cognitively intact and required assistance to complete activities of daily living. During an observation on 2/06/2024 at 9:39 AM, while conducting a resident interview, a staff member entered the resident's room without knocking and interrupted the resident interview process. During an interview on 2/06/2024 at 9:39 AM, Resident #11 stated that staff rarely knock and announced themselves. They indicated that staff just walked into resident rooms without ever knocking. Resident #11 had placed a sign on their door stating, Please knock before entering. They stated that staff would just come into the room without knocking, sometimes interrupting physician exams or meetings they were having with other staff. Resident #11 further stated that the facility constantly ran out of supplies, specifically the 3 extra-large incontinent briefs the resident wore. They stated that they had been left in soiled briefs for an extensive amount of time due to the constant decrease in supply for 3 extra-large incontinence briefs. Interview: During an interview on 2/08/2024 at 4:13 PM, Licensed Practical Nurse #2 stated that staff were supposed to knock on the door and announce themselves before entering residents' rooms. They stated that they had not had any residents complain to them that staff were not knocking or witnessed staff not knocking. They also stated that they would not be surprised if staff did not knock on resident doors. They stated they intended to be more diligent in noticing this practice and educate staff on the proper procedures. Licensed Practical Nurse confirmed there was a problem with residents' 3 extra-large incontinence briefs. They stated that there were 7-8 residents on their unit who wore 3 extra-large incontinence briefs and they were always in short supply of the briefs. They stated that they had not witnessed staff borrowing a 3 extra-large incontinence brief from one resident for another resident's care; but stated that it probably had happened at times due to the short supply. 10 New York Codes, Rule and Regulations 415.3 (c)(1)(i)

Based on record review and interviews during a recertification and abbreviated survey (Case # NY00312707) from 2/05/2024 to 2/12/2024, the facility did not ensure the residents were free from significant medication errors for 1 (Resident #327) of 1 resident reviewed for medication reduction. Specifically, for Resident #327, medication reduction was not properly transcribed and administered as ordered in a timely manner. This is evidenced by: Resident #327 Resident #327 was admitted to the facility with the diagnoses of metabolic encephalopathy (a series of neurological disorders not caused by primary structural abnormalities), severe sepsis with septic shock (a condition in which the body responds improperly to an infection including possible organ failure), and cirrhosis of the liver (a condition where scar tissue gradually replaces liver tissue); and was discharged from the facility prior to this survey. The Minimum Data Set (an assessment tool) dated 2/27/2023 documented the resident could understand and be understood by others and was cognitively intact. A document titled Consultation contained the recommendation to decrease lactulose (a medication prescribed to decrease the amount of ammonia in the blood) frequency from four times a day to three times a day on 3/13/2023. The Licensed Practical Nurse #5 documented the recommendations were noted on 3/15/2023. The Medication Administration Record, dated 3/2023, documented Lactulose oral solution 10 milligrams per 15 milliliters give 30 milliliters by mouth four times a day for hepatic encephalopathy continued to be administered to Resident #327 until 3/16/2023. A document titled Medication Error Report, dated 3/15/2023, documented the medication order dated 3/13/2023 was not updated until 3/15/2023. The type of medication error was documented as the wrong dose due to transcription error. A document titled In-Service Attendance Record, dated 3/15/2023, documented education was provided to one nurse (Licensed Practical Nurse #5) for consult transcription. During an interview on 2/12/2024, Registered Nurse #1 stated when a resident returned from an outside provider, the outside provider recommendations should be reviewed with the physician within one day. During an interview on 2/12/2024 at 11:23 AM, Licensed Practical Nurse #5 stated medication changes should have been made when the order was received to help prevent medication errors. During an interview on 2/12/2024 at 11:40 AM, Director of Nursing #1 stated medication changes should have been made as soon as the order was received. They stated that failure to transcribe a new medication order when it was made would be a medication error. 10 New York Codes, Rules, and Regulations 415.12(m)(2)

Based on interview and record review conducted during a Recertification survey from 2/05/2024 to 2/12/2024, the facility did not ensure that residents receive proper treatment and assistive device to maintain hearing abilities. Specifically, Resident #32 did not receive assistance with applying and removing bilateral hearing aids, and did not receive follow up Otolaryngology (a medical specialty which is focused on the ears, nose, and throat) visits for maintenance of hearing aids as recommended. This was evident for 1 of 27 residents reviewed for Communication/Sensory. This is evidenced by: Resident #32 Resident #32 had diagnoses including osteoarthritis (degeneration of joint cartilage and the underlying bone. It causes pain and stiffness, especially in the hip, knee, and thumb joints), difficulty walking, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), diabetes mellitus, major depression and hard of hearing. Review of the Minimum Data Set (a resident assessment tool) dated 11/23/2023 documented Resident #32 was understood, understood others and was cognitively intact. The comprehensive care plan initiated 9/22/2023 documented the resident required assistance with Activities of Daily Living related to limited mobility, Diabetes Mellitus, obesity, and inability to complete tasks; Interventions included a total mechanical lift with assistance of 2 or more staff for transfers. Resident #32 did not have care plan for alteration in hearing and or need for hearing device. Resident #32 did not have care plan to self-administer hearing aids. The Treatment Administration Records dated 01/01/2024 - 02/05/2024 for Resident # 32 documented staff were to apply bilateral hearing aids in the morning and remove at night, make sure hearing aids were charged at night, every evening shift remove hearing aids and place in medication cart. The day shift treatment administration records dated 02/06/2024, 2/11/2024, 2/19/2024 documented hearing aid placement nor removals were signed by a nurse. During an interview on 2/05/2024 at 11:45 AM, the resident was observed in their room sitting in a chair. Resident observed to be extremely hard of hearing. The resident did not have hearing aids applied, and hearing aides were seen in the resident's closet. Resident stated they asked for assistance in applying hearing aids, but staff would not assist. During an interview on 2/05/2024 at 11:50 AM , Licensed Practical Nurse #6 stated the resident refused their hearing aids. Licensed Practical Nurse #6 then walked to resident's room, located the hearing aids in resident's closet, and placed them on Resident #32. At the time of the observation, Resident #32 was very receptive and thankful to have hearing aids placed. The sheet titled Appointment and Transportation Requests, dated 9/09/2023, documented that Resident #32 was scheduled for an Otolaryngologist appointment at 8:00 AM on 11/09/2023. It further documented the resident refused to go to the appointment. There were no re-scheduled appointments for follow up otolaryngology hearing aid check. During an observation and interview on 2/08/2024 at 09:56 AM, the Resident's hearing aids were applied to both ears. Resident #32 stated right hearing aid was non-functioning. During an interview on 2/08/2024 at 09:59 AM, the Unit Manager #1 stated they were not aware of resident's right hearing aid was not functioning and would request an audiology consult. During an interview on 2/09/2024 at 10:05 AM, Resident #32 stated their right hearing aid was working. In an observation at this time, the switch was not turned to the 'on' position. During an interview on 2/09/2024 at 11:21 AM, Director of Nursing #1 stated Resident #32 was scheduled to be seen by otolaryngology but had refused several visits. Director of Nursing #1 stated nursing staff received training during general orientation on activities of daily living. 10NYCRR: 415.12(3)(b)

Based on observation, record review and interviews during a recertification survey from 2/05/2024 to 2/12/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 3 (Resident #s 2, 32 and 327) of 27 residents reviewed for Activities of Daily Living. Specifically, (A) Resident #'s 2 and 32 were not provided assistance with personal hygiene during morning care; (B) Resident #32 did not have a clean change of clothing and Resident # 2 was not provided sufficient extra-large incontinence briefs; (C) Resident #327 was not provided their weekly shower. This is evidenced by: The facility policy Activities of Daily Living Support effective 08/2016 and revised on 10/2019 documented residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Resident #2 The resident was admitted to the facility with the diagnoses of urinary tract infection, diabetes mellitus type 2, and hypertension. The Minimum Data Set (an assessment tool) dated 11/28/2023 documented the resident could understand and be understood by others; resident was cognitively intact. The Comprehensive Care Plan initiated 9/22/2023 documented the resident required assistance with Activities of Daily Living related to limited mobility, diabetes mellitus, obesity, and inability to complete Activities of Daily Living tasks. Interventions included a total mechanical lift with assistance of 2 or more staff for transfers. The following observations of Resident #2 were made: - On 02/05/2024 at 10:40 AM, resident was in bed wearing a hospital gown. - On 02/06/2024 at 11:00 AM, resident was in bed wearing a hospital gown. Both resident and roommate stated they were waiting for Certified Nurse Aide to assist them with morning care. Resident #2 was noted to have left over breakfast on overbed table, face with crumbs and hair was disheveled. - On 02/06/2024 at 11:10 AM, resident turned on call light, staff responded in 13 minutes and told the resident they would be back. - On 02/07/2024 at 10:13 AM, resident was in bed wearing hospital gown and stated they were waiting for assistance to get washed up. During an interview on 2/06/2024 at 11:15 AM, Resident #2 stated staff only provided care to them once a day if that. Resident #2 stated they waited for a very long time for care. Resident #2 stated Certified Nurse Aides came into their room and took 3 Extra-large incontinence briefs out of their dresser drawer and were later told that there were no briefs for them and could not be changed. Resident #2 further stated they had a foley catheter secondary to urinary incontinence, however, required assistance after soiling incontinence briefs. Resident stated their son brought in a personal supply of incontinence briefs so that they could get changed. During an interview on 2/07/2024 at 10:30 AM, Certified Nurse Aide #1 stated Resident #2 did not like to get up out of bed. They stated they would move to the next resident when resident refused and documented the resident's refusal. During an interview on 2/07/2024 at 11:00 AM, Registered Nurse #1 stated they had no knowledge of Resident #2 not receiving care or shortage of 3 extra-large incontinence briefs. During an interview on 2/07/2024 at 11:30 AM, Director of Nursing #1 stated they had no knowledge of Resident #2 not receiving care or shortage of 3 extra-large incontinence briefs. Director of Nursing #1 stated the Medical Records/Supply Officer ordered and tracked supplies and would be a contact for more information. During an interview on 2/08/2024 at 9:34 AM, the Medical Records/Supply Officer #1 stated Certified Nurse Aides were to come to them and request 3 extra-large incontinence briefs; 3 extra-large briefs were only provided to residents based on their weight. The Supply Officer stated that 3 extra-large briefs were rationed out. Supply Office #1 further stated that otherwise, Certified Nurse Aides would use them on residents who did not require large incontinence briefs; all other sizes were stocked on the units; the 3 extra-large incontinence briefs were locked in a secure location after hours. Resident # 32 The resident was admitted to the facility with the diagnoses of osteoarthritis, difficulty walking, chronic obstructive pulmonary disease, weakness, and depression. The Minimum Data Set, dated dated dated [DATE] documented the resident could understand and be understood by others, and was cognitively intact. The Comprehensive Care Plan initiated 3/17/2017, revised 11/02/2024, documented the resident required assistance with ADLs related to limited mobility, osteoarthritis, chronic left shoulder pain, and inability to complete Activities of Daily Living tasks. Resident required is a partial assist with 1 staff helper. Resident encouraged to use call light for assistance. During an observation on 2/05/2024 at 12:59 PM, South Unit room [ROOM NUMBER] call light remained on for 20 minutes. There were 6 staff in the vicinity of room [ROOM NUMBER] that did not answer light, instead went about other duties. During an observation on 2/07/2024 at 11:11 AM, a resident was sitting at the nurse's station on south unit yelling out repeatedly, please take me to the