Every finding on record at Wells Rehabilitation and Nursing Center

Based on observations, record review, and interviews during a survey, the facility failed to ensure residents were free from abuse for one (1) (Resident #1) of three (3) residents reviewed for abuse. On 02/04/2026, Resident #1 became combative during a shower, striking Certified Nurse Aide #2. Certified Nurse Aides #1 and #2 continued to provide shower care. Certified Nurse Aide #1 stated they continued the care and tried to deflect some of the blows toward Certified Nurse Aide #2. Resident #1 sustained injuries including skin tears, scattered bruising to right arm, hematoma (a localized collection of clotted or partially clotted blood outside blood vessels, often resulting from injury or trauma) on the back of head, a head laceration (cut), and a bruised left ankle. This resulted in actual harm of Resident #1 that is not Immediate Jeopardy and is past non-compliance. This is evidenced by:Resident #1 was admitted with the diagnoses of unspecified dementia (a group of symptoms affecting memory, thinking, and social abilities), chronic diastolic (congestive) heart failure (when the left lower chamber of the heart becomes stiff, leading to decreased blood flow and other complications) and chronic kidney disease (state of progressive loss of kidney function and the ability to remove waste from the body). The Minimum Data Set (an assessment tool) dated 01/02/2026 documented the resident was able to be understood, was able to understand others, and had intact cognition. The policy and procedure titled Abuse Prevention Manual, last revised 01/01/2026, documented it was their policy that residents environment would be free from verbal, mental, and physical abuse, mistreatment, neglect, misappropriation of resident's property, and exploitation. The policy and procedure titled Comprehensive Care Planning, effective 01/01/2026, documented a person-centered comprehensive care plan would be developed for each resident and includes the right to receive goods and services outlined in the plan of care and also the right to refuse treatment.The Comprehensive Care Plan titled Resident #1 is resistive to care and refuses showers was initiated on 12/10/2025 and included the interventions: If approaches are unsuccessful when combative and agitated, leave safe and reapproach.The Facility Investigation documented that on 02/04/2026 at 11:30 AM it was reported to Director of Nursing #1 that Resident #1 had been injured in the shower while combative with care. An investigation was completed, and a violation of the comprehensive care plan was found. Two (2) certified nurse aides (#1 and #2) were terminated as a result of this incident. The Progress Note dated 02/04/2026 at 12:38 PM written by Registered Nurse #1 documented Resident #1 was reported to be combative with care, at baseline, and Certified Nurse Aides #1 and #2 continued with the shower, resulting in injuries to the resident including:^Skin tear on left elbow measured one (1) centimeter by one (1) centimeter.^Skin tear left forearm measured six and a half (6.5) centimeters by four (4) centimeters with surrounding bruising measured at eight (8) centimeters by four (4) centimeters.^Scattered bruising to right arm.^Skin tear on right elbow one and a half (1.5) centimeters and able to be approximated with steri strips^Hematoma back of head measured two (2) centimeters by two (2) centimeters.^Laceration back of head below hematoma measured one (1) inch by one (1) inch.^Bruising to left ankle measured three (3) centimeters by three (3) centimeters. During an interview on 02/17/2026 at 11:51 AM, Registered Nurse #1 stated they were informed of the incident after it happened. The resident was already in their room when Registered Nurse #1 arrived. They assessed the resident's injuries and applied treatments as per the facility protocol for skin tears. The Medical Director was informed. They stated the two (2) certified nurse aides (#1 and #2) that were in the shower room with the resident were immediately removed from the floor and sent to Director of Nursing #1. They stated the resident, at baseline, was resistant to personal care such as showering and basic activities of daily living and the two (2) certified nurse aides were regulars on the unit and were familiar with the resident and their behaviors. They stated they do not know why Certified Nurse Aides #1 and #2 continued to shower the resident when the resident was being combative, but they should have stopped the shower and returned the resident to their room safely. They stated the resident was alert and oriented at baseline but had short-term memory issues that could affect recall of specific incidents.During an interview on 02/17/2026 at 12:24 PM, Director of Nursing #1 stated they became aware of the incident within 20 minutes of it occurring, and they removed Certified Nurse Aides #1 and #2 from the unit and immediately suspended them. Certified Nurse Aides #1 and #2 were terminated after the investigation showed a care plan violation with subsequent injury to the resident. They stated upon initiating the investigation they also started education for all staff, clinical and non-clinical, on customer service, abuse and abuse reporting, and the resident's right to refuse care. Certified Nurse Aides #1 and #2 had no prior incidents of care plan violations or abusive behaviors. They stated the certified nurse aides were well familiar with the resident and their behaviors. During an interview on 02/17/2026 at 3:30 PM, Certified Nurse Aide #3 stated they were familiar with the resident and had heard about the incident but had no direct knowledge of it. They stated the incident occurred on the day shift, while they work the evening shift. They stated that the resident had long standing behaviors and needed a gentle approach to get anything done with them. They stated the resident had a history of refusing showers for weeks at a time, allowing only the basic bed bath sometimes. They stated they received education that residents had the right to refuse care, even with dementia, and it was important for the residents that their choices be respected. They also stated they received education on abuse and reporting anything that seemed out of the ordinary, and how to interact with residents in a pleasant, friendly manner even if the residents were not being friendly. During an interview on 02/18/2026 at 10:36 AM, Certified Nurse Aide #1 stated they were not familiar with Resident #1's care, they had been asked by Certified Nurse Aide #2 to assist with a shower because the resident could become combative. They stated the resident was initially hesitant to take a shower, but when Resident #1 was informed their family member wanted the shower, Resident #1 reportedly stated I don't want to, but I'll do it. They stated the resident became combative after the shower started and the resident was striking Certified Nurse Aide #2. Certified Nurse Aide #1 stated they helped keep the resident from sliding off the shower chair and tried to deflect some of the blows toward Certified Nurse Aide #2. They stated they noticed the large skin tear on Resident #1's left arm and after the resident was dressed and, in their room, Certified Nurse Aide #2 reported it to the nurse.During an interview on 02/19/2026 at 12:44 PM, Medical Director #1 stated they were no longer the medical director for the facility. They stated they did assess Resident #1 after the incident on the same day and found minor injuries, no significant injuries. They stated they ordered radiography on head, arms, hips, and ankle with no significant findings. They stated the resident was unable to say how they struck their head resulting in the hematoma, but Medical Director #1 surmised it could have happened in the shower chair while the resident was resisting care. They stated they were not involved in the follow- up to the incident as they did not work at the facility any longer. During a telephone interview on 03/03/2026 at 10:30 AM, Family Member #1 stated that resistance to care was the resident's baseline. They stated it was one of the reasons the resident was placed in long term care because the resistance to care in the community setting led to the resident being unkempt and unable to take care of themselves. They stated they made the facility aware they would be visiting the resident the day the incident occurred. They visited the resident and found the resident bleeding and reported it to Director of Nursing #1 immediately and returned to the room where Registered Nurse #1 was wrapping the resident's arm with a bandage. They stated the resident was unable to state what had happened other than something happened in the shower but could not elaborate. Family Member #1 stated that over all they are happy with the resident's care at the facility. The Incidents by Incidents Type list for 120 days was reviewed and there were no other reported potential abuse cases.Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement at the time of the abbreviated survey. Removed the two (2) involved certified nurse aides (#1 and #2) and terminated them, preventing any further resident contact. All staff, clinical and non-clinical, were educated on 02/06/2026 on abuse prevention and reporting, customer service, and the resident's right to refuse care and treatment. Resident #1's comprehensive care plan was reviewed on 02/06/2026 and applicable interventions added.10 New York Codes, Rules, and Regulations 415.4(b)(1)(i)