bathroom, my stomach hurts, I have to poop really bad. Certified Nurse Aide #4 stated to Certified Nurse Aid #5, you know how [they do]. Both Certified Nurse Aids walked away without assisting the resident. Record review of staffing sheets dated 2/02/2024 - 2/05/2024 documented 4 Certified Nurse Aides and 2-3 Licensed Practical Nurses on 7 AM - 3 PM shift: 3 Certified Nurse Aides and 2-3 Licensed Practical Nurses on 3p-11p shift, and 2 Certified Nurse Aides and 1 Licensed Practical Nurse on 11p-7a shift. Record review of Certified Nurse Aide Accountability shower sheet for the week of 1/26/2024 to 2/06/2024 documented the resident refused shower on 1/26/2024 and 1/30/2024. Resident received shower 2/2/2024 and 2/6/2024. Record review of Grievance dated 7/21/2023 documented resident filed a grievance with facility for help during the night, stating they wait hour and half for assistance. During an interview on 2/05/2024 at 11:45 AM, the resident was observed in their room sitting in a chair wearing a hospital gown, and stated they were wearing a hospital gown as this was all the clean clothing available to them. Their laundry was taken and not returned. Resident #32 stated they waited hours on the toilet for assistance, at times they did not receive shower or care overnight. Resident observed to be extremely hard of hearing. The resident did not have hearing aids applied, and hearing aides were seen in the resident's closet. Resident stated they asked for assistance in applying hearing aids, but staff would not assist. During an interview on 2/05/2024 at 11:50 AM, Licensed Practical Nurse #6 stated the resident refused their hearing aids. Licensed Practical Nurse #6 then walked to resident's room, located the hearing aids in resident's closet, and placed them on Resident #32. At the time of the observation, Resident #32 was very receptive and thankful to have hearing aids placed. Record review revealed Resident #32 did not have a comprehensive care plan to self-administer hearing aids. During an interview on 2/07/2024 at 10:48 AM, Registered Nurse #1 stated there were typically 4-5 certified Nurse Aides on day shift, 3-4 on evening shift, and 1-2 overnights. There were missed showers at times and sometimes residents refused, which was documented in their electronic record system. They stated only a few residents would get up on overnight shift; most residents preferred to get up between 7:00 AM and 8:00 AM which was not always doable. They stated since it was a rehabilitation unit, physical therapy would send a list of who needed to get up first. Registered Nurse #1 stated those needing physical therapy would be prioritized to get up first. Registered Nurse #1 stated they had no knowledge of Resident #32 not having clean clothing, that there were always clean clothes, and if not, residents could wear sweat pants and T-shirt provided by the facility. During an interview on 2/07/2024, Registered Nurse #6 acknowledged difficulty with new laundry service and stated that many residents complained once laundry was put in mesh bag to go out for cleaning, they never saw see their items again. Registered Nurse #6 stated there was a new service in place since 11/28/2023, that the Administrator was aware and as of two weeks ago, had hired a full-time, in-house laundry person to sort clothing for residents upon return for outside laundry service. During an interview on 2/07/2024 at 2:15 PM, Administrator #1 stated they were gradually reducing agency staff; had a recent Town Hall meeting and addressed staff answering call lights timely. Administrator #1 further stated that management had been working on individual units to address concerns, specifically answering call lights. Administrator #1 stated residents could file a grievance for any missed items, and that the facility was aware of Resident #32 grievances and in process of addressing their concerns. Administrator #1 stated grievances were addressed immediately, however, resolution could take 1-2 weeks depending on the depth of investigation. Resident #327 The resident was admitted to the facility with the diagnoses of metabolic encephalopathy (a series of neurological disorders not caused by primary structural abnormalities), severe sepsis with septic shock (a serious condition in which the body responds improperly to an infection including possible organ failure), and cirrhosis of the liver (a condition where scar tissue gradually replaces liver tissue). The Minimum Data Set, dated dated dated [DATE] documented the resident could understand and be understood by others and was cognitively intact. The Kardex Report (list of Certified Nurse aide tasks) dated 2/28/2023 documented the resident was to receive a shower or bath every Tuesday and Thursday on the day shift. The Kardex Report documented the resident required the physical assistance of one staff member with bathing activity. The document titled Bathing for the dates 2/13/2023-2/28/2023, documented that no bath or shower were given to resident. On 2/21/2023 and 2/28/2023 the bathing activity was documented as NA or not applicable. During an interview on 2/12/2024 at 11:20 AM, Certified Nurse Aide #3 stated the resident should receive showers according to their Kardex. They stated they checked the Kardex for changes at the start of each shift. They stated if a resident refused a shower, they would inform the nurse and re-approach. During an interview on 2/12/2024 at 11:23 AM, Licensed Practical Nurse #5 stated that at the end of the shift, the nurse should check to make sure Certified Nurse Aide tasks were completed; this would include showers and bathing. Licensed Practical Nurse #5 stated they would expect the Certified Nurse Aide to inform the nurse if a resident refused a shower. During an interview on 2/12/2024 at 11:40 AM, Director of Nursing #1 stated audits should be performed at the end of the shift to ensure the Certified Nurse Aide accountability was completed and resident care had been completed. They stated they expected the Certified Nurse Aide and floor nurse (Licensed Practical Nurse or Registered Nurse) to communicate about any issues with resident care including if a resident refused care. 10NYCRR 415.12(a)(3)

Based on observations, record reviews and interviews conducted during the recertification survey from 2/05/2024 to 2/12/2024, the facility did not ensure the development of comprehensive person-centered care plans - that included measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs - as identified in the comprehensive assessment for 2 (Resident #s 14 and 327) of 27 residents reviewed for comprehensive care plans. Specifically, (1) for Resident #327, the facility did not ensure a comprehensive care plan was developed to address the use of indwelling urinary catheter; and (2) for Resident #14, the facility did not ensure a comprehensive care plan was developed to address the resident's dental care. This is evidenced by: The Policy and Procedure titled Care Plans - Comprehensive, dated 10/2019, documented the facility would develop a comprehensive, resident centered care plan for each resident based on the individual needs/problems of each resident. Resident #327 The resident was admitted to the facility with the diagnoses of metabolic encephalopathy (a series of neurological disorders not caused by primary structural abnormalities), severe sepsis with septic shock (a serious condition in which the body responds improperly to an infection including possible organ failure), and cirrhosis of the liver (a condition where scar tissue gradually replaces liver tissue). The Minimum Data Set (an assessment tool) dated 2/27/2023 documented the resident could understand and be understood by others and was cognitively intact. A document titled Consultation documented Resident #327 had been seen by an outside provider on 3/01/2023. The outside provider documented that an indwelling urinary catheter had been placed before Resident #327 returned to the facility. A Physician Order dated 3/15/2023 documented urinary catheter care was ordered. The Treatment Administration Record dated 3/2023 documented urinary catheter care was to be provided every shift. The Comprehensive Care Plan did not address the presence or maintenance of an indwelling urinary catheter. During an interview on 2/12/2024 at 11:17 AM, Registered Nurse #1 stated that all the resident's needs would require a comprehensive care plan to address them. Registered Nurse #1 stated they would expect a care plan to address medications and medical devices like an indwelling urinary catheter. During an interview on 2/12/2024 at 11:23 AM, Licensed Practical Nurse #5 stated a care plan should have been initiated as soon as there was a change. They stated they would go to the Director of Nursing or supervisor to initiate a care plan. During an interview on 2/12/2024 at 11:40 AM, Director of Nursing #1 stated that a resident's comprehensive care plan should include and address all parts of a resident's care. They stated this would include an indwelling urinary catheter along with resident needs such as dental care, hearing aids, nutritional interventions. Director of Nursing #1 stated that registered nurses on the unit were responsible for initiating a care plan but if the unit manager was not a registered nurse, they would expect the unit manager to alert a registered nurse on the need for a care plan. 48615 Resident # 14 Resident #14 was admitted to the facility with the diagnoses of Diabetes type 1 and partial limb amputation. The Minimum Data Set, dated dated dated [DATE] documented the resident could understand and be understood by others and was cognitively intact. During an interview on 2/06/2024 at 9:42 AM, Resident #14 was noted to have multiple missing and broken teeth. Resident #14 stated they wanted to see a dentist, but a dentist appointment had not been made. During record review on 2/06/2024 at 11:00 AM, the comprehensive care plans dated 10/19/2023 and 1/25/2024 did not include dental care. During an interview on 2/08/2024 at 11:30 AM, Director of Nursing #1 stated care plans were updated by the Unit Manager. During an interview on 2/08/2024 at 12:00 PM, Registered Nurse #1 stated the care plan would be updated. 10 New York Codes, Rules, and Regulations 415.11(c)(1)

Based on record review and interviews conducted during the recertification survey from 2/05/2024 to 2/12/2024, the facility did not ensure the Minimum Data Set (an assessment tool) was an accurate assessment reflective of each resident status at the time of assessment. Specifically, the discharge tracking Minimum Data Set was not accurately completed for 5 of 74 residents reviewed for accuracy related to proper discharge placement. This is evidenced by: During a review of records on 2/07/2024 for Resident #73 discharge for hospitalization , the resident was discharged to home and not to the hospital. The Medication Administration Record Section A documented that Resident #73 was discharged to a short-term general hospital. The nursing progress notes dated 11/10/2023 documented that Resident #73 was discharged to their family member's home with all belongings. In a review of records for discharge from 11/1/2023 to 2/7/2024, five additional resident discharges were inaccurately documented and did not correctly reflect the resident's discharge status at the time of assessment. During an interview on 2/12/2024 at 10:16 AM, Registered Nurse #3 stated they were responsible for overseeing the Minimum Data Set for each resident; they coordinated with all other departments and team members to ensure the accuracy of the Minimum Data Set. They stated they received the information based on the nursing progress notes on where the resident was discharged . They then would enter the Minimum Data Set and select the appropriate discharge status in section A. In reviewing three of the five residents with inaccurate discharge status, they stated that they needed to be corrected based on the documentation found in the nursing progress notes. Registered Nurse #3 stated they were unsure how that happened and were upset that it did happen, as it was their position to ensure it was correct. They stated that they would have to develop a system to double-check the accuracy of the information within the Minimum Data Set. 10NYCRR415.11(b)

Based on record review and interviews during recertification and abbreviated survey (Case #NY00322407) from 2/05/2024 to 2/12/2024, the facility did not ensure that all alleged violations of abuse, neglect, or mistreatment, including injuries of unknown source, were immediately reported to the State Agency for 1 (Resident #51) of 3 residents reviewed for abuse. Specifically, the facility did not report the allegations of abuse involving Resident #51 to the New York State Department of Health after becoming aware of the allegations on 8/09/2023 at 7:20 AM. This is evidenced by: Resident #51 was admitted to the facility on [DATE] with diagnoses of Atherosclerosis with unspecified peripheral vascular disease, type II Diabetes, and vascular Dementia with other behavioral disturbances. The Minimum Data Set (an assessment tool) dated 12/10/2021 documented that the resident usually could be understood and understood others, and that the resident had severely impaired cognition for daily living decisions. The facility's Policy and Procedure titled Abuse, last revised 2/2019, documented the facility prohibited the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone, including staff, family, friends, or other residents. The Administrator and Director of Nursing would be responsible for investigating and reporting to the appropriate State Agency(s) immediately (no later than 2 hours after allegation/identification of allegation) after identifying the alleged/suspected incident. The policy further defines abuse as the willful infliction of injury or intimidation resulting in physical harm, pain, or mental anguish. The policy describes verbal abuse as oral, written, or gestured language that willfully includes disparaging and derogatory terms to the resident. The New York State Department of Health Intake Information form dated 8/21/2023 documented that on 8/09/2023 at 7:20 AM, Resident #51 was potentially verbally abused by a staff member while going through the hallway. This allegation was reported by one of the witnesses to the incident, who immediately reported it to the Administrator and Director of Nursing. No report of the 8/09/2023 incident was made to the New York State Department of Health before 8/21/2023. The investigation and incident report dated 8/10/2023 documented that the staff housekeeper made derogatory comments to the resident, which the maintenance person also heard. The investigation stated that since the resident did not hear the derogatory comments, the Administrator ruled out verbal abuse. However, two individuals did hear the verbal comment made by the staff. The employee who conducted the verbal abuse on the resident was immediately suspended pending investigation and ultimately brought back and re-educated extensively on Abuse, Neglect, and Misappropriations. An investigation and incident report dated 12/05/2023 documented a resident-to-resident verbal altercation. The investigation documented that Resident #14 took off the leg rest of their wheelchair and tried to hit Resident #51. The incident was witnessed by a Licensed Practical Nurse who observed Resident #14 with the wheelchair leg rest in their hand, threatening to strike Resident #51. The statement made by Resident #14 documents that they tried to hit him with my leg rest. The investigation stated that since Resident #14 did not make contact with Resident #51, the Administrator documented that this ruled out any evidence of abuse. No report of the 12/05/2023 incident was made to the New York State Department of Health before 2/08/2024. During an interview on 2/08/2024 at 9:58 AM, Administrator #1 stated that incidents of verbal threats, physical harm, and residents were incidents of abuse. They further stated that any incident resulting in abuse should be reported to the New York State Department of Health. They stated that depending on the incident and how the potentially abused resident felt would determine whether the incident would be reported to the New York State Department of Health. The facility abuse policy was reviewed with Administrator #1, as Administrator #1 stated that they could not recall it. They stated that verbal abuse was the oral, written, or gestured language that willfully includes disparaging and derogatory terms to the resident. They stated regarding the incident on 12/05/2023, they did not believe it rose to an abuse situation since Resident #14 did not strike Resident #51; the resident did not feel uncomfortable, so Administrator #1 did not report it. Administrator #1 stated the gesture done by Resident #14 constituted potential verbal abuse according to their policy, and should have reported the incident to the New York State Department of Health. During an interview on 2/08/2024 at 11:38 AM, Resident #51 stated that they did not remember either incident. During an interview on 2/12/2024 at 9:43 AM, Director of Nursing #1 stated that they would consider abuse as any physical or verbal altercation, intimidation, or misappropriation of resident belongings done by staff or resident to resident. They stated that all cases of potential abuse should have been reported to the New York State Department of Health within the specific time of reporting. The incidents were reviewed with Director of Nursing #1, and they stated that the facility should have reported the incidents to the State Agency. 10 NYCRR 415.4(b)(2)

Based on record review and interview conducted during an abbreviated survey (NY00294027), the facility did not ensure that each resident received adequate supervision and assistive devices to prevent accidents for 1 (Resident #4) of 4 residents reviewed. Specifically, for Resident #4 who was care planned for floor mats next to bed when in bed, floor mats were not placed when the resident fell from the bed, resulting in a fall with fractures of the 8th and 9th right ribs. This was evidenced by: The facility policy Falls Management and Prevention, revised 01/2021, documented the facility provided an environment that was free from accident hazards over which the facility had control and provided supervision and assistive devices to each resident to prevent avoidable accidents. Resident #4 was admitted to the facility with diagnoses including dementia, general muscle weakness, and compression fractures of the lumbar spine (when the bones of your spine collapse). The Minimum Data Set (an assessment tool) documented the resident had severely impaired cognition. The at risk for falls Comprehensive Care Plan dated 2/20/2022 documented the resident was at risk for falls related to confusion, history of falls, immobility, and incontinence. The interventions included floor mats, concave mattress, and low bed. The Resident Care Card dated 4/03/2022 documented the resident was to have floor mats, concave mattress, and low bed. The Facility Investigation dated 4/08/2022 documented the resident was left in the bed, in low position, with call light in reach, however the Certified Nurse Aide forgot to put down the floor mat. Resident was found on floor 30 minutes after, complaining of right rib pain. An x-ray showed fracture of right 8th and 9th ribs. During an interview on 11/28/2023 at 11:00 AM, Certified Nurse Aide #1 stated they received training on following the resident's care plans. Certified Nurse Aide #1 stated they usually leaned floor mats against the bed or a nearby wall, so they did not forget to place them when the resident was put in the bed. During an interview on 11/28/2023 at 11:05 AM, Licensed Practical Nurse #1 stated they were educated regarding following resident care plans. During an interview on 11/28/2023 at 11:25 AM, Director of Nursing #1 stated all staff were educated on resident care plans during orientation, annually, and following any relevant incidents. During an interview on 11/28/2023 at 12:25 PM, Administrator #1 stated that at the time of the incident, the Director of Nursing and Administrator investigated it and provided the appropriate follow-up to prevent further occurrence. Administrator #1 further stated that they were not aware of any other incidents of injury resulting from Resident #4's care plan not being implemented. During an interview on 1/31/2024 at 12:08 PM, Physician #1 stated that according to the medical record, Resident #4 had a history of compression fractures, which meant the bones were prone to fractures due to weakness. I understand the fall mat was not in place, but can not say that would have changed the outcome of the fall. Call to the last known telephone number for the accused Certified Nurse Aide #4 was not answered and subsequent calls were blocked. Past non-compliance: Based on the following corrective action taken, there was sufficient evidence the facility corrected the non-compliance and was in substantial compliance for this specific regulatory requirement at the time of this survey: - Appropriate first-aid, medical care, and monitoring were provided to the resident on 4/08/2022. - The incident was reported appropriately to the State Survey Agency on 4/09/2022. - A facility investigation was commenced on 4/08/2022 at 1:45 PM to determine the cause of the fall resulting in injury to the resident. - Education was provided to the accused Certified Nurse Aide regarding following care plans on 4/08/2022 at 6:30 PM. - Education on fall management, care plans and abuse was provided to nursing, therapy, and activities staff on 4/8/2022, 4/9/2022, and 4/12/2022. - At the time of survey, record review of recent incident and accident reports revealed there were no additional significant injuries identified as resulting from care plans not being followed. 10 Code of Federal Regulations 415.12(h)(1)

Based on record review and interviews during an abbreviated survey (Case # NY00309545) the facility did not ensure each resident was provided emergency basic life support, including cardiopulmonary resuscitation (CPR), in accordance with related physician's orders such as Do Not Resuscitate (DNR) for one (1) (Resident #1) of six (6) residents reviewed for advanced directives. Specifically, for Resident #1, who had a Medical Order for Life Sustaining Treatment (MOLST) form that documented DNR, the facility did not ensure that when the resident became unresponsive and without vital signs, the facility did not refer to another resident's MOLST that documented CPR and initiated CPR. The findings include: The Policy and Procedure (P&P) titled Advanced Directives- MOLST NY last revised [DATE], documented, All residents have the right to formulate an advanced directive and to request, refuse and discontinue treatments. Advanced directives will be respected in accordance with state law and facility policy. The MOLST form is designed to be used statewide by healthcare practitioners and facilities. Completion of the MOLST is done via discussions with the patient, healthcare agent or surrogate and qualified, trained healthcare professional that defines the patient's goals for care, reviews possible treatment options and ensures shared, informed decision-making. The form may be used to issue any orders concerning life-sustaining treatment in hospitals, hospices and nursing homes. The P&P titled Code Blue/CPR last revised [DATE], documented that the intent of the policy was to maintain the safety of the residents in an emergency. The policy read that emergency care and equipment shall be maintained and available for all residents. Personnel need to have completed training on the initiation of cardiopulmonary resuscitation and basic life support (BLS). Advanced directives are to be provided upon admission. The procedure included that a CPR team should be selected and identified for each shift in the case of an actual cardiac arrest. A designated team leader on each shift would be responsible for coordinating the rescue effort and directing other team members during the rescue effort. The CPR team should include at least one (1) nurse, one (1) Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN) and two (2) Certified Nurse aides (CNA), all of whom gave received training and certification in CPR and BLS. Staff members assigned or identified to assist during a code blue should be responsible for bringing the crash cart and automated external defibrillators (AED) to the scene of the code. If an individual (resident, visitor or staff member) is found either turning blue; unresponsive; not breathing normally; not breathing; having no palpated pulse within ten seconds or choking, the staff member is to stay with the resident, call for assistance, have staff members checking for advanced directives and call a code blue. The code blue should be announced over the public address (PA) system and include where in the building or room number the code is. The procedure included the team leader shall initiate CPR unless it is known that a DNR order specifically prohibits CPR and/or external defibrillation for that individual or if it is unknown, it is important to confirm through the facility's code status identification system before initiating CPR. Staff should be instructed to bring the resident's record to verify the resident's code status. Resident #1 was admitted to the facility with diagnoses which included rhabdomyolysis, dementia and acute kidney disease. The Minimum Data Set (MDS, an assessment tool) dated [DATE], documented the resident could be understood and could understand others and was assessed as having moderate cognitive impairment for decisions of daily living. A MOLST form dated [DATE] documented Resident #1 had a Do Not Resuscitate (DNR) order (the resident did not wish for CPR to be performed in the event they stopped breathing and/or did not have vital signs present). The Comprehensive Care Plan (CCP), dated [DATE], documented Resident #1 had a MOLST and was a DNR status. Tasks/ interventions in the care plan included to educate the resident and/designated representative on advance directives quarterly and/or as needed, reviewed and revised as needed and the resident's advance directives will be filed and readily accessible in the medical chart. An Advanced Directives Audit dated [DATE] through [DATE] revealed at the time of the audit, Resident #1's orders in the electronic medical record (EMR) had not been updated to reflect a DNR order as was indicated on the MOLST form completed on [DATE]. From [DATE] to [DATE] the MOLST form order did not match the EMR order; this was identified by the facility via the auditing to be corrected. A Physician Order dated [DATE] documented Resident #1 was a DNR. An Investigative Form dated [DATE] documented, at approximately 11:43 AM, a code was called from the Rehabilitation Department, the resident was found unresponsive at 11:43 AM in Rehabilitation gym. A code blue was called, and CPR was initiated after staff asked code status and it was stated full code. CPR lasted less than one minute because it was verified that the resident had a DNR order per (their) medical record and MOLST. The investigation findings were documented as follows: -The resident's name was identified inaccurately: - An incorrect code status was announced; -The resident was not wearing a name bracelet; therefore, staff were unable to identify the resident readily. -Staff who responded initially checked the medical record for another resident leading