Based on record review and interviews during the recertification and abbreviated survey (Case #NY00338006), the facility did not ensure the resident's right to be free from neglect for 1 (Resident #48) of 18 residents reviewed for abuse and neglect. Specifically, on 4/03/2024, Certified Nurse Aide #2 did not use two-person assist for bed mobility as required in Resident #48's Comprehensive Care Plan while providing care to the resident. Resident #48 rolled out of bed onto the floor. Resident #48 sustained a pelvis fracture (a break of the bony structure of the pelvis). This resulted in actual harm that was not immediate jeopardy. This is evidenced by: Resident #48 was admitted with diagnoses of pulmonary edema (fluid collection in the chest cavity causing breathing difficulty), legal blindness, and chronic kidney disease (dysfunction of kidneys that never gets better). The Minimum Data Set (an assessment tool) dated 8/10/2024 documented the resident had severe cognitive impairment, could be understood, and sometimes understand others. A facility policy titled Point of Care dated 8/2014 documented the activities of daily living codes used to indicate resident abilities and the required staff responsibilities for each code, including the number of people required to give personal care to residents. A facility policy titled Comprehensive Person-Centered Care Plans dated 10/2000 documented the information derived from the comprehensive assessment enabled the staff to plan care that allowed the resident to reach their highest practicable level of functioning and included, but was not limited to: physical and mental function status, ability to perform activities of daily living including bathing, dressing, grooming, transferring, ambulation, toilet use, eating, and other communication systems. It also documented determining the resident's needs for staff assistance and assistive devices or equipment to maintain or improve functional abilities. Resident #48's Comprehensive Care Plan for Activities of Daily Living initiated on 1/31/2022, and last revised on 7/11/2024, documented Resident #48 required assistance with Activities of Daily Living related to dementia, legal blindness, and decreased mobility. Interventions documented included AM/PM care per policy and refer to Point of Care task record and Kardex (resident care card followed by Certified Nurse Aides) for specific care information. Resident#48 required assistance with meals, documented as a total care; bathing: shower two person assist, provide sponge bath when a full shower cannot be tolerated, and monitor resident's skin with AM/PM care. Resident #48's Comprehensive Care Plan for falls, initiated on 1/31/2022 and last revised on 7/11/2024, documented the resident was at risk for falls secondary to confusion and generalized weakness. The resident fell from bed during personal care on 4/03/2024, which was also documented under Focus of Falls. The goal was to be free from falls daily. Interventions documented include; refer to Plan of Care task record and Kardex (resident care card followed by Certified Nurse Aides) for specific care information, transfer mechanical lift with two-person assist, and physical therapy and/or treatment accordingly. Resident #48 was documented as non-ambulatory and required assistance to transfer to and from bed and the chair. Resident #48's Certified Nurse Aide accountability and Care Guide dated 3/2024 documented the resident was dependent for two-person assist mechanical lift transfer in and out of bed, two-person assist for showering and bathing, two-person dependent for turning and position to roll both to the left and right, dependent for locomotion on the unit, and dependent for activities of daily living. Nursing notes dated 4/03/2024 at 1:04 PM, documented the resident fell from the bed and was noted to have full range of motion and no viable injuries. The resident's attending physician and the resident's husband were notified of the fall. Nursing note dated 4/03/2024 at 5:39 PM written by Registered Nurse #1 documented the resident had vomited. This was again documented at 6:25 PM. Nursing notes dated 4/03/2024 at 6:35 PM, the Nurse Practitioner #1 was made aware of the resident's continued vomiting and ordered the resident be sent to the hospital for a Computed Tomography scan. Resident #48 Hospitalist History and Physical dated 4/04/2024 at 12:14 AM documented Resident #48 was referred to the emergency room for evaluation of projectile vomiting over the last few hours. Patient rolled out of bed and fell . Chest, abdomen, and pelvis computed tomography (CT) showed evidence of acute nondisplaced right inferior pubic ramus fracture (a break in a group of bones that make up part of the pelvis) and likely nondisplaced right superior ramus fracture (a break in one of the bones that make up the pelvic ring) and nondisplaced fracture of the right sacral ala (a break in the sacral bone). No surgical intervention was required for treatment. The facility investigation dated 4/08/2024, documented on 4/03/2024 Certified Nurse Aide #1 and Certified Nurse Aide #2 put Resident #48 back in bed. Certified Nurse #1 left the room and Certified Nurse #2 continued to give care. Certified Nurse #2 rolled Resident #48 onto their side by themselves, and the resident rolled off the bed and onto the floor. Initially upon assessment of Resident #48, it was documented Resident #48 did not have complaints of pain. It further documented later the same day, the resident complained of pain and was vomiting. The medical team at the facility determined the resident should be sent to the hospital. The investigation determined Certified Nurse Aide #2 failed to follow the plan of care, received a verbal and written warning following the incident, had not had any previous disciplinary reports, and was counseled. The investigation also documented the plan of correction which included mandatory in-service scheduled 4/17/2024 for following the plan of care and a random quality assessment conducted on five residents per week for 3 months then monthly specifically related to turning and repositioning of residents who required assistance with Activities of Daily Living. On 9/10/2024, Resident #48 declined to be interviewed. During an interview on 9/11/2024 at 9:38 AM, Certified Nurse Aide #1 stated Director of Nursing #1 spoke to them the next day they worked after the fall on 4/03/2024. Certified Nurse Aide #1 stated it was reinforced that Certified Nurse Aides should check the Point Click Care system to double check tasks like transfer status. Certified Nurse Aide #1 stated they now made sure they checked resident's care requirements before they do anything with residents they do not know. They stated if they observe any staff assisting resident who require two-persons by themselves, they would stop the employee and educate them on where they should look for information about the resident. They stated if a new resident was on the unit and they did not know if the resident was a one or two person assist, they would not make assumptions about the resident's care. They would ask their coworkers and check on the computer for orders and direction. During an interview on 9/11/2024 at 10:16 AM Certified Nurse Aide #2 stated after Resident #48's fall, there was house wide education done regarding resident care. The education provided was an information packet with a post-test and there had also been at least 1 but possibly 2 staff meetings devoted to reinforcing how to care for residents responsibly. The education provided, reinforced to look in Point Click Care every day and ask questions if the Certified Nurse Aide did not know what to do. Certified Nurse Aide #2 stated if a new resident came to the unit, there would be a discussion on their care needs. They stated if they saw a new employee handling a two person assist resident by themselves, they would intervene, help them finish the task, and then show them where to find the information they were lacking. Additionally, Certified Nurse Aide #2 stated they would also tell the charge nurse what had happened regardless of if there was an incident or not. They stated under no circumstances would they try to give a two-person care by themselves. During an interview on 9/11/2024 at 10:20 AM, Licensed Practical Nurse #2 stated after resident's fall, education was given house wide. Required in-service education reminders were sent to staff on Point Click Care. Licensed Practical Nurse #2 stated the fall on 4/03/2024 was considered a major event for the facility. Everyone was educated on how to avoid it. Licensed Practical Nurse #2 stated they were not on the 2nd floor when the fall happened but heard about it within hours of it occurring. Licensed Practical Nurse #2 stated they understood if they did not know what a resident's needs were, they would ask and get help before trying to do anything with residents. During an interview on 9/11/2024 at 10:24 AM, Registered Nurse #1 stated everybody received education after Resident #48's fall. Registered Nurse #1 stated they assessed the resident at the time of the fall on 4/03/2024. The resident did not appear to be injured until later in the day when the resident complained of pain. New staff were educated on reading care plans and Kardex (resident care card followed by Certified Nurse Aide) before giving care. The therapy department met with new staff to teach them how to handle residents based on the level of need they required. Registered Nurse #1 stated all the departments have been involved with reinforcing safety with all the staff. Additionally, Registered Nurse #1 stated Certified Nurse Aide #2 was one of their best Certified Nurse Aides, the fall was an accident. They also stated they felt confident stating the facility did everything it could to make sure the staff had been educated to the best of their abilities to ensure events like this one would not happen again. During an interview on 9/12/2024 at 9:15 AM, Director of Nursing #1 stated staff discussed incidents in morning report every morning. Falls were discussed during the Inter Disciplinary Team meetings. Director of Nursing #1 stated they and other nursing staff talked to providers to implement changes for residents that fell . If there were no physical things that could be done to prevent falls, they would look at medical reasons for why residents fell . There was a team approach to keeping the residents safe. When asked if the medical staff were involved in the Quality Assurance of this incident and others, Director of Nursing #1 stated either the medical doctor or the nurse practitioner were involved with all the Quality Assurance meetings.? Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement at the time of this survey: Certified Nurse Aide #2 was suspended for 4 weeks and counseled on turning, positioning, and handling residents requiring assistance with Activities of Daily Living. Completed facility wide education on 4/17/2024 on the following policies: Abuse/Crime Prohibition, Transfers, and Point of Care. A facility assessment of transfer status of all residents, ensuring accuracy of resident records was done on 4/04/2024. Quality and Assessment audit on 10 residents per month for 3 months including all three shifts was completed to make sure the plan of care was being followed dated 4/04/2024 through 9/05/2024. Additionally, a Quality Assurance audit was conducted weekly with 4 staff including all 3 shifts on abuse, neglect, and mistreatment for three months. After 3 months the audit was conducted monthly with 5 staff members for 3 months. Documentation provided dated 4/25/2024 through 8/02/2024. 10 New York Codes, Rules, and Regulations 415.4(b)(1)(i)

Based on record review and interviews during the recertification survey, the facility did not ensure that residents and/or their designated representative were fully informed of their right to an expedited review of a service termination for 2 of 3 residents reviewed. Specifically, the facility did not ensure 2 (Residents #141 and #142) who received Medicare Part A services, received timely notification (2-day notification) of the termination of services with the required form Notice of Medicare Non-Coverage, Form CMS 10123-NOMNC. This is evidenced by: There was no documented evidence that residents #141 and #142 received 2-day notification prior to the termination of rehabilitative services. During an interview on 9/06/2024 at 11:34 AM, Fiscal Clerk #1 stated that they could not account as to why residents #141 and #142 did not receive a 2-day notification prior to the termination of Medicare services. During an interview on 9/06/2024 at 11:37 AM, Administrator #1 stated that the Fiscal Clerk would be re-educated on the 2-day notification. 10 New York Codes, Rules and Regulations 415.3 (g)

Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice. Specifically, opened medications had no open and/or expiration dates for 1 (2nd floor medication cart) of 2 medication carts reviewed. This is evidenced by: The facility's Medication Storage and Expiration of Medications policy revised on ,d+[DATE] documented, once any medication or biological product was opened, follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Record the date opened on the medication container when the medication had a shortened expiration date once opened. Record calculated expiration date based on date opened on the medication container. The facility's Medication Administration Procedures policy dated ,d+[DATE] documented to not give a medication if the label was unclear or illegible. During an observation on [DATE] at 12:10 PM, 2nd floor, Cart #1 contained 1 Troujeo Max Solostar insulin pen with no expiration date, 1 Basaglar Kwik Pen insulin pen, and 1 Aspart insulin pen both without open dates or expiration dates. At the time of observation, Licensed Practical Nurse #1 stated the insulin pens must have been new because the cart was checked the previous day. During an interview on [DATE] at 12:10 PM, Licensed Practical Nurse #1 stated that new insulin pens should have had a sticker on them with the date opened and the expiration date written on them. Licensed Practical Nurse #1 stated they would not use an unlabeled pen and go ask the unit manager what to do as they had just started working at the facility. Licensed Practical Nurse #1 stated that they knew not to use the unlabeled pen, but they were unclear how to procure a new one. During an interview on [DATE] at 9:08 AM, Registered Nurse #1 stated the policy regarding labeling and storage of insulin pens was that when pens are opened, they should be labeled with the date opened and the expiration date. Registered Nurse #1 stated that if a staff member were to remove an insulin pen and saw that it was not labeled, the expectation was they would not use the unlabeled pen and procure a new one and label it appropriately. During an interview on [DATE] at 9:15 AM, Director of Nursing #1 stated they spoke to nurses about labeling medications often. They stated if two Registered Nurses were on every evening, one nurse would be tasked to go through all the medication carts weekly and check for expired or mislabeled medications. Director of Nursing #1 stated that this was last done on [DATE]. Additionally, the Director of Nursing #1 stated nurses discuss expiration dates and labeling medications. 10 New York Codes, Rules, and Regulations 415.18(d)

Based on observation, record review, and staff interview during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the concentration of quaternary ammonium compound chemical sanitizing rinse (QAC) was less than that required by the manufacturer and equipment required cleaning. This is evidenced as follows. The kitchen was inspected on 10/21/2021 at 10:36 AM. The concentration of QAC used to sanitize food contact equipment was found to be 150 parts per million (ppm) when measured at 71 degrees Fahrenheit (F). The manufacturer's label directions stated the concentration is to be between 200 ppm and 400 ppm when the solution is measured between 65 F and 75 F. The refrigerator shelving and door gaskets in the 1st floor nourishment area were soiled with food particles. Record review of the education given to dietary employees revealed that it did not provide specifics on how to check the QAC concentration and to clean refrigerator door gaskets. The Food Service Director stated in an interview on 10/21/2020 at 11:06 AM, that staff will be educated to properly clean refrigerators and to ensure the QAC is at the correct concentration. The Administrator stated in an interview on 10/25/2021 at 2:48 PM, that the Food Service Director will ensure the QAC concentration and cleaning issues will be addressed and will be reviewed for compliance. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.110, 14-1.112