to the full code identification. -The error was corrected immediately by checking the correct resident's chart indicating DNR; DNI; and -CPR was initiated and the resident responded simultaneously while the facility identified the error. The facility's investigation included that several staff responded to the code blue in the therapy gym. It documented that unknown staff were calling the resident by the incorrect name and it was unknown which staff yelled out full code. The investigation documentation included that fifteen (15) chest compressions were performed by Licensed Practical Nurse Unit Manager (LPNUM) #2 and fifteen (15) chest compressions were performed by the Director of Nursing (DON). LPNUM #1 had come into the therapy room with a chart belonging to the wrong resident and ran back to grab the correct chart. LPNUM #1 came back into the therapy gym and yelled that the resident was a DNR code status. The DON then stopped compressions and called off the code blue. According to the documentation, simultaneously the resident became responsive and alert and began speaking with nursing staff. A MOLST form dated [DATE] was completed after the incident and Resident #1 elected to have their code status be changed and CPR should be performed should they stop breathing or lacking vital signs. The resident elected to not be intubated or have a feeding tube placed in the event they become unresponsive. A Physician Order dated [DATE] documented that Resident #1's code status was a CPR, Do Not Intubate (DNI). During an interview on [DATE] at 10:28 AM, Certified Nurse Aide (CNA) #1 stated they had taken a test on CPR & DNR statuses a couple of days ago. CNA #1 stated if they found the person unresponsive, they would yell out for help and pull the bathroom call light (which is used for emergencies) and tell the nurse and announce (code blue) on the PA system. They said code blue and the room number would be announced. They said if it was not in the resident's room, they would go get the resident's chart and take it to the location where the resident was. They said the nurse would check the residents code status. They stated they were unaware of the facility having a CPR/code team. During an interview on [DATE] at 11:04 AM, CNA #4 stated they had recently completed a training on CPR at the facility. They stated if they found a resident unresponsive, they would call out for the nurse and follow their instructions. They stated that the information on code status was found in the resident's chart and EMR. They stated if an emergency was occurring, they would bring the resident's chart. They stated they were unaware of a facility CPR/code team. During an interview on [DATE] at 11:11 AM, Registered Nurse (RN) #1 said if they were to find an unresponsive resident or if another staff were to call out that they found an unresponsive resident, they would go to the room, check the vital signs of the resident, check code status via bracelet worn by the resident, and the resident's chart. They stated they did not know anything about the facility having a CPR/code team. During an interview on [DATE] at 11:14 AM, Occupational Therapist (OT) #1 said they were in the therapy room at the time the code blue was called on [DATE]. OT #1 stated a resident's code status order was entered into the EMR. They said code status must be verified via the MOLST form in the paper chart before CPR is initiated. OT #1 said nursing staff would typically grab the chart while they are responding to the code. They said if the resident is in a common area of the facility, then someone needs to run down to grab it from the unit. They said, the plan is to have a code-status list in the therapy room going forward. During an interview on [DATE] at 11:23, LPN #3 stated they did not receive recent training on CPR. LPN #3 stated they could find the resident's code status in the resident's chart. LPN #3 stated the pink colored MOLST form in the chart documented the resident's code status. LPN #3 said they did not know anything about a CPR/code team at the facility. During an interview on [DATE] at 11:59 AM, the Licensed Practical Nurse Unit Manager (LPNUM) #1 stated the facility policy is that staff should check the advanced directive order in the EMR and the MOLST form which is in the chart. They said during the incident on [DATE], the wrong room number was called out to retrieve the chart for and they retrieved the chart for the room and bed position that had been called out. LPNUM #1 said when it was realized it was the wrong chart, they ran to get the chart for Resident #1. LPNUM #1 said when they returned with Resident #1's chart, they called out that the resident was a DNR. LPNUM #1 said when they entered the therapy gym compressions were being given by LPNUM #2. LPNUM #1 said the resident was transferred to the hospital following the incident and the MOLST form was sent out with the resident to the hospital. They stated they did not know and were unaware the facility had a CPR/code team. During an interview on [DATE] at 12:31 PM, the Director of Social Work (DSW) said they completed MOLST forms with the residents within days upon admission. They said a verbal order would be obtained upon admission. The DSW said some residents will come to the facility will have an order from the hospital until a new order is obtained. The DSW said when a MOLST form is completed, it needs to have two witnesses and be signed by physician or provider such as a Nurse Practitioner. The DSW said Resident #1 came with an order from the hospital for CPR to be performed, however, when the MOLST form was completed with the resident at the facility on [DATE], they made their wishes known that they wanted to be a DNR. The DSW said Resident #1 was self-responsible for decisions about their care. They said they performed an audit of resident's advanced directives/MOLST forms from [DATE] to [DATE] and had discovered Resident #1's order was not updated to reflect the resident's wishes on the MOLST form completed on [DATE]. They said the order was corrected and the Resident #1 had an order to be DNR at the time they became unresponsive on [DATE]. During an interview on [DATE] at 12:58 PM, LPNUM #2 said they were near the therapy gym at the time the code blue was announced over the PA. LPNUM #2 said there were already a few nurses present in the room when they arrived. LPNUM #2 said nursing staff had started to put the resident on a bed, but they instructed them to move the resident to the floor in case CPR would need to be done. LPNUM #2 said they placed their hand on the resident's neck and felt no pulse and then placed their hand on the resident's wrist as they were lowered to the floor and felt no pulse. LPNUM #2 said the resident was not breathing and they called out for someone to get the resident's chart and check the code status. LPNUM #2 said they did not know the resident since the resident did not reside on the unit they managed. They said one of the nurses near the door of the therapy room yelled out full code and therefore they began chest compressions. LPNUM #2 said they assumed the nurse knew the resident. They said it was the wrong name that was called out and the incorrect order was yelled out. They said there were a bunch of nurses present in the therapy gym and near the door. They said LPNUM #1 came with Resident #1's chart and then informed that the resident was a DNR status. LPNUM #2 said they immediately stopped chest compressions and the resident began to breath a moment after they stopped performing compressions. They said this was the first code blue they had responded to at the facility. LPNUM #2 said there was too many people in the room and in the doorway during the code. During an interview on [DATE] at 1:25 PM, the DON said they responded to the code blue called on [DATE]. The DON said they yelled out, what's the code status? They said they delegated for a nurse to document, while LPNUM #2 was checking for a pulse and there were no breath sounds. The DON said, someone yelled out that (they) are a full code (CPR should be performed) and LPNUM #2 started chest compressions. The DON said it was determined that the code status that was yelled out was not for Resident #1. They said once the correct chart was obtained and determined that Resident #1 had a DNR code status, chest compressions were stopped. They said the facility's CPR/code team should be indicated on the schedule and staff designated specific tasks during the response. The DON said the CPR/code team was not being indicated on the schedule. They said when nursing staff respond to a code blue, it should be verified that the correct chart/order is being provided to the correct resident. The DON said all staff working in the building should have training on the facility's policies and procedures on what to do during a code blue and how CPR/DNR code status should be determined. During a follow-up interview on [DATE] at 3:21 PM, the DON said the CPR/code blue team procedure had just been implemented as of the shift that was working in the facility at the current time (3:00 PM to 11:00 PM shift) . They said all staff were to receive re-training on the facility's procedure prior to starting on their shift on a care unit. They said after part of previous training staff had received; there should be two-identifiers checked including the EMR which had a photo of the resident. They said the code status order should be checked in EMR but then verified with the hard copy of the MOLST form in the chart. During an interview on [DATE] at 4:42 PM, Resident #1 said they were aware of the incident that occurred on [DATE]. They said, I guess I just passed out. They said they were a little sore but said, I'm glad they did, regarding staff performing chest compressions on them. They said, I wouldn't be alive if they didn't. The resident was observed to have a light green and purple colored bruise the size of a half-dollar coin on the left side of their chest near their sternum. 10 NYCCR 415.3 (e)(2)(iii)

Based on observations, record review, and interviews during an abbreviated survey (Case #'s NY00288482, NY00302885, and #NY00302027), the facility did not ensure services by sufficient numbers of each type of personnel on a 24-hours basis to provide nursing care to all residents in accordance with resident care plans. Specifically, the facility did not ensure that there were a number of nurse aides to provide care and respond to each resident's basic needs and individual needs as required by the resident's diagnoses, medical conditions, or plan of care. Findings include: The Facility Assessment, dated 7/28/2022, does not specify the amount of staffing required to meet each resident's needs each day and during emergencies. During observations on; -10/12/22 at 12:40 PM, Resident #7 hair that was dirty, saturated, and appeared oily. The resident was tearful. -10/12/2022 at 2:11 PM, the call light activated for room [ROOM NUMBER]-A. During interview with Resident #6, the resident said that they had a bowel movement and needed care. When asked how long their call light had been on, the resident stated it has been about 30 minutes. During an observation and interview on 10/13/2022 at 2:50 PM, Resident #5 was observed seated in their wheelchair near the nurse's station on the North Care Unit. The resident's pants were saturated in the groin area and there was a strong smell of urine. The resident said, I've been asking them to change me since this morning, I told them my whole body is wet. The resident pointed towards their room and said, go look at my bed, the whole bed is wet too. The resident's bed was observed to be saturated through an incontinence pad that was on the bed. Four nursing staff were at the nurse's the station and the resident asked the staff if they could be changed. One of the nursing staff replied, you're going to have to give us a few minutes. The resident stated I have been asking you all day and no one will help. The North Unit Staff assignment sheet, dated 10/4/2022, documented one CNA during the 11:00 PM to 7:00 AM shift. The North Unit staff assignment sheet, dated 10/9/2022, documented there was no CNA from 3:00 PM until after 6:00 PM. A review of the facility's Punch Exception and Lunch Authorization Form dated 10/9/2022 for CNA #8 documented that there was only one (1) CNA in the whole facility at the time of the shift. During an interview of 10/11/2022 at 3:02 PM, Resident #3 stated that they were left soiled for several hours the previous weekend. They stated, nobody showed up for work, there was only one aide and one nurse. The resident said they tried to hold their urine as long as they could, however, after more than an hour they had an accident which then left them wet for extended period of time (they estimated another hour). During an interview on 10/11/2021 at 4:00 PM, CNA #2 said staffing expletive named. There is not enough staff to efficiently provide adequate care. When asked for an example, the CNA stated that a resident was left in their urine all day. They were not changed until they used the bathroom on the floor, yesterday (10/10/2021). The CNA stated they were notified that the resident needed incontinent care at the beginning of their shift (4:00 PM). The nurse told them they didn't know who the resident belonged to, but they urinated on the floor. During an interview on 10/12/2022 at 12:40 PM, Resident #7 stated they had not received a shower in three (3) weeks. The resident had a family member on speaker phone who said that they had been contacting the facility and asking for the resident to receive a shower. The resident stated that they felt dirty, nasty and itchy. They said the facility did not have enough staff to provide care to the residents. They said during the previous weekend, they had turned on their call light for assistance with incontinence care and their call light was not answered for an hour and a half. They said, if I could walk, I would do it myself, but I have to depend on the staff. During an interview on 10/12/2022 at 1:50 PM, the Director of Social Work (DSW) stated Resident #7 had reported they had not received a shower in three weeks. The DSW had followed up with nursing staff and was told Resident #7 received a shower. The DSW stated that after they observed Resident #7's hair, they clearly have not received a shower. They stated they planned to follow up again. In a follow up interview on 10/12/2022 at 1:55 PM, Resident #7 said that they were told that they might not be able to receive a shower that day. They said they were on their way to participate in an activity but felt frustrated that they had to attend while feeling dirty. They said, I'm sure the staff would not want their loved to be treated this way, I'm sure they would want them to be showered. During an interview on 10/12/2022 at 1:50 PM, LPN #2 said that Resident #7 was not likely to receive a shower that day because they did not think there was enough staff to provide a shower. They said, we only have one aide, so they (Resident #7) are not going to be showered. They said according to the shower schedule, the resident was scheduled to receive a shower the day before. They said sometimes they would walk in the building and there are zero aides. During an interview on 10/12/2022 at 1:52 PM, LPN #1 stated that they felt there is not enough staff to provide care adequately and effectively to the residents on the unit. LPN #1 stated that there is currently one (1) aide and two (2) nurses on the unit for the 1st shift with a current census of 39 residents and it is usually like that. Sometimes there are no aides on the unit. When asked how they ensure residents receive care, LPN #1 stated that If ADLs are not completed by the end of the shift, they do not get done. During an interview on 10/12/2022 at 2:00 PM, CNA #6 stated they feel like there is not enough staff to efficiently perform their tasks. During an interview on 10/12/2022 at 2:21 PM, the South Unit Nurse Manager stated there is not enough staff to effectively provide care to the residents. Each unit is supposed to have three (3) or (4) CNAs and a CNA to float because they also go with the residents to appointments. The South Unit is normally staffed more than the North Unit. The goal is to try to keep two (2) CNAs on each unit but that doesn't always happen. Today (10/12/2022) is a really bad day. It's been like this for the past month. During an interview on 10/14/2022 at 3:42 PM, the Director of Nursing (DON) stated that they did not review the facility assessment and did not know what information it contained. The DON stated that the facility assessment should be used to determine the staffing requirement. The required staffing is dependent on the resident's needs. The South Unit should be staffed higher because it is the Rehab Unit with greater acuity. When asked about routine changes to the staffing assignments, the DON said that staffing is an issue everywhere and staffing agencies are not always helpful. During an interview on 10/17/2022 at 4:12 PM, the Director of Social Work (DSW) was asked about the number of residents reporting that they had not received a shower, they said that they were aware of numerous residents that reported not receiving showers in the past few weeks. They said, we only have one aide at times, it's not realistic for one aide to complete care. 10NYCRR 415.13 (a)(1)(i-iii)

Based on record review and interviews during an abbreviated survey (Case #NY 118), completed on [DATE], the facility did not promptly notify the ordering physician of a laboratory result that fell outside of clinical reference range for 1 (Resident #15) of 3 residents reviewed. Specifically, the facility did not notify the physician of a significantly low sodium level from [DATE] through [DATE]. Subsequently, on [DATE], the resident fell and sustained multiple injuries to the face, head, knees and elbows, and was admitted to the hospital intensive care unit for a critically low sodium level and altered mental status. This resulted in actual harm that is not immediate jeopardy. This is evidenced by: The Policy and Procedure (P&P) titled Lab/Test Results - Reporting last revised ,d+[DATE], documented that, upon completion of the test, the lab was to send written results to the facility. The nurse was to call or fax the abnormal results to the physician (MD). When the nurse called or faxed the results to the physician, the nurse was to write on the lab slip that the results were faxed/called to the MD, along with the MD's fax/phone number and the date/time they were faxed/called. If the MD was called, the nurse was to document on the slip that the results had been reported. The P&P titled Lab - Procedure last revised in ,d+[DATE], documented lab results were to be checked by the Clinical Nurse, and the physician was to be notified of the results. The notification may be written on the Lab Results Form. All lab results were kept in a designated place until seen and signed by the physician. Resident #15 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated [DATE], documented the resident had moderate cognitive impairment. The Comprehensive Care Plan (CCP) did not include a care plan for the care and management of the resident's liver disease. The Nursing Progress Note dated [DATE] at 6:48 PM, documented Resident #15 presented to the hospital on [DATE] with mental status changes, weakness, and fall, and was diagnosed with [CONDITION(S)] (a significant complication of liver disease characterized by alterations of personality, consciousness, cognition and motor function). The resident's past medical history included end stage [CONDITION(S)], and history of [CONDITION(S)]. A Medical Note dated [DATE], written by MD #1 documented Resident #15 was admitted with alcohol dependence, liver [CONDITION(S)], weakness in both legs, [CONDITION(S)] and poor compliance with medications [MEDICATION(S)] and [MEDICATION(S)] (prescribed to help prevent [CONDITION(S)]). A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #2 documented the resident was to have a comprehensive metabolic panel (CMP - a test that measures substances in the blood, one of which is the sodium level). The Laboratory Telefax Activity Report with a sent to facility date of [DATE] at 2:04 PM, documented results for a CMP that was drawn on [DATE]. The sodium level was 126, with a reference range of ,d+[DATE] MEQ/L. There was no documentation on the report and/or in Nursing Progress Notes that MD #2 was notified. A Nursing Progress Note dated [DATE] at 6:13 PM by Licensed Practical Nurse (LPN) #3, documented the resident had been lethargic (abnormal state of drowsiness) and was sleeping a lot. The resident was very off balance when standing and was reminded to use the walker even when in their bedroom. There was no documentation the MD had been notified. An Accident and Incident (A&I) form dated [DATE] at 1:00 AM, documented the resident was found kneeling on the floor, holding onto the wheelchair, and tried to get up. There was no apparent injury and MD #2 was notified at 3:29 AM. The Certified Nurse Aide (CNA) Statement dated [DATE] at 1:00 AM, and attached to the A&I, documented the resident was very unbalanced standing up as they tried to get the resident into bed. A Nursing Progress Note dated [DATE] at 3:29 AM by the RN, documented that, at 1:00 AM, a nurse said the resident was kneeling on the floor in their room and then got up by themself and sat in the chair. There was no injury. The RN documented MD #2 was texted. There was no documentation that MD #2 responded to the text message. An A&I dated [DATE] at 12:56 PM, documented Resident #15 was found on the floor in their bedroom and was trying to get up. There was no apparent injury and MD #2 was notified that evening (the time was not documented). A Nursing Progress Note dated [DATE] at 1:25 PM by LPN #3, documented Activities staff heard a bang and found the resident on the floor in their bedroom. The resident was laying on their side and tried to get up. The supervisor came to evaluate and there were no injuries. An A&I report dated [DATE] at 4:20 PM, documented the resident had an unobserved fall in their room. Resident #15 was disoriented, face bloodied , and was lying face up under the bedside sink. The resident was drooling, shaky, and non-verbal, and had multiple head contusions, a split lip, swelling to the nose and forehead with possible broken nose, and abrasions on the knees and elbows. MD #2 and MD #3 were contacted, and a decision was made to have the resident transported to the hospital for laboratory tests and imaging. The Hospital Emergency Department (ED) Report dated [DATE], documented Resident #15 had altered mental status upon arrival and was unable to provide a personal history or information. There were multiple areas of bruising and abrasions on the face and body. The resident was unable to tolerate a CT Scan (diagnostic imaging) so the family was contacted and agreed that the resident needed to be intubated (a tube was inserted in the airway to assist with breathing) for possible [CONDITION(S)] (bleeding inside the skull or brain) and further evaluation. The resident's sodium level was 119. The provider's clinical impression documented the resident had [CONDITION(S)] (an abnormally low sodium level) and a secondary impression was documented as altered mental status, [CONDITION(S)], hyperammonemia (excess [MEDICATION(S)] in the blood), and nasal bone fracture. The patient was admitted to the ICU for [CONDITION(S)] (abnormally low sodium level) and altered mental status. The Hospital Cumulative Summary Report dated [DATE], documented the resident's sodium level was 119 on [DATE] at 5:59 PM. During an interview on [DATE] at 1:19 PM, the LPN Manager (LPNM #1) stated nursing staff were supposed to send the resident's laboratory results to MD #2. Staff usually texted MD #2 first to check for availability for a call, and MD #2 usually called back. LPNM #1 did not recall seeing the sodium level of 126 on [DATE] and said they would generally notify the MD right away for a level that low. LPNM #1 said any nurse that obtained lab results should have written a note in the Electronic Medical Record (EMR) about the result and that the MD was notified. LPNM #1 reviewed the resident record and stated there was no documentation of the low sodium level being reported to the MD. During an interview on [DATE] at 8:45 AM, LPN #3 stated lab results were faxed directly to the Director of Nursing's (DON) office and then the Unit Manager retrieved the results and notified the MD. LPNs did not see laboratory results when they were sent to the facility. If there was an abnormal lab result, the RN or the Unit Manager was supposed to call the physician. During an interview on [DATE] at 2:44 PM, the Director of Nursing (DON) stated that, when a lab test result was received, if it was normal, the MD was to be made aware and the result put in the MD's folder. If the result was out of the normal reference range, the MD and family were to be notified. Additionally, a note was to be documented in the EMR about the result, that notifications were made, and any MD instructions. During an interview on [DATE] at 3:53 PM, MD #3, the facility medical director, stated it was not unexpected that Resident #15's sodium level to waxed and waned because of the resident's liver disease. If the resident had a low sodium level, the resident's clinical picture was very important, and if MD #3 had been called on [DATE] and was told the resident's sodium level was 126 and the resident was acting okay, nursing staff would have been instructed to monitor the resident. Since the resident was sleeping a lot, and was off balance on [DATE], they would have looked at the resident's diuretic medication and fluid intake, possibly held the medication, and repeated the lab test. MD #3 stated nursing staff should have notified MD #2 of the sodium level of 126, and that the resident had changes in condition. Staff should then have documented the notification in the medical record and should have documented any instructions from the MD. MD #3 also stated MD #2 should have been notified that the resident's sodium level was 126 when the laboratory result was received on [DATE]. If the MD had been notified, the resident's diuretic medication and blood pressure medication could have been reviewed and changes made if needed. 10 NYCRR 415.20