Based on observation, record review and interview during a recertification survey the facility did not ensure each resident was treated with respect and dignity and cared for in a manner and in an environment that promotes maintenance or enhancement of quality of life for 1 (Unit 2) of 2 resident dining rooms and 4 (Resident #'s 2, 4, 70, and #73) of 5 residents reviewed for dignity. Specifically, the facility did not ensure staff were interacting with residents rather than with each other while assisting residents with meals in 1 of 2 dining rooms; Specifically, for Resident #2, the facility did not ensure the resident's pants were not urine soaked, that a puddle of liquid was not beneath the resident's chair and feet, and that the odor of urine did not permeate a public area of the unit where the resident was observed sitting in a recliner chair; for Resident # 4, the facility did not ensure the resident's right to privacy was protected in the resident dining room; for Resident # 70, the facility did not ensure the resident's request to stop being fed was honored for; Resident # 73, the facility did not ensure the resident's personal space was protected when staff entered her room without knocking and pushed the resident's wheelchair from behind without informing the resident first. This is evidenced by: Finding #1 The facility did not ensure staff were interacting with residents rather than with each other while assisting residents with meals in the Unit 2 dining room. During observation(s) on 5/06/19 at 12:44 PM, 5/07/19 at 8:51 AM, 5/07/19 at 12:24 PM staff were sitting with residents in the dining room, having personal conversations among each other, and had minimal interactions with the residents. During an interview on 5/08/19 03:07 PM, the Director of Nursing (DON) stated she would not expect to hear personal conversation in the dining room, and she had spoken about not having personal conversations in the dining room with staff during CNA meetings. During an interview on 5/09/19 at 7:35 AM, the Food Service Director (FSD) #1 stated the DON has educated staff on dining with dignity. During an interview on 05/09/19 at 8:36 AM, Registered Nurse (RN) #1 stated the Director of Nursing (DON) had spoken with the staff several times about dining room etiquette and staff on the unit have been educated. She stated conversations in the dining room should have been focused around the residents and include the residents. Staff should not have personal conversations. Finding #2 The facility did not ensure the resident's pants were not urine soaked, that a puddle of liquid was beneath the resident's chair and feet, and that the odor of urine did permeate a public area of the unit where the resident was observed sitting in a recliner chair. Resident #2: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severe cognitive impairment and was rarely able to make herself understood, and sometimes able to understand others. The Comprehensive Care Plan (CCP) titled Bladder Incontinence related to (r/t) Confusion and dated 4/25/18 documented that the resident will be clean, dry and odor free daily through next review. Interventions included cleaning the peri-area with each episode of incontinence. The CCP titled Resident Requires Assistance with ADL's (activity of daily living) r/t Dementia dated 4/11/17, documented that the resident's ADL's will be met daily as evidenced by being clean, neat and well groomed. Interventions included; enjoys being in recliner near nurses station after meals to watch tv and nap, ensure dignity during care, and toilet every 2-4 hours as needed. During an observation on 5/6/19 at 9:32 AM, Resident #2 was sitting in the lounge across from the nursing station in a recliner chair. She was sitting on a wet incontinence pad, the front of the resident's pants were wet, and the resident's feet were in a large puddle of liquid on the floor in front of the chair. The odor of urine was strong in the area. The resident was notably restless. The resident was continuously changing her position in the chair. At 10:15 AM, a staff member entered the lounge area with a nourishment cart and at the same time the resident was observed trying to make an attempt to stand. The staff member told Resident #2 to sit back down. At 10:25 AM, a housekeeping staff member walked into the lounge and passed by Resident #2. At 10:45 AM, a Certified Nurse Aide (CNA) approached Resident #2 and took her to her room. During an observation on 5/7/19 at 08:11 at AM, the resident was sitting in the lounge across from the nursing station in a recliner chair. The incontinence pad that the resident was sitting on was wet and the front of the resident's pants were wet. There was a strong urine odor in the area where the resident sat. At 08:21 AM, a nurse walked into the lounge area and addressed another resident. At 08:28 AM, a CNA covered the resident with a clothing protector and sat down next to her and fed her breakfast. At 08:39 AM ,breakfast was over and the CNA walked the resident to her room to be changed. During an interview on 5/7/19 at 2:00 PM, CNA #2 stated that the resident requires total assistance with checking and changing. After breakfast the resident is taken to her room for toileting and changing, then she is checked every 2 hours for toileting. During meals a CNA is assigned to watch the residents that are not in the dining room, monitoring the halls and the lounge area. If any staff member saw that the resident was wet, they should have changed her. When CNA #2 brought her breakfast tray to her that morning he saw that she was wet, but she was grabbing at the breakfast tray. CNA #2 thought it best to feed her then take her to be changed. During an interview on 05/07/19 at 02:10 PM, CNA #3 stated that all staff are supposed to be toileting or changing residents in need, it does not matter if the resident is not assigned to the CNA. Yesterday (5/6/19) a helping hands staff member came to me and said Resident #2 needed to be changed, and I brought her to the room and toileted her. The resident often does not urinate on the toilet and a short while after she will be soaked. During an interview on 05/07/19 at 02:13 PM, LPN #4 stated that any staff member who notices a resident is wet should report it to a nurse or CNA or change her. It is the job of all staff members to take care of a resident in need. The housekeeper should have reported to someone that Resident #2 was wet, and any nursing staff member could have changed her. During an interview on 05/07/19 at 02:34 PM, Registered Nurse Manager (RNM) #3 stated the CNAs have their own assignment and provide initial care to those residents. Once the initial care is done any staff member could have changed her. RNM #3 would have changed her if she saw her wet. This is not the norm in this facility, anyone could change them. All departments are taught if they see a resident in need, they should report it. Finding #3 The facility did not ensure the resident's right to privacy was protected in the resident dining room. Resident #4: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severely impaired cognition, could sometimes understand and could rarely or never make himself understood. During an observation on 05/07/19 at 9:06 AM, the Nurse Practitioner (NP) and Registered Nurse (RN) #2 entered the resident dining room to see the resident while he was being assisted to eat his breakfast. Residents at his table were also eating breakfast. The resident stopped eating for the NP to visually examine his eyes and face. After the NP finished her examination, she and the RN stood behind the resident's wheelchair in the dining room to discuss the resident's medical condition. The conversation could be overheard by others. During an interview on 05/07/19 at 3:09 PM, RN #2 stated the resident was in the dining room eating breakfast when the NP went to see him for redness to his left eye. She stated the resident should not have been seen by the NP in the dining room. She stated she should have removed the resident from the dining room for privacy. During an interview on 05/08/19 at 11:02 AM, the NP stated she went to see the resident for eye redness in the dining room yesterday. She stated she would not normally see residents in the dining room but due to limited time she did. She stated resident information should not have been discussed where it could be overheard by others. She stated she had not thought that seeing a resident in the dining room for a medical concern was a possible dignity issue. She stated she would be more mindful of seeing residents in private locations and would also be more mindful of where she was when discussing residents medical. Finding #4 The facility did not ensure that the resident was not being fed when the resident did not want to be fed. Resident #70: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Data ((MDS) dated [DATE], documented the resident had moderately impaired cognition, could usually understand others, and could sometimes make herself understood. During an observation on 5/08/19 at 9:15 AM, the resident was being fed breakfast by staff in a common area with other residents aroun. The resident was yelling out and coughing during the meal. During an observation on 5/06/19 at 12:30 PM, Resident #70 was being fed in the common area with the television on. The resident was yelling no and help. The Certified Nursing Aide (CNA) stated I am trying to help you, but you are yelling in my ear. The resident continued to yell no and help. The CNA continued to feed the resident fluids and solids. At 12:49 AM, the resident stated don't feed me anymore, I don't want anymore. The CNA continued to try to feed the resident. During an interview on 5/07/19 at 12:40 PM, CNA #5 stated the resident is able to tell you what she wants at meals. She stated the resident seemed tired today. During an interview on 5/08/19 at 11:52 AM, Registered Nurse (RN) #2 stated the resident can make her needs known. 10NYCRR415.3(c)(1)(i)

Based on observations, record review, and interviews during a recertification survey the facility did not ensure that it developed and implemented a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, for five Residents (# 33, 42, 70, & 91) of 22. Specifically: for Resident #33, the facility did not ensure that that her care plan for toileting was implemented and addressed the fact that she was continent, that Resident #42 had a care plan to address the different types of pain, that Resident # 70 &91's care plans for pain had interventions individualized for those residents . This is evidenced by: Resident #42: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact, able to make her understood and able to understand others. The Physician (MD) Orders dated 3/6/19, documented [MEDICATION NAME] 150 milligrams (mg) three times per day (tid) for [MEDICAL CONDITION] and [MEDICATION NAME] 72 hr, apply patch [MEDICATION NAME] every 72 hours for pain. The MD orders dated 3/18/19 documented [MEDICATION NAME] 4 mg tid for muscle spasms. The comprehensive care plan (CCP) titled Risk for pain related to [MEDICAL CONDITION], low back pain with history of back surgery, and history of knee replacement. On 3/16/19, the resident had complaints of muscle spasms and numbing of legs. Interventions included; monitor effectiveness of pain medication regime; monitor location, intensity, and duration of pain; administer warm packs and/or ice per PT recommendations. The care plan did not differentiate interventions given the three types of pain the resident experienced, neuropathic, bone and muscle cramping. During an interview on 05/06/19 at 10:55 AM, the resident stated that she had constant pain. She had neuropathic pain and was on 300 mg [MEDICATION NAME] twice per day for that. She stated she had a botched back surgery in the past couple years and it left her in constant pain to her low back and hips, she was awaiting a Orthopedic appointment to schedule another back surgery. She stated the nurses do not give her anything for pain when it gets bad. , During an interview on 05/08/19 at 10:00 AM, the Occupational Therapist stated that the resident's pain fluctuated day to day, some days the pain would be greater than other days. A couple of days she was unable to do therapy. She had neuropathic pain in her extremities that never got better, and she had back and hip pain. PT would give her moist heat treatments in therapy. During an interview on 05/09/19 at 12:45 PM, the Director of Nursing (DON) stated the staff should have been addressing her pain with or without meds. The Standing Medical Order for Tylenol could have been used for her pain. The [MEDICATION NAME] would not help with breakthrough pain, she would have needed something more. The staff could have used different options to make her comfortable. The care plan should address the residents different types of pain, and interventions to treat. Resident #33: The resident was admitted to the nursing home on 5/15/17 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having moderately impaired cognitive skills for daily decision making, and that she was not on a toileting program and frequently incontinent. It documented that the resident understood and was understood by others. During an interview on 5/06/19 at 9:47 AM, the resident stated she knew when she had to go to the bathroom, but she was sometimes incontinent if staff did not get there fast enough. Bedside Kardex documented toilet per toileting schedule, monitor for any pattern of incontinence and adjust toileting schedule as needed. During an interview on Certified Nursing Assistant (CNA) #8 stated that for the most part the resident knew when she had to go, and is usually continent. She is at times incontinent but does not think it is caused by not getting to the light they are usually quick to answer call bells. During an interview on 5/09/19 at 12:21 PM, the MDS Coordinator stated she was responsible for care planning and thought the resident lacked bladder tone and this made her incontinent at times; this should have been addressed in her care plan. They had not tried a bladder training program but should have because she was continent at times. During an interview on 05/08/19 04:06 PM the DON stated that the resident was continent at times and would sometimes ring to be toileted. They could not tell by the CNA documentation if the resident was being toileted per her care plan. They had talked to staff about documenting when the resident was toileted or changed; staff were having difficulty getting it done as they were moving right to the next person. Additionally, her CCP was not person centered; it should document that was continent when she wanted to be. Resident #91: The resident was admitted to the nursing home on 4/21/17 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having mod cognitive skills for daily decision making. It documented that the resident understood and was understood by others. A Comprehensive Care Plan for at risk for pain dated 4/21/17, documented administer medications per MD order; monitor for non-verbal signs and symptoms of pain i.e. grunting, moaning, restlessness, irritability and grimacing and monitor the location, intensity, and duration of the pain. On 5/2/19, the following interventions were added: use the pain scale; administer warm packs and /or ice per physical therapy recommendation and /or MD order. monitor the effectiveness of pain medication regime, monitor for changes in sleep patterns, decreased functional abilities, or resistance to care and utilize diversion techniques. During an interiew on 5/09/19 at 12:21 PM, the MDS Coordinator stated the pain care plan was not person centered to this resident. She did not think there was an order for [REDACTED]. 10NYCRR 415.11(c)(3)(i)