Based on medical record review and staff interview during an abbreviated survey (Case #NY 382) the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one (#3) of five residents reviewed. Specifically, the resident was complaining of severe pain throughout the night, and the physician was not notified until later the following morning at which time the resident was sent to the emergency room (ER) for evaluation with a diagnosi of sepis. This was isolated and resulted in actual harm that is not immediate jeopardy. This was evidenced by: Resident #3 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having intact cognition. The Comprehensive Care Plan (CCP) for Indwelling Catheter dated 1/9/13, documented the resident had a Foley catheter. The nursing progress note dated 6/3/13 at 11:06 am, documented the resident completed antibiotics for the treatment of [REDACTED]. The nursing progress note dated 6/4/13 at 8:18 am, documented there was no repeat urinalysis needed at this time as the resident had no signs or symptoms of infection present. The nursing progress note dated 6/6/13 at 7:34 am, documented the resident was found crying out in pain at 3:00 am. The resident stated the pain was in his penis and lower abdomen. The resident's catheter was repositioned with positive effect. The nursing progress note dated 6/11/13 at 12:55 am, documented the resident was complaining of pain at his catheter site. The resident was given Tylenol with good effect. The medical progress note dated 6/11/13 at 3:57 pm, documented the resident had penile discomfort. It documented to continue with the Foley catheter and that irrigation would be ordered as needed to see if it alleviated the resident's complaints of penile discomfort. It further documented if the irrigation did not provide relief to consider sending the urine for a culture. The nursing progress note dated 6/19/13 at 7:59 am, documented the resident continued to complain of penile pain. The resident's Foley was irrigated without effect and then changed. The resident was also medicated with Tylenol with effect. The nursing progress note dated 6/27/13 at 9:54 am, documented the resident was yelling out and his Foley was irrigated with difficulty. The medical progress note dated 6/27/13 at 9:54 am, documented the resident was seen for ongoing issue of pain in penis. The resident was noted to have a 20 French Foley catheter inserted although he had an order for [REDACTED]. A bladder scan was to be performed every shift, and if the post void residual was greater than 300 mL the Foley catheter was to be reinserted. The nursing progress note dated 6/27/13 at 10:37 pm, documented the resident was complaining of pain in the genital area and was given Tylenol with relief. It further documented the bladder scan results were 500 mL, resident voided 240 mL with difficulty. The nursing progress note dated 6/28/13 at 4:02 am, documented the resident's post void residual was 440 mL and the Foley catheter was reinserted. The resident was also medicated with Tylenol for discomfort. The nursing progress note dated 6/28/13 at 10:46 pm, documented the resident was complaining of pain in the groin area and his Foley catheter was irrigated. The resident was also medicated with Tylenol with some relief. The nursing progress note dated 6/29/13 at 2:28 am, documented the resident was complaining of penile pain and was given pain medication with little relief. The resident was up in the wheelchair most of the shift, with several attempts to place back to bed however resident continued to yell out in pain and roll around in bed. The Foley catheter was flushed with little effect. It further documented the nursing supervisor was made aware. There was no documented evidence of a Registered Nurse assessment in the resident's medical record during this time frame. There was no documented evidence the physician was contacted and made aware of the resident's condition. The nursing progress note dated 6/29/13 at 11:23 am, documented the resident was calling out in pain, the pain was getting worse, and was not relieved with pain medication. At this time, the physician was called and an order to send the resident to the emergency room (ER) was obtained. The nursing progress note dated 6/29/13 at 2:20 pm, documented the resident was complaining of severe pain in the perineal and rectal area. Tylenol was given without relief. Vital signs documented were: blood pressure 158/103, pulse 102, temperature 97.4, and respirations 17. The supervisor and physician were made aware and the resident was transferred to the hospital. During an interview on 8/19/13 at 3:10 pm, Licensed Practical Nurse (LPN) #1 stated that he worked the evening on the same day the resident's catheter was removed. He stated that the bladder scan showed a post void residual of 500 mL. When asked why the resident's Foley catheter was not reinserted at this time per physician's orders [REDACTED]. During an interview on 8/14/13 at 1:00 pm, LPN #2 stated that she was the nurse on duty overnight 6/28/13 to 6/29/13. She stated when she received report from the previous shift she was told the resident was complaining of pain. The resident was in his bed at the beginning of her shift, however was anxious, restless, and continuing to complain of pain. She stated the resident got out of bed and was up all night into the next shift. She stated she gave the resident pain medication and irrigated his Foley catheter with no relief. She made the nursing supervisor aware, however she was not sure if the supervisor made the physician aware. She stated she asked the supervisor again at around 6:00 am, however did not get an answer. She added they usually do not call the physician overnight if it is not a major emergency, and stated she did not call the physician herself. She stated no further direction was given to her from the supervisor, but she passed it along to the next shift supervisor because she usually takes action quickly. During an interview on 8/15/13 at 3:05 pm, LPN #3 stated he was the nurse on duty on during the day shift 6/29/13. He stated when he received report from the overnight nurse, she stated the resident was up all night and yelling in pain. She told him she gave the resident pain medication and irrigated his Foley catheter with no effect. LPN #3 stated he went to check on the resident and he continued to complain of pain. He irrigated the resident's Foley and it was functioning appropriately. He stated he took the resident's vital signs and medicated him with Tylenol. He stated the pain medication provided no relief therefore he notified his supervisor and the physician and sent the resident to the ER. During an interview on 8/14/13 at 11:00 am, the Registered Nurse Manager (RNM) agreed that the resident had been in pain for a long time and the physician should have been made aware of the resident's condition overnight 6/28/13 to 6/29/13. She further stated there should have been vital signs and further interventions documented, as the resident continued to complain of pain all night and into the following morning. During an interview on 9/16/13 at 3:25 pm, the physician stated he was not made aware of the resident's pain level until the following morning when he ordered to send the resident to the ER for evaluation. He stated he would expect to be notified if a resident was in pain that was not relieved by nursing interventions. He stated at the very least he could have ordered a different pain medication to be taken from the facility's emergency medication kit, in an attempt to alleviate the resident's pain. During an interview on 8/14/13 at 12:00 pm, the Director of Nursing (DON) agreed that the physician should have been made aware of the resident's status overnight 6/28/13 to 6/29/13. She stated further intervention should have been made to relieve the resident's pain. 10 NYCRR415.12

Based on medical record review and staff interview the facility did not ensure that residents are free of any significant medication errors for one (#23) of four residents reviewed. Specifically, the facility did not ensure adequate monitoring of a residents [MEDICATION NAME] ( used to reduce spasms) pump ( a device placed under the skin used to administer a preset doseage of medication). The pump ran out of the medication and the resident required hospitalization . This resulted in actual harm that is not Immediate Jeopardy. This was evidenced by the following: Resident #23: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as cognitively intact. Review of the neurology consult dated 10/03/2011 documented the resident will be seen for follow up assessment on 1/30/12 at which time her [MEDICATION NAME] pump will be refilled. This consult was signed off by the attending physician. A review of the medical record did not find documented evidence of a January 2012 neurology consult. The nurses note dated 3/5/12 documented the resident complained both hands had a lot of pain and she was shaking. The resident requested an appointment with neurology. The nurses note dated 3/6/12 documented the resident was complaining of dry heaves and assessment revealed absent bowel sounds at which time the resident was then sent to the hospital for evaluation. The discharge summary from the hospital dated 3/10/12 documented the discharge [DIAGNOSES REDACTED]. The discharge summary further documented the pump had run out of [MEDICATION NAME] about 3 weeks prior to admission. The discharge summary further documented that after the pump was refilled the patient was feeling much better and ready for discharge. A black-box warning on [MEDICATION NAME]'s labeling warns against abrupt discontinuation of the drug. Such action can lead to withdrawal symptoms that may be life threatening. Among the sequelae are high fever, altered mental state, exaggerated rebound [DIAGNOSES REDACTED], and muscle rigidity that has progressed in rare cases to multiple organ-system failure, and death. Careful attention must be paid to programming and monitoring infusion systems, refill schedules and procedures, and pump alarms. The physician orders did not include an order for [REDACTED]. The resident comprehensive care plan (CCP) titled Comfort/Pain dated 3/23/11, with a reviewed date of 3/31/12, documented that the resident will experience a decrease in pain daily. One of the documented interventions for this goal is the [MEDICATION NAME] pump. There were no interventions or directions of what to monitor for with this pump. There was no documentation regarding the operations of this pump found in the medical record. The Activities of Daily Living (ADL) Certified Nurses Aide (CNA) care plan revised 1/25/12 does not have anything documented on it regarding the pump. The facilities appointment calendars for the months of December 2011, January 2012, February 2012, March 2012 and April 2012 have no evidence the resident had an appointment. The only appointment for the resident to see neurology was scheduled for 4/30/12. There were no January 2012 neurology appointments for this resident on the calendar as recommended by the neurologist. During an interview on 4/2/12 at approximately 9:30 am the unit clerk (UC) stated the process of appointments and how they are made are as follows: The nurse who receives the consult from the appointment completes the appointment and transportation request form then gives the form to the front desk who then confirms and/or schedules the appointments. Any nurse can fill out the form. During an interview on 4/2/12 at 10:53 am the UC stated there were no appointment slips for neurology follow up for this resident. During an interview on 4/5/12 at 9:15 am the Scheduler of the facility stated that if she was made aware of the appointment she would have had it documented on her calendar. There was no documentation for neurology in January 2012. The next scheduled appointment is 4/30/12. During an interview on 4/2/12 at approximately 8:00 am the Registered Nurse Unit Manager (RNM) stated that the nurse accepting the resident and consult is the one responsible for making the appointment form. She further stated that ultimately it is the RNM responsibility and that the appointment was missed on the consult. The RNM further stated when asked about the monitoring of the [MEDICATION NAME] she was not aware of any monitoring that was needed by the facility. She does try to track the appointments for the resident and the next appointment that she has is 9/7/12. When asked about a care plan for the [MEDICATION NAME] the RNM stated there was no care plan specific for the [MEDICATION NAME] or what if anything to monitor. She stated there was no CCP to direct staff on the [MEDICATION NAME] pump, how to monitor or to be aware of when the refills were needed. During an interview on 4/2/12 at 11:30 am the Registered Nurse Practitioner from the neurology office who cares for the resident, stated the resident was a no show for the January appointment. She stated that the [MEDICATION NAME] pump is refilled every 6 months but monitored more frequently as needed. If the [MEDICATION NAME] runs out there is a potential that a person could die from the abrupt withdrawal. The residents [MEDICATION NAME] pump was first inserted on 10/27/2008. She stated that on filling of the device they can tell when the refill is needed. They then schedule the appointment before the patient leaves with a 2 week window incorporated in case an appointment needs to be rescheduled. She further stated there are things the facility should be monitoring for such as the resident may have more spacticity or become too flaccid. During an interview on 4/2/12 at 6:50 am the Licensed Practical Nurse (LPN) stated they (the facility) doesn't do anything for the pump, the resident goes out to have the pump evaluated. She was not sure how often the pump is evaluated. She is not aware of any monitoring that is needed for the [MEDICATION NAME] pump. During an interview on 4/2/12 at 10:45 am the the CNA who cares for the resident stated there was not anything different they monitor the resident for other than any other resident. She did further state that they do Foley care for this resident. When specifically asked about the [MEDICATION NAME] pump of if she was ever told what to monitor for this she was not aware of any, she didn't know what a [MEDICATION NAME] pump was. During an interview 4/2/12 at 9:07 am the attending physician stated that the [MEDICATION NAME] pump is managed by the neurologist. She does not have any training on [MEDICATION NAME] pumps and does not do any oversight for the pump. When asked why the resident was admitted to the hospital she stated that the original thought was that the resident had MS symptoms but was later discovered after evaluation at the hospital that the [MEDICATION NAME] pump ran out of medication. The MD stated she honestly doesn't know how that happened. She doesn't monitor the pump. During an interview on 4/3/12 at 8:25 am the Director of Nurses (DON) who when questioned what, if anything, the facility should be monitoring for a resident with a [MEDICATION NAME] pump, she stated that she did not know anything about [MEDICATION NAME] pumps but would probably need to learn. 10NYCRR 415.12(m)(2)