Based on observations, record review, and interviews during a recertification survey the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan (CCP), and the residents' goals and preferences, for three (Resident #'s 42, 70, and #91) of seven reviewed for pain. Specifically, for Resident #42, 70, and #91, the facility did not ensure that the resident's received adequate pain management. This is evidenced by: The Policy & Procedure titled Pain Management dated 8/2018 documented, it is the policy of the Nursing Home to provide adequate pain management to keep the residents as comfortable as possible. Each Resident each shift and with each pain medication pass will be asked to rate his/her pain according to the MDS pain rating scale. The response will be documented on the electronic Medication Administration Record (eMAR). Documentation for routine pain management needs to include the number from the scale. If resident has pain you need to re-approach 1/2 hour to 1 hour later documenting the effectiveness of the pain medication, using the MDS pain rating scale. Resident #42: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact, was able to make self understood and could understand others. It documented the resident had pain almost constantly, making it hard to sleep at night, and the pain intensity was 5 out of ten. The CCP titled Risk for pain related to (r/t) [MEDICAL CONDITION], low back pain with history of (h/o) back surgery, h/o knee replacement documented the following interventions; administer medications per MD order, warm packs and/or ice per PT recommendation and MD order, monitor effect of pain medication regime, monitor location, intensity, duration of pain, and offer snack or beverage as diversion to pain. The Pain assessment dated [DATE], documented [MEDICAL CONDITION] pain to the legs and back. The pain level was 6 out of 10. The best pain level was 4, and the worst pain level was 10. The Physician order [REDACTED]. Side lying wedge in bed for comfort and positioning. The MD orders dated 3/13/19, documented to change [MEDICATION NAME] to 300 mg twice per day (bid). The MD orders dated 4/12/19, documented to discontinue the [MEDICATION NAME]. The eMAR dated 3/2019, documented a Pain Scale routine every shift to monitor for pain. Pain levels documented: 03/9/19 - pain of 7 on the evening shift; 3/10/19 - pain of 5 on the evening shift; 3/15/19 - pain of 5 on the day shift; 3/16/19 - pain of 10 on the day shift. There was no documentation that the resident received any as needed pain (prn) medication for the pain levels. The eMAR dated 4/2019, documented a Pain scale routine every shift to monitor for pain. Pain levels documented: 4/15/19 - pain of 9 on the evening shift; 4/16/19 - pain of 7 on the evening shift; 4/17/19 - pain of 7 on the evening shift; 4/19/19 - pain of 5 on the evening shift; 4/20/19 - pain of 6 on the evening shift; 4/21/19 - pain of 5 on the evening shift; 4/25/19 - pain of 5 on the day and evening shift; 4/28/19 - pain of 10 on the evening shift; 4/30/19 - pain of 5 on the evening shift. There was no documentation that the resident received any as needed pain (prn) medication for the pain levels. The eMAR dated 5/2019 documented a Pain Scale routine every shift to monitor for pain. Pain levels documented: 5/3/19 pain of 5 on the evening shift; 5/4/19 pain of 7 on the evening shift; 5/7/19 pain of 5 on the day shift. There was no documentation that the resident received any as needed pain (prn) medication for the pain levels. The Physician's (MD) progress note dated 4/12/19, documented the resident was seen for follow-up to her [MEDICAL CONDITION] (damage or disease affecting peripheral nerves ([MEDICAL CONDITION]) in roughly the same areas on both sides of the body, featuring weakness, numbness, and burning pain), spinal stenosis, [MEDICAL CONDITION] and [MEDICAL CONDITION]. We will discontinue the patient's [MEDICATION NAME] (treats severe pain) at this time, and will continue her other chronic medications. The patient will be continued on [MEDICATION NAME] (used to treat pain caused by nerve damage due to diabetes, shingles ([MEDICAL CONDITION]) infection, or spinal cord injury, this drug works best when the amount of medicine in your body is kept at a constant level), patient has been seen by Orthopaedic surgery for [REDACTED]. During an interview on 05/06/19 at 10:55 AM, Resident #42 stated that she had constant pain. She had neuropathic pain and was on 300 mg [MEDICATION NAME] twice per day for that. She stated she had a botched back surgery in the past couple years and it left her in constant pain to her low back and hips, she was awaiting a Orthopedic appointment to schedule another back surgery. She stated the nurses do not give her anything for pain when it gets bad. , During an interview on 05/08/19 at 10:00 AM, the Occupational Therapist stated that the resident's pain fluctuated day to day, some days the pain would be greater than other days. A couple of days she was unable to do therapy. She had neuropathic pain in her extremities that never got better, and she had back and hip pain. PT would give her moist heat treatments in therapy. During an interview on 05/08/19 at 10:15 AM, Certified Nursing Assistant (CNA) #1 stated she is in pain more days than she is not. Sometimes her pain is so bad that I help her with total care, even though she is a limited assist. There are times she can have a good day. During an interview on 05/08/19 at 11:28 AM, the MD stated in my opinion her pain is under control. My last conversation with her she said she feels so much better. The resident came in with a [MEDICATION NAME] order and it was discontinued per the resident request, she did not like the way it made her feel. The nurses should be offering something when she has pain, or call the MD. The MD was not aware there were times of pain documented and nothing was done for her. During an interview on 05/08/19 at 11:28 AM, the Registered Nurse Manager (RNM) #3 stated when the resident complains of pain it is due to her behavior, she tends to exaggerate. She is on the [MEDICATION NAME] for her pain and that is effective. The therapy department provides hotpacks for her pain, she asked for one the other day. She does not have an order for [REDACTED]. During an interview on 05/09/19 at 08:25 AM, the Physical Therapist (PT) stated the resident would have intermittent pain during therapy and PT would do moist heat for her. Since she was discontinued from therapy the PT thinks her pain has increased due to immobility. I gave her a hot pack this past week, don't know what they do for her on the unit when she has pain. During an interview on 05/09/19 at 08:45 AM Licensed Practical Nurse (LPN) #4 stated the resident often says she has no pain, she is more needy of wanting things when her husband is here. If she did have pain I would check her meds and let the Nursing Supervisor know and the MD would be called. LPN did not know why pain was documented and nothing was given to the resident. The resident's husband came to me and requested a hot pack the other day and Physical Therapy came up with one. There are no interventions on the treatment record for her pain. During an interview on 05/09/19 at 12:45 PM, the Director of Nursing (DON) stated the staff should have been addressing her pain with or without meds. The Standing Medical Order for Tylenol could have been used for her pain. The [MEDICATION NAME] would not help with breakthrough pain, she would have needed something more. The staff could have used different options to make her comfortable. Resident #70: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Det ((MDS) dated [DATE], documented the resident had moderately impaired cognition, could usually understand others, and could sometimes make self understood. Observations during the following dates and times: On 5/07/19 at 8:59 AM, the resident was screaming ow during care. On 5/07/19 at 10:30 AM, the resident was lying in her bed yelling, help, who is out there? On 5/08/19 at 9:48 AM, the resident refused therapy, and stated to the Certified Nursing Assistant (CNA), I don't want therapy, I want to go to bed. Staff did not assist the resident to bed. On 5/08/19 at 9:51 AM, the resident was sitting in a geri chair in her room. The resident stated I want to go to bed, I feel like I'm going to vomit. A CNA offered the resident a bucket. The resident stated I don't feel good today, I feel sick to my stomach. Staff shut the door to the resident's room. The resident was heard yelling ow. A nurse entered the room to address the residents daughter and left the room. The resident's complaints of nausea and pain were not addressed. A CCP titled At risk for Pain dated 3/4/19, documented; medications as ordered by the MD, to monitor for non-verbal signs of pain i.e. restlessness, irritability, and grimacing, and monitor and document for probable cause of pain for each pain episode. It did not document that the resident had a [MEDICAL CONDITION]. A Pain Management questionnaire dated 5/3/19, documented that the resident reported a pain level of 7 out of 10 at the time of the questionnaire, and that at best the pain is a 3 and at worst the pain is an 8 out of 10. It documented that the current regime for pain was to administer [MEDICATION NAME] (narcotic pain medication) and that the administration of [MEDICATION NAME] was effective. A Medical Doctor's order dated 5/3/19, documented [MEDICATION NAME] 5 milligrams (mg)-325 mg one time order; give one by mouth one time only for pain. A Medication Administration Record (MAR) dated 5/3/19, documented that [MEDICATION NAME] 5/325 mg was administered at 9:32 AM for a pain level of 6. The MAR did not include a post pain level follow-up. A Progress Note dated 5/3/19, by the DON, stated the MD was notified of the resident's pain and that the one-time dose of [MEDICATION NAME] was effective. A new order was obtained for [MEDICATION NAME] 5/325 mg three times a day for pain. A New Orders/Changes sheet (a form the nurse documents MD orders that need to be checked for accuracy and implemented by a second nurse), dated 5/3/19, documented to discontinue Tylenol and add [MEDICATION NAME] 5/325 mg; 1 three times a day for pain. The eMAR from 5/3/19 - 5/7/19, documented an MD order for Tylenol 500 mg; one tablet three times a day. The eMAR did not include documentation for [MEDICATION NAME] 5/325 mg three times a day. During an interview on 5/08/19 at 10:30 AM, the Director of Physical Therapy stated the resident was having pain, and it was interfering with her progress in physical therapy. During a telephone interview on 5/08/19 at 11:09 AM, CNA #6 stated the resident always yelled. During an interview on 5/08/19 at 12:28 PM, the DON stated she did not know what happened with the resident's orders. They got the order last week, but it never showed up on the eMAR and no one picked up on it. Nurses were supposed to check orders to make sure they were correct and should have ensured the orders were on the MAR. During an interview on 05/09/19 10:48 AM, RN #1 stated she was not aware that the resident's orders were not entered on the MAR. The facility's system for importing orders was fairly new and there was no follow up check of the New Orders/Changes sheet to ensure that the nurse's were doing the second check and sending the orders to the MAR and Treatment Administration. Record (TAR). Resident #91: The resident was admitted to the nursing home on 4/21/17, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having mod cognitive skills for daily decision making. It documented that the resident understood and was understood by others. During an observation on 5/07/19 at 4:03 PM, the resident was yelling out for help from her room. When the surveyor entered the room the resident was lying on her back in bed. The resident was crying and holding her right lower back. The resident stated she was having back pain and had asked for pain medication, but they had not brought it to her yet. Within a minute, CNA #9 and CNA #10 entered the room. When the resident was crying, CNA #10 told her she would get her pain medication around 5:00 PM. CNA #9 stated to the resident that she could report it to the nurse if she wanted. The surveyor informed the CNA that she should report the resident's pain to the nurse. At 4:07 PM, CNA #9 came back into the resident's room after reporting the resident's pain to Licensed Practical Nurse #7. CNA #7 told the resident she could not have another pill until 5:00 PM, but they could sit her up. Review of the Medical Doctor (MD) orders documented the following: 10/17/17 - [MEDICATION NAME] (a narcotic pain medication 7.5/325 milligrams (mg); give one four times a day for low back pain; 09/28/17 - [MEDICATION NAME] HCL 4 mg; 1 daily as needed for muscle spasms. A Comprehensive Care Plan for At Risk for Pain dated 4/21/17, documented administer medications per MD order; monitor for non-verbal signs and symptoms of pain i.e. grunting, moaning, restlessness, irritability and grimacing and monitor the location, intensity, and duration of the pain. On 5/2/19, the following interventions were added; use the pain scale; administer warm packs and /or ice per physical therapy recommendation and /or MD order; monitor the effectiveness of pain medication regime; monitor for changes in sleep patterns; decreased functional abilities; or resistance to care and utilize diversion techniques. A Progress Note dated 4/1/19 at 6:09 AM, documented that the resident was throwing things, yelling and hit staff. When the LPN asked her why she was acting that way, the resident stated she was in pain. The pain level documented on the MAR for 4/1/19 at 6:00 AM, was 0. Review of the eMAR for the date of 5/7/19 at 6:00 PM, included documentation that the resident's pain level was 0. Review of the progress for the date of 5/7/18, did not inlude documentation that the resident was crying from pain. A Progress Note dated 5/6/19 at 10:35 AM, written by the Social Worker (SW) documented the resident reported that her back hurt and the SW reported it to the Nurse Manager. The progress notes did not include documentation that the resident had been assessed by a nurse or that non-pharmacological interventions were attempted to alleviate the resident's pain. The eMAR dated from 4/1/19 - 5/8/19 documented the resident received [MEDICATION NAME] on 152 occasions. Of the 152 occasions there were 23 occasions when the resident's pain level was between 5-10, and of those 23 occasions, 6 occasions were documented in the progress notes and on 22 occasions follow-up pain levels were documented. An MD annual progress notes dated 4/5/19, documented the only concern was that the resident continued to have back pain. The resident was in significant pain due to chronic back pain and the plan was to continue the resident's current chronic medications. During an interview on 5/07/19 a 04:05 PM, CNA #10 stated she knew the resident had a lot of pain and that the resident received medication for pain at 5:00 pm and a pain patch at night. During an interview on 5/07/19 a 04:07 PM, CNA #9 stated the resident cried in pain from her back everyday. During an interview on 5/08/19 at 10:42 AM, Licensed Practical Nurse (LPN) #7 stated she did not know what [DIAGNOSES REDACTED]. The resident will have behaviors and complain when she wanted to go to bed. She worked the day shift and it was not usual for her to ask for pain medication during the day. She did not feel she should have gone down to check the resident when CNA #9 reported the resident was complaining of pain because she was giving medications to other residents. She told the CNA to tell the resident she could get a pain pill at 5pm. During an interview on 5/08/19 at 11:07 AM, RN #1 stated that she expected the nurse to see the resident when she complained of pain. The nurse should have come in checked on the resident and an RN assessment should have been done. The resident did have chronic pain but would have behaviors when she wanted things immediately. There should be follow-up pain levels after pain medication is given and the MD should have been made aware the resident was experiencing increased pain. During an interview on 5/08/19 at 12:32 PM, the DON stated staff should have assessed the resident when she complained of pain. During an interview on 5/08/19 at 3:11 PM, the DON stated that they had not ever had an IDT meeting with the family, the MD and the IDT team to discuss dealing with the resident's pain. During an interview on 5/08/19 at 12:46 PM, the MD stated that staff should report the resident's pain to the nurse, the nurse should assess and document the pain. He was aware that the resident was having pain but the son who is the HCP, adamantly refused for the facility to give her any additional pain medications. 10NYCRR415.12

Based on observation, record review and interview during the recertification survey, the facility did not ensure a policy was developed regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Specifically, the facility did not ensure the policy for bringing food(s) in from outside of the facility included a process for assisting residents in accessing and consuming the food if a resident is unable to do so on his/her own and the facility did not provide information for family and visitors on safe food preparation and handling practices. This will be evidenced by: A Policy and Procedure (P&P) titled Bringing Food(s) in From Outside the Facility dated 10/2017, documented foods brought in by family memberes or guests will be reported to the Charge Nurse, who would notify Food and Nutrition Services (Diet Technician or responsible staff) for these foods to be received, appropriately stored, and added to the resident's daily menu if appropriate. The food would be stored in the kitchen with the resident's name and date it was received. The P&P did not include education to families on safe food handling and storage practices, and did not include information regarding residents that can't access and consume foods on his/her own. During an interview on 5/09/19 at 7:23 AM, the Dietetic Technician (DT) stated she is unsure of the process for foods brought to residents from home. During an interview on 5/09/19 at 7:35 AM, the Food Service Director (FSD) stated there is no education provided to families on safe food handling. 10NYCRR415.14(h)

Based on observation, record review and interviews during a recertification survey and an abbreviated survey (Case #NY 270) the facility did not ensure the resident's physician was consulted when there was a significant change in the resident's physical, mental, or psychosocial status and when there was a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for 1 (Resident #42) of 1 resident reviewed for infections. Specifically, for Resident #42, the facility did not ensure the physician was notified that the resident, with a recent history of [MEDICAL CONDITIONS] (a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon), was having frequent episodes of loose stools and rectal irritation. This is evidenced by: Resident #42: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact, was able to make self understood and could understand others. The Comprehensive Care Plan (CCP) titled At risk for skin breakdown due to decreased mobility, occasional oozing of bowel dated 3/6/19, documented interventions that included; treatments per MD (physician) orders, medications per MD orders, and to notify the MD of any changes. The CCP titled Resident at risk for decline in physical & medical status secondary to history of [MEDICAL CONDITION], resident had occasional loose stools dated 3/6/19, documented to notify the MD of any changes, and medications per MD order. The nursing admission note dated 3/6/19, documented that the resident had a past medical history that included diarrhea, [MEDICAL CONDITION], and a history of [MEDICAL CONDITION]. MD order dated 3/6/19, documented the resident was to receive [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME], treats diarrhea) 2.5-0.025 mg and to give 1 tablet every 24 hours as needed for diarrhea (loose stools). MD order dated 5/4/19, documented the resident was to receive [MEDICATION NAME] (anti-diarrheal) 2 mg every 6 hours as needed for loose stools. The (MONTH) 2019 bowel movement (BM) record that Certified Nurse Aide's (CNA's) used to document resident bowel movements included documentation the resident had loose/diarrhea BM's on seven occasions (3/15/19, 3/16/19, 3/18/19, 3/19/19, 3/21/19 and 2 times on 3/25/19). The Medication Administration Record [REDACTED]. The CNA BM record dated (MONTH) 2019 documented the resident had 12 episodes of loose/diarrhea BM's (4/4/19, 4/12/19, 4/14/19, 4/15/19, 4/16/19, 4/20/19, 4/21/19, 4/22/19, 4/26/19, 4/28/19, 4/29/19, and 4/30/19). The MAR indicated [REDACTED]. The CNA BM record dated (MONTH) 2019 documented the resident had 9 episodes of loose/diarrhea BM (5/1/19, 5/3/19, 3 times on 5/4/19 and 2 times on 5/5/19). The MAR indicated [REDACTED]. The resident received [MEDICATION NAME] on one occasion (5/4/19). A nursing progress note dated 5/3/19 at 10:07 PM, written by a Registered Nurse, documented the resident had loose stools 5 times that shift. The resident was complaining of rectal discomfort and had tiny openings around the rectum from irritation. [MEDICATION NAME] lotion was put on the area. Review of the Treatment Administration Record (TAR) dated 5/2019, did not include documentation for the treatment to or monitoring of the resident's rectal area. Review of the nursing progress notes from 3/6/19 thru 5/7/19, did not include documentation that the resident's MD was notified the resident was having loose stools. Review of the MD notes dated from 3/6/19 thru 5/7/19, did not include documentation that the MD was aware the resident was having loose stools. During an interview on 5/6/19 at 10:30 AM, Resident #42 stated that prior to coming to the nursing home, she was in the hospital and treated for [REDACTED]. The diarrhea started a few weeks after admission and had recently become much worse. She stated the nurses had not taken a sample of her stool for testing. During an interview on 5/08/19 at 11:28 AM, the MD stated he was not aware the resident had frequent episodes of diarrhea. He stated he should have been notified by the nurses and stated with the resident's recent history of [MEDICAL CONDITION], the resident should probably be tested for [MEDICAL CONDITION]. During an interview on 5/08/19 at 11:31 AM the Registered Nurse Manager #3 stated that frequent loose stools had not been reported to her, She was not sure the resident was really having loose stools. She stated she saw one the other day that the resident said it was diarrhea and there was a small spot on the diaper. She stated the resident exaggerates and was told the nurses need to see the BMs. During an interview on 5/09/19 at 08:45 AM, LPN #4 stated on Saturday her husband came to the nursing station and asked for [MEDICATION NAME] for loose stools. The resident reported loose stools and the nurses did not always see them. LPN did not know if the MD had been notified. She did not know about the open areas to the rectum. The LPN stated the MD should have been notified of the loose stools and the sore rectum. During an interview on 5/09/19 at 09:00 AM, CNA #1 stated the resident had frequent diarrhea BMs. The CNA stated sometimes there was so much diarrhea that it traveled up her back. The CNA's reported it to the nurses. The resident's rectum was very sore, but was better. During an interview on 5/09/19 at 12:45 PM, the Director of Nursing stated she was not aware the resident was having loose stools and had a history of [REDACTED]. 10NYCRR 415.3(e)(2)(ii)(b)

Based on record review and interviews during a recertification survey, the facility did not ensure the residents and/or resident representatives were provided with specific notification when the facility determined that the residents no longer qualified for Medicare Part A services and Medicare benefit days remained for 3 of 3 residents reviewed for Beneficiary Protection Notification. Specifically, for Resident #'s 59, 293, and #294, the facility did not ensure the residents or resident representatives were informed of the beneficiary's potential liability for payment and related standard claim appeal rights using the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), form CMS- . This is evidenced by: The facility was unable to provided documentation that the SNFABN was issued to the identified residents or the resident representatives. During an interview on 5/09/19 at 11:12 AM, Accounts Receivable #10 stated she was unable to find documentation that the SNFABN was issued for the identified residents. She stated she was not familiar with the SNFABN form and it had never been explained as to why the SNFABN had to be issued. During an interview on 5/09/19 at 12:57 PM, Accounts Receivable #11 stated her department would be responsible for issuing the notification, but the facility was not aware that the SNFABN was required. 10NYCRR 415.3 (g)

Based on record review, and interviews during a recertification survey the facility did not ensure that it addressed the resident's goals of care and treatment preferences. If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose, and update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities, for one (Resident #22) of two residents reviewed for discharge to the community. Specifically, for Resident #22, the facility did not ensure a referral was made to the appropriate entities when the resident stated she wanted to go home. This is evidenced by: Resident #22: The resident was admitted to the nursing home on 4/20/18, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having intact cognitive skills for daily decision making. It documented that the resident understood and was understood by others. Progress notes for the following dates documented: 4/25/19 - The Social Worker (SW) documented the resident had a bad day and was weepy. The resident stated she would like to go home. The resident missed her husband and pets. Will offer additional support. 2/12/19 - The SW documented that the resident had been weepy again about wanting to go home. 1/24/19 - The nurse documented that the resident was weepy again about issues with her daughter and wanting to go home. 1/14/19 - the resident was weepy stating she wanted to go home. 1/09/19 - the resident was still insisting she wanted to go home. 1/07/19 - the SW documented the resident has been very weepy lately. The resident was crying because she wanted to go home. The resident was reminded that she could not take care of herself both physically and medically. Her husband was also unable to care for her. The resident continued to be weepy stating she just wants to go home. During an interview on 5/06/19 at 10:11 AM, the resident stated she gets depressed because she wants to go home. During an interview on 5/07/19 at 10:28 AM, Certified Nursing Assistant (CNA) #11 stated the resident got weepy and stated she wanted to go home at times. CNA #11 stated that when this happens she informs the nurse. During an interview on 5/07/19 at 12:29 PM, the Social Worker (SW) stated the resident had verbalized quite often that she wanted to go home. The SW stated that a referral to Open Doors (an agency that assists residents to return to the community) had not been made but should have been. 10NYCRR 415.11 (d)(3)