Based on observation, record review and staff interview, the administrator failed to ensure that the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well being for each resident, during a partial extended abbreviated survey (#NY 800). Specifically, the administrator failed to ensure that the Abuse Prevention policy was operationalized and the facility failed to have systems in place to ensure thorough investigations were preformed after allegations were made that family members may have been tampering with a resident's oxygen, and that a Registered Nurse Supervisor may have violated the resident's plan of care. The facility's failure to thoroughly investigate to determine if abuse and neglect had occurred placed all of the residents at risk. This resulted in no actual harm but had the potential for serious harm that is Immediate Jeopardy to residents health and safety. This is evidenced by: Abuse - F225 Scope/Severity L During an interview on 3/29/11 at 1:15 pm the Administrator stated that approximately one month ago he had heard that family member (FM) #1 may have been turning off the Resident #1's oxygen, but this was not investigated. He could not recall who he had heard this from. The Administrator stated that this was a difficult family with frequent complaints and that it was difficult to know what was just a family fighting and what needed to be investigated. He stated that, because the Department of Health was looking at this issue, it probably should have been investigated. During an interview on 3/29/11 at 2:05 pm the Administrator stated that after thinking about this issue, he was not sure if he would have investigated the allegation that an FM was tampering with the resident's oxygen. He stated that this family had frequent complaints, and were fighting one another, and this just seemed like rumors. During an interview on 3/29/11 at 3:50 pm the Administrator stated that he could not recall when, but FM#1 had reported to him that an Registered Nurse Supervisor (RNS) had allowed Resident #1 to smoke on 2/23/11 even though her oxygen saturation was less than 90%, contrary to the physicians order, and the resident had to go to the hospital for respiratory distress. At the time that FM#1 reported this, he did not see the necessity of investigating it because the resident's FM's made frequent complaints and there was a lot of infighting between FM#1 and FM#2. No investigation into this allegation was done. 10NYCRR415.26

Based on observation, staff interviews, family interviews and medical record review during a partial extended abbreviated survey (Case #NY 800), it was determined for two (Resident #'s 1&3) of four residents reviewed, that the facility failed to ensure that all reports of potential abuse/neglect were investigated in a thorough and timely manner to ensure that the resident remained safe and that services were delivered in accordance to the resident's plan of care, physicians orders and according to the resident's wishes. The facility also failed to recognize and act upon allegations of abuse/neglect, to prevent the possibility of further abuse/neglect which poses a serious risk to resident safety. The facility also failed to investigate injuries of unknown origin to rule out the possibility of abuse, neglect and mistreatment, therefore failing to prevent the possibility of further abuse. Specifically, staff was aware that at least one member of a resident's family may have been removing the resident's oxygen and tampering with other oxygen related equipment including the flow delivery system. Staff reported these allegations to several levels of the facility's administration, with no subsequent action taken to ensure resident safety. Additionally, the facility failed to investigate all injuries of unknown origin including facial bruising. This resulted in no actual harm with the potential for serious harm that is Immediate Jeopardy to the health and safety of residents and Substandard Quality of Care. This had the potential to effect all 76 residents residing in the facility. This was evidenced by: Resident #1: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident to have moderately impaired cognition. The Policy and Procedure (P&P) for Prevention of Resident Abuse, Mistreatment, Neglect and Misappropriation of Resident Property dated 6/06 and revised on 9/22/08, documented that all alleged incidents of resident verbal, mental, or physical abuse, mistreatment, neglect and suspicious injuries of unknown origin were to be investigated. The P&P for Incident and Accident (I&A) Reporting and Follow-Up dated 9/03 and revised on 10/27/10, documented that all incidents and accidents were to be reported with forms completed in a timely manner and reviewed by the Interdisciplinary Team (IDT) during morning report. The P&P listed examples of incident and accidents that required an I&A, and that it was not an all inclusive list. One example was unanticipated medical events, and this category included examples listed as "code blue, suicide attempts, behavioral issues, etc." When an incident or accident occurred, it was the responsibility of the Nursing Supervisor/Charge Nurse to assure that the I&A and the follow-up were completed. If there was an alleged physical abuse, the Nursing Supervisor/Nurse Manager were to immediately notify the Administrator who was to conduct the required investigation. If the Administrator was not in the building at the time, the Administrator was to give direction to the Nursing Supervisor/Nurse Manager to initiate the investigation until the Administrator arrived. The P&P for Oxygen Therapy dated 11/2005 and revised on 9/22/08, documented that oxygen therapy was to be documented on the resident's TAR each shift by the RN or LPN. When a Pulse Oximeter (a machine that measures oxygen saturation in the blood) was used, the oxygen saturation was to be documented on the TAR and/or nurses notes. an order for [REDACTED]. Resident #1'sComprehensive Care Plan (CCP) for Resident Smoking dated 3/29/10 documented that the resident was to receive oxygen at a rate of 2 liters a minute while in bed, and as needed if the oxygen saturation (percentage of oxygen in the blood) was below 90%. The Hospitalist Discharge Summary dated 3/2/11 at 1:17 pm, documented that the resident had been in the hospital for [MEDICAL CONDITION] exacerbation and required oxygen. The resident was to be discharged to the facility and was to receive oxygen at 2-3 liter a minute. A nurses note dated 3/2/11 at 10:01 am, documented that the resident was readmitted to the facility from the hospital, and that oxygen remained on the resident at 3 liters a minute continuously. The Physician's History and Physical dated 3/3/11 at 11:35 am, documented that the resident returned from the hospital after an exacerbation of [MEDICAL CONDITION] and that the resident was now on oxygen at a continuous rate of 3 liters a minute. The Activities of Daily Living (ADL) Certified Nursing Assistant (CNA) Care Plan dated 3/9/11, and was used by staff to know what care each resident required, documented that the resident was to receive oxygen at a rate of 3 liter a minute as needed. The Treatment Administration Record (TAR) for the month of 3/11, documented that from 3/2/11 through 3/17/11, the resident was to receive Oxygen at a rate of 3 liters a minute as needed. Beginning on 3/17/11 at 12:00 am, the resident was to receive 2 liters of oxygen a minute when in bed, and as needed when out of bed if the resident's oxygen saturation was below 90%. Each shift was signed for from the 7:00 am through 3:00 pm shift on 3/17/11 through the same shift on 3/29/11. The liter flow was transcribed inaccurately. Finding #1: The facility failed to protect this resident from potential abuse. Staff was aware that at least one member of the resident's family was removing the oxygen and tampering with other oxygen related equipment including the flow delivery system. Staff reported these allegations to several levels of the facility's Administration, with no subsequent action taken to ensure resident safety. During an interview on 3/28/11 at 11:44 am the Director of Social Work (SW) stated that toward the beginning of the month ( 3/11), family member (FM) #2 reported to her and RNM #1 that she was concerned because FM#1 was trying to get the facility in trouble. FM#2 said that FM#1 was tampering with this resident's oxygen by changing the flow rates, turning off the oxygen or removing the oxygen from the resident then taking pictures of it with her cell phone. The SW stated that this information was reported to the Interdisciplinary Team (IDT) and discussed, and that it was decided that this was a family feud. The SW stated that she did not question FM#1 about this, and did not document the conversation because she assumed RNM#1 would document and investigate the matter. She also stated that she did not document issues and problems between family members. During an interview on 3/28/11 at 12:15 pm FM#2 stated that after the resident returned from the hospital in the beginning of the month of March 2011, FM#1's behaviors had become concerning to her and it started because the Health Care Proxy had been changed from FM#1 to FM#2. She stated that she was concerned that FM#1 may be tampering with the resident's oxygen and then taking pictures of it in an effort to get the facility in trouble. FM#2 stated that she reported this to RNM#1, the SW and to the Administrator. During an interview on 3/28/11 at 2:15 pm Licensed Practical Nurse (LPN) #1 stated that sometimes after FM#1 leaves the resident's room after visiting, the resident's oxygen appeared to be changed. She said that sometimes the oxygen flow rate was different, and sometimes the oxygen was turned off or removed from the resident. LPN#1 stated that this has been an ongoing problem for 4 to 6 weeks and that she had reported this to Registered Nurse Supervisor (RNS) #1, the Director of Nursing (DON) and to the Administrator. She stated that the Administrator thanked her for the information and that it would be looked into. During an interview on 3/28/11 at 2:50 pm CNA#1 stated that approximately two weeks ago she noticed that it appeared that FM#1 and FM#2 were changing the resident's oxygen flow rate and removing the resident's oxygen. She stated that she never actually saw either FM do this, but that after the FM's had been in the room with the resident, the oxygen flow rates were often different or the oxygen had been removed from the resident. She stated that she reported this to RNM#1 on at least a couple occasions. CNA#1 also stated that this had been happening frequently in the past couple weeks and was continuing to happen. She also stated that she had never seen the resident remove the oxygen herself. During an interview on 3/29/11 at 2:11 pm LPN#2 stated that for the last 4 to 6 weeks the behaviors of this resident's family members have escalated. She stated that staff on the unit often complained that FM#1 and FM#2 were changing the resident's oxygen and that sometimes staff found the oxygen turned off. She also stated that she has found the oxygen flow levels different after FM#1 visits the resident in her room. She stated she has reported this to RNS#1. During an interview on 3/29/11 at 2:17 pm Registered Nurse (RN) #1 stated that there has been a, "bunch of times," that she had found that the resident's oxygen flow level was different after FM#1 visited the resident. She stated that this occurred as recently as the week of 3/21/11 through 3/27/11. RN#1 stated that whenever she found the oxygen rate to be different after FM#1 left, she changed the rate back to what it was supposed to be. She also stated that she did not report this to the RNS because this had been an ongoing problem and everyone knew about it. During an interview on 3/29/11 at 2:55 pm LPN#5 stated that both FM's were tampering with the resident's oxygen by changing the flow rate and removing the oxygen from the resident. She stated that she never saw the FM's tampering with the oxygen but the flow rate was often different after the FM's left the room, and on a couple occasions the oxygen had been removed from the resident. She stated that this resident was not known to remove the oxygen herself. LPN#5 stated that she had reported her concerns to RNM#1 on several occasions, and RNM#1 said that she would take care of the problem. She also stated that this problem with the family began two to three weeks ago and appeared to be continuing. During an interview on 3/29/11 at 5:35 pm LPN#4 stated that she did not always work on this resident's unit, but that she had cared for her on occasion. LPN#4 said that she had heard rumors that FM#2 had tampered with the resident's oxygen. She stated that she never actually saw FM#2 changing the oxygen, but that there had been occasions when the oxygen flow rate was different after FM#2 left the room, and once the oxygen machine was found turned off. She did not check the resident's oxygen saturation, but would put the oxygen back on to what it should have been running. LPN#4 stated that she has complained about this to various other nurses and specifically identified RNS#1, and RNM#1 as being two of the nurses she reported this to. LPN#4 also said that this resident was not known to her to remove her oxygen herself. During an interview on 3/30/11 at 7:52 am RNS#1 stated that the two FM's were having difficulties with one another, and that their behaviors in the facility were, "awful." RNS#1 said that staff have come to him and stated that FM#1 and FM#2 may