Based on observation, record review and interview conducted during a recertification survey, the facility did not ensure that residents in need of respiratory care, received such care consistent with professional standards for 2 residents (Residents #59 and Resident #70) of 2 residents reviewed. Specifically: For Resident #59 and 70, the facility did not ensure a physician's order and indication for use was obtained for the administration of oxygen. This is evidenced by: The Facility Policy and Procedure (P&P) titled Physicians Routine Standing Orders, dated 2/2018, documented a Procedure for Limited Use Respiratory Standing Order for; Oxygen (02) 2-3 Liters (L) as needed (PRN) vial nasal cannula (NC) up to 5L/minute (min) PRN via mask. The Facility Policy and Procedure (P&P) titled Oxygen by Concentrator, dated 12/2013, documented a general instruction to adjust liter flow as ordered by the physician. Resident #59: The resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident's cognition was severely impaired. The resident usually understands others and usually make self understood. A physicians standing order dated 12/18/18, documented 02 at 2-3L/min PRN via nasal cannula (NC) up to 5L/min via mask every shift to maintain 02 Saturation (sats) Observations of Oxygen flow rates; 05/06/19 at 10:41 AM - 1.0 liter via NC, 05/06/19 at 11:59 AM - 1.5 liters via NC, 05/07/19 at 02:51 PM - 1.5 liters via NC, 05/08/19 at 07:32 AM - 1.5 liters via NC, 05/09/19 at 07:58 AM - 1.5 liters via NC. Nursing progress notes and physician orders did not include documention of the current oxygen flow rate of 1.5 liters, or that the physician was notified for an order to decrease in oxygen flow rate. Review of the Treatment Records (TARS) dated 4/1/19 through 5/7/19 documented the the residents oxygen saturations performed every shift ranged between 90% to 98%. During an interview on 5/08/19 at 7:32 AM, Licensed Practical Nurse (LPN) #4 stated the resident's oxygen flow rate was set at 1.5-liter NC. The resident had a limited use physicians standing order for 02 at 2-3L/min PRN via NC up to 5L/min via mask every shift to maintain 02 sat. The standing oxygen order was used for someone who was short of breath or their oxygen saturation fell below 90 (normal 95-100%). There should have been an order for [REDACTED]. During an interview on 5/08/19 at 11:33 AM, the Medical Director stated physicians standing orders should be used in an emergency and the resident should be seen by the physician at the next visit. There should be specific oxygen orders to address each resident's health status. During an interview on 5/09/19 at 7:43 AM, the Registered Nurse Unit Manager (RNUM) #3 stated the resident is on continuous oxygen. During an interview on 5/09/19 at 8:22 AM, the Director of Nursing (DON) stated the limited use, physicians standing order for oxygen is for short term use, and the resident should have had an updated physicians order for oxygen with an indication for use. Resident #70: The resident was readmitted to the facility on [DATE], after a post-acute hospital with a [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was unable to complete the cognition interview. The resident can sometimes makes self understood, and sometimes understands others. A physician's standing order dated 5/3/19, documented 02 at 2-3 L/min PRN via NC up to 5L/min via mask. During an observation on 5/07/19 at 3:33 PM, LPN #1 performed a room air 02 sat on the resident, which read 91% and replaced the resident's oxygen and LPN #1 stated the oxygen flow rate is set at 1-liter NC. During an observation on 5/07/19 at 4:00 PM, the resident's oxygen flow rate was set at 1 liter via NC. During an interview on 5/07/19 at 4:10 PM, RNUM #2 stated the resident came back from the hospital on [DATE] and they activated the physicians standing order for oxygen that documented 02, 2-3 L PRN NC up to 5L/min mask. She decreased the resident's 02 to 1 liter via NC yesterday and documented it in the progress notes that 02 sats were 94% on 1 liter and they would wean as the resident was able. She should have obtained an order for [REDACTED]. During an interview on 5/07/19 at 4:15 PM, Registered Nurse (RN) #4 stated the physician should have been notified and an order obtained for the oxygen with an indication for use. 10NYCRR415.12(k)(6)

Based on observation, manufacturer's directions review, and staff interview during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Chemicals used in food equipment sanitizing are to be at the correct concentration, food contact surfaces are to be cleaned after use, and non-food contact surfaces must be kept clean. Specifically, the concentration of quaternary ammonium compound chemical sanitizing rinse (QAC) was less than that required by the manufacturer, food contact equipment required cleaning, and non-food contact equipment was not clean. This is evidenced as follows. The kitchen was inspected on 05/06/2019 at 8:45 AM. The concentration of QAC used in the sanitizing rinse sink, and the third sink, was found to be at 0 parts per million (ppm) when measured at 70 degrees Fahrenheit (F). The manufacturer's label directions stated the concentration is to be between 150 ppm and 400 ppm when the solution is measured between 65 F and 75 F. The cutting boards on the storage rack under the food prep table were soiled with food debris, and the exhausted fan guards were covered in dust. The Dietary Director stated in an interview on 11/26/2018 at 9:40 AM, that the chemical sanitizer bottle that feeds the sanitizing sink was empty. The Dietary Director stated there would be a discussion with staff about proper cleaning procedures of the cutting boards and the exhaust fan guards. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.110, 14-1.112

Based on observation and staff interview during the recertification survey, carbon monoxide detection was not provided in accordance with adopted regulation. The International Fire Code, (YEAR) Edition Section 915 Carbon Monoxide Detection, requires carbon monoxide detection in all areas with gas operated equipment. Specifically, carbon monoxide detection was not installed in an area with gas fuel fired equipment. This is evidenced as follows. Observations on 05/07/2019 at 1:55 PM, revealed a fuel burning appliance in the kitchen and laundry rooms without a carbon monoxide detection device. The Plant Operations Director stated in an interview on 05/07/2019 at 2:05 PM, that he was unaware that it was a requirement to provide carbon monoxide detection in these areas. 483.70 (b); (YEAR) International Fire Code, Section 915

Based on record review, and interviews during the recertification survey, the facility did not ensure training was provided to their staff on dementia management and resident abuse prevention. Specifically, the facility did not ensure staff were educated on factors related to dementia care and abuse prevention, including conflict resolution, anger management skills, and identifying and addressing staff burnout, frustration, and stress. This is evidenced by: Review of an undated in-service titled Caring for Residents with Dementia provided by Registered Nurse (RN) #7 did not include information related to conflict resolution between staff and residents, visitor and resident, and resident to resident conflicts, anger management, and identifying and addressing staff burnout, frustration, and stress in staff. During an interview on 5/09/19 at 10:23 AM, RN #6 was not able to provide documentation that facility staff had received been educated on resolving conflicts, anger management skills, and identifying and addressing staff burnout, frustration, and stress in staff prior to survey exit. 10 NYCRR 415.49(b)

Based on interview and record review during a recertification survey the facility did not establish and maintain an infection prevention and control program (IPCP) designed to help prevent the development and transmission of communicable diseases and infection. Specifically, the facility did not develop and implement a Water Management Plan (WMP) in accordance with adopted regulations. This is evidenced as follows. A potable water WMP was not available for survey review. The Administrator and the Director of Plant Operations stated in an interview conducted on 01/24/2018 at 10:00 am, that a potable water WMP has not been developed. 10 NYCRR 483.80(a)(1)(2)(4)(e)(f)

Based on record review and staff interviews during the recertification survey the facility did not ensure that 1 (Resident #80) of 1 residents reviewed for restraints, maintained the right to be free from physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. This is evidenced by: Resident #80: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident to be rarely understood, rarely able to understand and severely impaired cognitive skills. The Facility policy titled, Restraints - Application of, last revised 7/2015, documented; No resident will be restrained except when authorized by the physician for a specific need and time period. Physical restraint ordered must include the: Conditions for use, and release per policy. A physician's orders [REDACTED]. Directions: No directions specified for order. The order did not document a specific need or time frame and did not include the conditions for use or release schedule. The Comprehensive Care Plan (CCP) documented the resident requires G/L with tray as needed for safety and positioning. Date initiated 1/9/18. The CCP did not document under what conditions or why the restraint would be used, for how long it could be left on, or how often it should be released while on. Progress Notes documented the restraint was used 3 times: 12/18/17 - Restless, trying to get out of bed, confused. Attempts to re-orient unsuccessful. In Geri-Lounger with tray table for safety per nursing judgment. 12/19/17 - Attempting to get out of Geri-Lounger which she was placed in for safety with tray. 12/22/17 -Restless and confused, trying to stand from wheelchair. Put into Geri-lounger with tray table for safety per nursing judgement. During an interview on 1/24/18 at 2:25 pm, the Director of Nursing (DON) reported there was no restraint consent and the CCP was incomplete. Both the physician's orders [REDACTED]. During an interview on 1/25/18 at 12:28 pm, Registered Nurse (RN) #1 reported staff should be documenting in the progress notes what was happening that resulted in needing the restraint, what they tried before using the restraint, how long the restraint was used, and the resident's response to the restraint. During an interview on 1/25/18 at 1:24 pm, the DON reported the Geri-lounger and tray were not being used, so the order was discontinued.

Based on observation, record review and interview during a recertification survey and abbreviated survey (Case #NY 473) the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice for 1 of 6 (Resident #336) residents reviewed for pain management. Specifically, Resident #336's complaint of pain was not addressed timely or adequately upon admission. This was evidenced by: Resident #336: The resident was admitted to the facility on [DATE], at approximately 2:00 pm, with the [DIAGNOSES REDACTED]. The resident was discharged to another facility on 4/5/17. Facility progress notes dated 3/30/17: 2:25 pm - A social worker documented the resident arrived about 2:00 pm and mentioned that his feet were hurting a lot, and I have passed this info to the floor. 2:57 pm - A occupational therapist documented the resident was alert, oriented and cooperative, currently with complaints of pain in lower extremities. Resident refused a standing activity stating a high pain level. There was no documentation of reporting or relieving the pain. 3:00 pm - A physical therapist documented the resident currently reports he is unable to stand or attempt to walk due to his extreme bilateral foot pain. There was no documentation regarding reporting or relieving the pain. The Pain Assessment Interview, documented a yes response to the questions: Resident had pain in the last 5 days; Making it hard to sleep; and limited day to day activity. Pain frequency was documented as almost constantly, severe with a pain rating of 7 out of 10. There was no date or time documented. The Omnicell (An automated dispensing cabinet that allows medications to be stored and dispensed near the point of care while controlling and tracking drug distribution), inventory documented all the medications that were stored within, to include [MEDICATION NAME] 5/325 mg. The Omnicell inventory did not include the 7.5/325 mg dose of [MEDICATION NAME]. The admission physician orders [REDACTED]. The physician order [REDACTED]. (MONTH) take [MEDICATION NAME] 5/325 mg from Omnicell now. The electronic Medication Administration Record [REDACTED]. The EMAR documented the first administration of pain medication was [MEDICATION NAME] 5/325 mg given 3/30/17 at 5:37 pm for a pain scale rating of 5 out of 10. There was no documentation of the effectiveness of the pain medication. The progress notes dated 3/30/17 had no documentation of the effectiveness of the pain medication administered at 5:37 pm or documentation of calling the physician and obtaining an order for [REDACTED]. The progress note dated 3/30/17 at 8:06 pm, written by the Registered Nurse Supervisor (RNS) #6 documented the resident was a demanding individual with little or no patience, demanding pain medication immediately to treat his foot and back pain, states has history of gout in both feet also in 2010 fell off a roof fracturing L1-L5 (lumbar spine). Alert and oriented and as noted very demanding and complaining individual. There was no documentation that the physician was notified of the continued pain. The progress note dated 3/30/17 at 10:28 pm, written by the Registered Nurse Supervisor (RNS) #6 documented, resident wants better pain control, I asked resident to give me time to check this out and if necessary I will call the physician, resident was given another pill. Resident advised me earlier that he gets [MEDICATION NAME] every 6 hours at home for many years due to his back injury from a fall in 2010. The EMAR dated (MONTH) (YEAR) documented, [MEDICATION NAME] tablet 7.5/325 mg, give 1 tablet as needed (prn) for pain bid (twice per day). The EMAR documented a second dose of pain medication [MEDICATION NAME] 7.5/325 mg given at 10:28 pm on 3/30/17, for a pain scale rating of 5 out of 10. The effectiveness of the pain medication was documented as ineffective. The progress note dated 3/30/17 at 3:50 am, written by the RNS #8 documented, informed by resident's son via phone that the resident called him due to excruciating discomfort. Medicated at this hour with [MEDICATION NAME] 7.5/325 mg, repositioned for comfort as he wanted. The EMAR dated (MONTH) (YEAR) documented, [MEDICATION NAME] tablet 7.5/325 mg, give 1 tablet prn for pain bid. The EMAR documented a third dose of pain medication given at 4:24 am for a pain scale rating of 10:10. During an interview on 1/22/18 at 9:00 am, the social worker (SW) stated she would have reported Resident #336 complaints of pain immediately, but she did not remember who she reported it to, does not usually document the nurse. The SW stated she documented 2:00 pm as an approximate time which meant within 15 minutes of that time. During an interview on 1/22/18 at 9:25 am, the Registered Nurse Manager (RNM) stated Resident #336 was intubated while in the hospital and had been taken off his [MEDICATION NAME] medication for his gout. The RNM remembered talking to the resident about being back on his gout medication and that it would take some time to build up in his system and help to relieve his pain. The resident came in at the change of shift and the physician had to have been in the facility for the admission orders [REDACTED]. A new admission resident would have their standing orders of Tylenol to use before the pharmacy delivered their pain medications. The [MEDICATION NAME] 5/325 mg dose was ordered at 5:05 pm, to be taken from the Omnicell. There is no documentation of when the physician was called or when he returned the call to obtain an order for [REDACTED]. During an interview on 1/22/18 at 4:00 pm, the evening shift RNS stated that the process for giving pain medication to a new admission resident would be for the nurse to call the physician for an order. The nurse could also give Tylenol (treats minor aches and pains) from the Standing Medical Orders. The RNS stated the only thing I can think of is the resident did not want Tylenol. If they don't want the Tylenol we have to call the MD (medical doctor) for another order including an order to use the Omnicell drugs and that could take hours for the physician to call back. Generally the RNS will do the new admission paperwork and assessments the first thing on his shift. The RNS did not document the time that the assessments were completed and did not remember the time. During an interview on 1/22/18 at 4:30 pm, licensed practical nurse (LPN) #2 stated, when a new admission comes in and has pain, we call the MD and get an order for [REDACTED].>LPN #2 stated she remembered Resident #336 refused Tylenol from the Standing Medical Orders. If the nurse had to call the physician for an order of pain medication, sometimes it could take hours for the MD to call back. During an interview on 01/24/18 at 10:05 am, the occupational therapist (OT) stated he did not remember how he communicated Resident #336's pain to the nurses, but knows that he would have notified nursing right away. He documented the resident evaluations in the progress notes and the nurses would see that. It is a rule here that if a resident is in pain, nursing should be notified right away and OT stated he always did. During an interview on 01/24/18 at 02:56 pm, the Director of Nursing (DON) stated she did have a problem with the physician calling the nurses back in a timely manner. The DON had spoken to the physician and asked him to call nursing in a more timely manner. The DON stated that recently, the physician calling back had been much better. Nurses should be writing the times they speak to MD and or take orders off. Should be doc the times they do assessments.

Based on record review and interview during the recertification survey, the facility did not ensure a policy was developed for the monthly medication regimen review (MRR) that included time frames for the different steps in the process. During an interview on 1/25/18 at 2:15 pm, the Director of Nursing (DON) reported she did not have a facility policy for MRR, only one from Omnicare (pharmacy) and upon review, it does not address time frames or the facility staff's steps in the process.

Based on observation, record review and interview during the standard recertification survey, the facility did not provide each resident with sufficient fluid intake to maintain proper hydration and health for one (#66) of seven residents reviewed for hydration/dehydration. Specifically, the facility did not ensure there was a specific plan to address Resident #66's inadequate fluid intake, and did not ensure effective monitoring to identify the resident's inadequate fluid intake for 4/2015 and 5/2015. Subsequently, the resident was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. Resident #66 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set of 5/28/15 assessed that the resident had moderately impaired cognitive ability for decision making. The Policy and Procedure (P&P) for Monitoring of Fluids, with a revision date of 7/2012, documented that each shift was responsible for monitoring the intake of each resident on the 24 Hour Intake and Output (I&O) record. If the resident's intake was below 1200 milliliters (ml) for more than two consecutive days, the resident was to be offered extra fluids frequently throughout each shift. If the resident's intake was below 1200 ml for three consecutive days, an order was to be written from the Standing Orders for a Basic Metabolic Panel (BMP, a set of blood tests). A Comprehensive Care Plan (CCP) was initiated 11/21/14 for at risk for dehydration and electrolyte imbalance secondary to abnormal laboratory tests from 11/7/14. The care planned goals were that electrolytes would be within normal limits; the resident would be free of signs and symptoms of dehydration (poor skin turgor, dry lips) daily; the resident would consume at least 2075 ml of fluid daily. The Approaches/Plan included: provide the resident with preferred beverages; monitor for sudden lethargy, confusion, agitation; monitor skin turgor and mucous membranes; schedule and monitor labs; encourage the resident to drink adequate fluids; I&O (intake and output). The Admission Nutritional assessment dated [DATE], documented minimal nutritional needs for fluids (based on 25 to 30 cc per kilogram of body weight) as 2075 to 2490 cc per day. The 30 Day Nutritional Update dated 3/14/15, documented the average amount of fluids daily for the previous five days was approximately 1248 cc per day. The required fluid intake needs remained at 2075-2490 cc per day. The Update documented the resident needed continual encouragement to drink. There was no documented change to the CCP at that time to address the suboptimal fluid intake. On 3/19/15 the CCP for Dehydration Risk was updated to document labs as follows: BUN (blood urea nitrogen- a measure of kidney function) = 24 and elevated; Creatinine (another measure of kidney function) =1.39 and elevated; Sodium (an electrolyte) = 145 and normal; Chloride (an electrolyte) = 111 and elevated. The seven day fluid average was low at 1300 cc per day. A Physician's Note dated 4/17/15 documented that the nurses had reported that there was no change in the resident's overall medical condition and the resident remained medically stable. The physician reviewed the resident's CCP which was appropriate and was to continue to be followed. A Nurses Note dated 5/3/15 at 7:12 pm, documented that the resident's appetite was poor and he required encouragement to drink. The undated Risk Assessment Profile documented that from 5/12/15 through 5/18/15, the resident's oral fluid intake was fair at 50%. The facility I&O records for April and May 2015 documented that the resident's fluid intake in cc per day for each of the following times periods were: 4/1/15- 4/7/15 =1708 cc 4/8/15-4/14/15 =1580 cc 4/15/15- 4/21/15= 1508 cc 4/22/15-4/28/15 =1119 cc 4/29/15 -5/5/15 = 1264 cc 5/6/15- 5/12/15 =1290 cc 5/13/15 - 5/20/15 = 1260 cc 5/21/15 - 5/26/15= 798 cc There was no documentation in the resident record that the physician had been notified that the resdient was not reaching his daily fluid intake goal. The Quarterly Nutritional Update dated 5/13/15 documented the average amount of fluids daily for the past 7 days was low at 1290 cc per day and that the resident needed at least 2075 cc per day. It was written in that staff were aware to encourage fluids. The Update documented that the resident had a history of [REDACTED]. There was no documented change to the CCP to address the resident's suboptimal fluid intake. On 5/13/15 the CCP was updated to document labs on 5/4/15 as follows: BUN = 31 and elevated (normal value 7 to 18); Creatinine = 1.49 and elevated (normal value 0.5 to 1.5); Chloride = 109 and elevated (normal value 98 to 108). The seven day fluid average was documented as low at 1300 cc per day. It was also documented that the resident had a history of [REDACTED]. On 5/15/15, the CCP was updated to continue with the plan of care. There were no changes made to the plan of care to address suboptimal fluid intake. A Physician's Note dated 5/20/15 documented that the nurses had reported that there was no change in the resident's overall medical condition and the resident remained medically stable. The physician's review of the resident's CCP documented that it was appropriate and was to continue to be followed. There was no documentation in the resident record of signs or symptoms of dehydration. A Nurses Note dated 5/26/15 at 10:47 am, documented that the resident was weak and lethargic, and required much encouragement to lift his head and open his mouth for medications. After medications were given, the resident let the medications run out of his mouth. There was no documentation that the physician was notified. A Nurses Note dated 5/26/15 at 4:06 pm, documented that the resident had increased lethargy. His skin was pale in color, warm and dry. The physician was notified and blood tests were ordered. A Nurses Note dated 5/26/15 at 7:49 pm, documented that the resident was lethargic but responsive. He would not open his mouth for dinner and could not stay upright. The nurse received an order to obtain a urine sample from the resident for testing. A Nurses Note dated 5/26/15 at 9:19 pm, documented that a urine sample was obtained from the resident, and his urine was dark amber in color. A Nurses Note dated 5/27/15 at 3:35 am, documented that fluids were encouraged but the resident did not drink them. A Nurses Note dated 5/27/15 at at 8:48 am, documented that the resident was lethargic, had a poor appetite, and his urine was dark and cloudy. A Nurses Note dated 5/27/15 at 6:09 pm, documented that the physician was notified of the resident's abnormal lab results and his [MEDICAL CONDITION]. The physician ordered to start an intravenous (IV) infusion of [MEDICATION NAME] 5% with 1/2 Normal Saline (D51/2) at 100 ml (milliliters) per hour and repeat a BMP in 48 hours. There were multiple attempts to establish a peripheral IV site without success. The physician was made aware that an IV site could not be established and the physician gave an order to send the resident to the hospital for evaluation. A Nurses Note dated 5/27/15, documented that the hospital had called to notify the facility that the resident had been admitted with [DIAGNOSES REDACTED]. A Hospital Discharge Summary dated 5/30/15, documented that the resident arrived at the hospital severely lethargic and had severely dry oral mucosa with diminished skin turgor and skin tenting. Laboratory values documented that the resident's blood tests were: sodium = 154 (normal value 136 to 145); chloride = 118; BUN = 51, and Creatinine = 1.5. In the emergency department the resident received 1.5 liters of normal saline to treat the dehydration and [MEDICAL CONDITION]. The Physician's Impression was documented as altered mental status and lethargy secondary to dehydration and [MEDICAL CONDITION]. The Hospital Course section of the Hospital Discharge Summary documented that the resident's urine had a specific gravity of 1.030 (normal value 1.000 to 1.030) and a urine osmolality of 913 (normal value 500 to 800), which were appropriate responses to dehydration with urinary concentration, which indicated that the resident did not have essential or [DIAGNOSES REDACTED] insipidus (form of diabetes insipidus primarily due to pathology of the kidney). During an observation on 7/21/15 at 8:06 am, Licensed Practical Nurse (LPN) #1 attempted to give this resident his medications. The resident allowed the liquid to run out of his mouth onto his clothing. After continued encouragement, the resident drank all of the fluid containing a medication. During an interview on 7/22/15 at 7:57 am, the Certified Dietary Manager (CDM) stated that she was responsible for reviewing the resident's fluid intake on a quarterly basis, and that the Inservice Director was supposed to monitor the intake more frequently. During an interview on 7/22/15 at 8:38 am, the Director of Nursing (DON) stated that at the end of each shift the LPN and/or the Registered Nurse (RN) were supposed to look at the I&O sheets. If a resident had poor intake the nurse was to look back to see how long it had been poor. The P&P was that if fluid intake was less than 1200 ml for three days, the physician was to be notified and a BMP was to be obtained. The DON reviewed the resident record and stated that the Registered Dietician (RD) had documented that this resident was to receive 2075 ml of fluid each day, and that this resident was known since his admission to be difficult to get him to drink. She stated that the resident could be choosey about what he did and did not want to do, and that he had poor dentition. The DON reviewed the resident's fluid intakes for 4/2015 and 5/2015 and stated that his poor overall fluid intake probably lead to his hospitalization for dehydration on 5/27/15. She stated that there should have been care plan changes on 5/13/15 when the RD documented that the resident's average amount of fluids daily for the previous seven (7) days was low at 1290 cc per day. Nursing did not identify the poor fluid intake because they had followed the P&P and the resident did not have three consecutive days of less than 1200 ml until the days prior to his hospitalization . During an interview on 7/22/15 at 9:22 am, the Registered Nurse Manager (RNM) stated that it was very difficult to get this resident to drink. The P&P was that if a resident drank less than 1200 ml for three (3) consecutive days, that constituted poor fluid intake, and the nursing staff followed the P&P. During an interview on 7/22/15 at 10:40 am, the Medical Director, who was also this resident's physician, stated that this resident's longstanding fluid intake deficit contributed to the resident being admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. During an interview on 7/22/15 at 2:50 pm, the CDM stated that this resident was not a good drinker and that she was aware of this resident's low intake. She stated that in 5/2015, she had communicated with the nursing staff that they needed to encourage this resident to drink. During an interview on 7/22/15 at 2:50 pm, the RD stated that she was aware that this resident was not a good drinker. She reviewed the fluid intake for 4/2015 and 5/2015 and stated that his fluid needs for those months had not been met. She stated that both she and the CDM reviewed I&Os, and that nursing staff usually informed them if there was a significant decline in a resident's food and/or fluid intake. If the nursing staff had informed them of this resident's low fluid intake, the CDM would then review the I&Os. She stated that they (the RD and the CDM) did not review I&Os on a weekly basis. She stated that there were other interventions, like always giving the resident his medications with fluids such as Med Pass (a supplemental dietary drink) instead of pudding or applesauce, that could have been implemented in the resident's plan of care but were not. The RD stated that this resident's low fluid intake in 4/2015 and 5/2015 contributed to him being admitted to the hospital with [REDACTED]. 10NYCRR 415.12(j)