be changing the resident's oxygen flow rates. When he asked staff if they actually saw the FM's doing this, they had told him that they had not. RNS#1 told staff that if they saw the FM's do this to let him know, otherwise he could not accuse them without someone seeing it happen. He stated that he did not know if the DON and the Administrator were aware of staff saying that the FM's were tampering with the resident's oxygen. RNS#1 also stated that this resident's oxygen saturation levels dropped very quickly so she had to be watched closely. During an interview on 3/31/11 at 9:24 am RNM#1 stated that this resident's family was very difficult, that the two FM's did not get along. FM#2 told her a few weeks ago that she was concerned that FM#1 was changing the resident's oxygen flow rate and removing her oxygen. FM#2 told her that FM#1 was taking pictures of the resident's oxygen being off in an effort to get the facility in trouble. Several staff had reported to her suspicions that the FM's were tampering with the resident's oxygen and even removing it from the resident, and that, the whole facility knew that the FM's were changing the resident's oxygen. RNM#1 stated that after staff and FM#2 reported the allegations to her, she reported this to the DON and the Administrator. In conversation with the DON and Administrator it seemed that this was just rumors from staff and the complaining of a difficult family. She stated that the FM's were very difficult and had many complaints, and it was difficult to figure out what was true with this family. RNM#1 said that on one occasion she had been in the resident's room before the FM's had come to visit, and the oxygen was on the resident and the flow rate was correct. FM#1 then came to visit the resident and came out of the room and complained that the resident's oxygen was off. When RNM#1 went into the room, the oxygen machine (oxygen concentrator) was unplugged. The RNM#1 then plugged the machine back in. She did not discuss this with the FM or document this occurrence because she did not actually see the FM unplug the machine. During an interview on 3/29/11 at 12:45 pm the DON stated that she had heard the allegation that FM#1 may have been tampering with the resident's oxygen. FM#2 had told RNM#1 that FM#1 was doing things to sabotage the facility, and taking pictures with her cell phone. The DON stated that there was no investigation into the allegation but that she discussed these concerns with the SW and the general consensus was that this was a family matter, as the two FM's were in disagreement with the plan of care for the resident. During an interview on 3/29/11 at 1:15 pm the Administrator stated that approximately one month ago he had heard that FM#1 may have been turning off the resident's oxygen, but this was not investigated. He could not recall who he had heard this from. The Administrator stated that this was a difficult family with frequent complaints and that it was difficult to know what was just a family fighting and what needed to be investigated. He stated that, because the Department of Health was looking at this issue, it probably should have been investigated. During an interview on 3/29/11 at 2:05 pm the Administrator stated that after thinking about this issue, he was not sure if he would have investigated the allegation that an FM was tampering with the resident's oxygen. He stated that this family had frequent complaints, and were fighting one another, and this just seemed like rumors. During an interview on 3/31/11 at 11:45 am the Medical Director stated that he was not aware of the allegation that this resident's FM's may have been tampering with her oxygen. He stated that allegations should be looked into to see if they produce evidence, but that an investigation did not mean that the allegations were necessarily true. During a telephone interview on 4/1/11 at 10:49 am the resident's physician stated that she was not aware of the allegation that this resident's FM's may have been tampering with her oxygen. She stated that if there was such an allegation, then she would have expected that someone would look into it for the sake of the resident's safety. Finding 2: The facility failed to investigate an allegation that an RNS did not follow the plan of care by taking the resident outside for a cigarette when her oxygen saturation was less than 90%. This allegation was reported to an RNM and to the Administrator. The Comprehensive Care Plan for Resident Smoking dated 3/29/10, documented that the initial smoking evaluation of this resident was completed on 3/19/10. Documented interventions included that the resident was to be monitored by staff during smoking, to report any unsafe smoking to a Nurse Manager/Nursing Supervisor. The resident was to receive oxygen at a rate of 2 liters a minute while in bed, and as needed if the oxygen saturation (percentage of oxygen in the blood) was below 90%. A nurses note dated 1/30/11 at 4:38 pm, documented that the resident was continuously requesting to go outside to smoke even though her oxygen saturation was low. The physician was made aware and ordered the resident's oxygen saturation before the resident went outside to smoke, and that the resident was not to smoke if her oxygen saturation was less than 90%. A Physician's Telephone Order dated 2/1/11 at 10:56 am, documented that the resident's oxygen saturation level should be over 85-90% before the resident could go outside to smoke. The Treatment Administration Record (TAR) for 2/2011, documented to hold cigarettes during scheduled smoke times if her oxygen saturation was below 90%. The 24 Hour Report dated 2/1/11 at 5:06 pm, documented that the resident's cigarettes were to be held during scheduled smoke times if her oxygen saturation was below 90%. The ADL CNA Care Plan dated 3/9/11, documented that the resident's oxygen saturation was to be taken before going out to smoke and if it was less than 90% the resident was not to have a cigarette and that it was to be documented. A nurses note dated 2/23/11 at 3:25 pm, documented that the resident's oxygen saturation was 81% while she was receiving 4 liters of oxygen a minute. The resident was complaining of shortness of breath, the RNS was called to assess the resident and the physician was notified. The physician ordered the resident to be transferred to the hospital. A nurses note dated 2/23/11 at 11:27 pm, documented that the resident was admitted to the hospital with [REDACTED]. The Hospitalist Discharge Summary dated 3/2/11 at 1:17 pm, documented that the resident had been in the hospital for [MEDICAL CONDITION] exacerbation and required oxygen. The resident was to be discharged to the facility and was to receive oxygen at 2-3 liter a minute. During an interview on 3/29/11 at 2:32 pm FM#1 stated that LPN#2 had informed her that on 2/23/11, when the resident had been sent to the hospital in respiratory distress, she had taken the resident's oxygen saturation level and it was 81%. LPN#2 told RNS#1 about the oxygen saturation level but RNS#1 took the resident outside for a cigarette anyway, even though the physician had ordered that the resident was not to smoke if her oxygen saturation was less than 90%. LPN#2 told FM#1 that she reported this to RNM#1 and to the Administrator. FM#1 then stated that she spoke to the Administrator about this and she was told that he would look into it. During an interview on 3/29/11 at 3:59 pm LPN#2 stated that this resident was having shortness of breath, but wanted to go out for a cigarette. The physician had ordered the resident not to smoke if her oxygen saturation was less than 90%. LPN#2 took the resident's oxygen saturation and it was in the high 70%'s to low 80%'s. She reported this to RNs#1, who told her that the resident had a right to smoke, and that he could go to jail for refusing the resident her rights. RNS#1 then took the resident outside for a cigarette. Approximately one hour later, the resident was in respiratory distress and had to be transferred to the hospital. LPN#2 stated that she reported this to RNM#1 and believed this occurred on 2/23/11. During an interview on 3/30/11 at 7:52 am RNS#1 stated that the physician had ordered the resident not to smoke at her regularly scheduled smoking time if her oxygen saturation was less than 90%. On one particular day, he was not sure of the date, at approximately 10:00 am, the resident was sitting near a door and was waiting to go outside for a cigarette. He took the resident's oxygen saturation level and it was in the mid-90%'s, so he took her outside for a cigarette. That afternoon the resident's oxygen saturation dropped, she was started on oxygen and was sent to the hospital. RNS#1 stated that he did not document the resident's oxygen saturation and that he could not recall the date of this occurrence. He stated that he did not believe this was on 2/23/11. RNS#1 reviewed the medical record and stated that he could not narrow down the date that this happened. During an interview with RNM#1 on 3/31/11 at 9:24 am, she stated that staff and FM#1 had reported to her that RNS#1 had taken the resident out for a cigarette on 2/23/11 even though her oxygen saturation was less than 90%. She stated that she reported this allegation to DON#2 (the former Director of Nursing who did not return repeated phone calls and messages to her) and to the Administrator. RNM#1 stated that she was told by the Administrator that she was finger-pointing and that she needed to stop it. During an interview on 3/30/11 at approximately 3:00 pm LPN#2 stated that she may have been wrong about the date that RNS#1 took the resident outside for a cigarette after she found the resident's oxygen saturation to be low. She stated that she thought it might have occurred on 1/30/11 (which contradicted her interview on 3/29/11 at 3:59 pm). She stated that after RNS#1 took the resident outside for a cigarette after she informed him that the resident's oxygen saturation was low, she called the physician who then ordered the resident not to smoke if her oxygen saturation was below 90%. During an interview on 3/29/11 at 3:50 pm the Administrator stated that he could not recall when, but FM#1 had reported to him that an RNS had allowed the resident to smoke on 2/23/11 even though her oxygen saturation was less than 90% and the resident had to go to the hospital for respiratory distress. At the time that FM#1 reported this, he did not see the necessity of investigating it because the resident's FM's made frequent complaints and there was a lot of infighting between FM#1 and FM#2. No investigation into this allegation was done. 2. Resident #3: The facility did not investigate an injury of unknown origin. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nurse's notes dated 1/13/11 at 8:24 am documented "ecchymotic areas to right and left arms; caregivers stated that the resident refuses to wear geri-sleeves; will continue to try to re-apply." Interdisciplinary Team Review of the alleged bruising was completed on 1/14/11 and documented to continue with plan of care, encourage the resident to wear her geri-sleeves ( to protect the arms from bruising). Nurse's notes dated 1/31/11 at 2:14 pm documented that the physician was aware of an ecchymotic area under the resident's right eye. Nurse's notes on 2/1/11 at 2:13 am documented that the right eye ecchymosis continues. When requested, the facility was not able to provide an I&A report or investigation for the right eye ecchymosis. During an interview on 3/30/11 at 3:30 pm the LPN #1, who wrote the nurse's note on 1/31/11, stated she remembered the ecchymotic eye incident and thinks the resident got the bruised eye from hitting the Hoyer lift. During an interview on 3/30/11 at 4: 30 pm the facility Administrator stated he was not able to locate an I&A report, but he would expect one to be completed for a bruise of unknown origin. When asked if there were any changes made to the resident's care plan, the Administrator stated none that he was aware of. During an interview with the facility's Corporate Director of Quality Initiatives on 3/31/11 at 11:10 am, she stated that there was a nurses note dated 1/31/11 at 2:14 pm, that identified a bruise below the resident's right eye. An I&A was completed but it could not be located. She also stated that she spoke to RNM #2 who said that an I&A had been completed and was reviewed by the IDT and that the IDT agreed that the bruise was likely caused by the resident bumping into a Hoyer lift in the hallway. During a telephone interview on 3/31/11 at 3:07 pm the RNM#2 stated that she recalled the bruise on the resident's face on 1/31/11. To the best of her memory, she completed an I&A and it was discussed at the morning meeting. After the morning meeting, she turned the I&A into the Administrator. She said that this resident had a tendency to wheel her wheelchair in direct lines, and if that meant she would run into something or someone, then that was what she would do. RNM#2 also stated that this resident frequently had to be redirected from going into other resident rooms. When she learned of the bruise, she felt that the resident probably bumped into a Hoyer lift that was in the hallway. At the time of the bruise, it did occur to her that there were two residents on the unit that may have hit her if she ran into them with her wheelchair. One of the residents that she thought about had a long history of [MEDICAL CONDITION]. She stated she did not interview staff or residents about this. During an interview on 3/31/11 at 5:00 pm the DON stated that when I&A's were reviewed in the IDT meeting, they were logged in to the I&A Log. The DON reviewed the I&A Log and stated that the I&A for a bruise on this resident on 1/31/11 had not been documented on the Log. 10 NYCRR 415.4(b)(1)(ii)