Based on medical record review and staff interviews during complaint investigation (#NY 246) the facility did not ensure that two (2) (Residents' #1 and #2) of five (5) residents reviewed received the necessary care and services to maintain the highest practicable physical well-being in accordance with the individualized plan of care. Specifically, Resident #1 care card documented the need for leg rests on her wheelchair. Om 10/18/14, Resident #1 was assisted by Certified Nurses Assistant #1 (CNA #1) from the dining room in her wheelchair, however, the leg rests were not on the wheelchair and Resident #1's left leg became caught under the wheelchair. Resident #1 responded in pain however; the accident went unreported. Resident #1 reported pain to at least three more CNAs during the following 12 hours. The resident was not assessed by a Registered Nurse until she was found crying in pain on 10/19/14. Resident #1 was diagnosed with [REDACTED]. This resulted in actual harm that is not immediate jeopardy. Resident #2 was observed without his care planned leg rest on his wheelchair. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This is evidenced by: Resident #1 Resident #1 was readmitted to the facility on ,[DATE]//14 diagnosed with [REDACTED]. Resident #1's Brief Mini Mental Status (BIMS) dated 6/9/14 assessed the resident with moderate cognitive impairment. Resident #1's care card for October 2014 documented that the resident was non-ambulatory and required adaptive equipment including a wheelchair with bilateral leg rests. Accident/Incident Report dated 10/19/14 at 7:30 am documented that Resident #1 was noted with a large bruise with swelling and pain on the left anterior shin area and the resident is crying out in pain. Nurse's Note were reviewed and there are no nurses notes from 10/14/14 until 10/19/2014 at 10:22 am. Nurse's note dated 10/19/14 at 10:22 am documented that Resident #1 was given Tylenol 650 milligram (mg) at 7:30 am for complaint of left shin pain. Nurse's note dated 10/19/14 at 10:25 am signed by RN #1, documented that during morning care, Resident #1 was noted with a large purple bruise and swelling in the left shin area. The area was very painful to touch or with movement, the physician was contacted and an x-ray of the tibula/fibula was obtained. X-ray report dated 10/19/14 documented Resident #1 with a spiral type mid to distal tibia fracture and a proximal fibular fracture is noted, the latter about the knee. Nurse's note dated 10/19/14 at 11:29 am, documented confirmation based on the x-ray of a fractured tibula/fibula and an Orthopedic consult was ordered. In a statement prepared for the facility investigation dated 10/19/14, CNA #1 documented that she pushed Resident #1 out of the dining area, her left leg got caught under the wheelchair but Resident #1 did not scream in pain and CNA #1 did not notice any bruising. In a statement prepared for the facility investigation dated 10/19/14, CNA #2 documented that she was the CNA assigned to Resident #1 for the 3:00 pm - 11:00 pm shift. CNA #2 documented that after dinner, Resident #1 was complaining of pain in her leg. CNA #2 documented that she reported to Licensed Practical Nurse #1 (LPN #1) that the resident was "acting out more than usual about her leg" and LPN #1 responded with "okay." CNA #2 documented later in the shift, during a transfer into bed, Resident #1 was still saying that her leg was bothering her and during care Resident #1 stated that her leg hurt. In a statement prepared for the facility investigation dated 10/19/14, LPN #1 documented that CNA #2 reported that Resident #1's leg was bothering her. LPN #1 documented that he told CNA #2 to let the supervisor know. In a statement prepared for the facility investigation dated 10/19/14, CNA #4 assigned to the 11:00 pm - 7:00 am shift documented that during rounds Resident #1 was complaining of left leg pain. CNA #4 documented that she reported Resident #1's complaint to LPN #2. In a follow-up statement prepared for the facility investigation dated 10/20/14, CNA #2 documented that on 10/18/14 she and CNA #3 assisted the resident from bed to her wheelchair, the resident refused her leg rests as she usually did, so CNA #2 left the leg rests off. CNA #2 documented that she usually applies the leg rests before transporting the resident to the dining area. CNA #2 documented that she did not transport the resident to the dining area that day. In a follow-up statement prepared for the facility investigation dated 10/20/14, CNA #1 documented that she did not notice leg rests on Resident #1's wheelchair. In a statement prepared for the facility investigation dated 10/20/14, LPN #2 documented that at no point during the 11:00 pm - 7:00 am shift was she notified that Resident #1 had a complaint of pain. During an interview on 11/3/14 at 9:00 am with the Director of Nursing (DON) and the Administrator, the DON stated that she was contacted at home on 10/19/14 with a report of a possible injury of unknown origin to Resident #1. The DON stated that she instructed the nursing supervisor to begin an investigation and learned that the resident had a confirmed tibula/fibula fracture. The DON stated that the investigation revealed that on 10/18/14 CNA #1 did not report an incident in which Resident #1's leg became stuck under her wheelchair. Resident #1 continued to complain of pain to the CNAs on the 3:00 pm - 11:00 pm and the 11:00 pm - 7:00 am shifts, despite the aides allegedly reporting to the LPNs, the resident was not assessed by an RN. The DON stated that Resident #1 did not receive pain medication nor was her complaint of pain assessed until 10/19/14 at about 7:30 am. The DON stated that staff have been disciplined and all staff have been reeducated on abuse, neglect and mistreatment reporting as well as the need to report resident refusals immediately. During an interview on 11/3/14 at 2:00 pm, CNA #1 stated that she doesn't work at the facility often but was familiar with Resident #1. CNA #1 stated that she was not assigned to Resident #1 on 10/18/14 but did assist her from the dining room when Resident #1's foot became stuck under her wheelchair. CNA #1 stated that Resident #1 said "ouch" and CNA #1 asked if she was okay, to which Resident #1 responded "yes". CNA #1 stated she did not think to report the incident. During an interview on 12/4/14 at 2:10 pm, CNA #2 stated that she was assigned to Resident #1 on 10/18/14. CNA #2 stated that she assisted Resident #1 into her wheelchair from bed and Resident #1 wanted to watch television in her room and did not want the legs rests to the wheelchair on while in her room. CNA #2 stated that this is a routine for Resident #1 and that she did not report to anyone that Resident #1 was refusing her leg rest because Resident #1 would use them once out of her room. CNA #2 stated that on 10/18/14, she did not assist Resident #1 to the dining room and is not aware of who did. CNA #2 stated that when she entered Resident #1's room after dinner, Resident #1 complained of leg pain. CNA #2 stated that she reported the Resident's leg pain to LPN #1 at that time. CNA #2 stated that later in the evening, she and CNA #3 transferred Resident #1 to bed when she screamed in pain. CNA #2 stated that she went back to LPN #1 and explained that she understood that Resident #1 is known to have some anxiety but Resident #1 was acting much differently. During an interview on 12/4/14 at 3:30 pm, CNA #4 stated that she is routinely assigned to Resident #1 and at approximately 12:00 am on 10/19/14, she assisted Resident #1 who was complaining of pain in her leg. CNA #4 stated "I knew right away that something was different about Resident #1's complaint of pain." CNA #4 stated that she reported Resident #1's complaint to LPN #2 but is not sure what action LPN #2 took at that time. CNA #4 stated later in the shift, she overheard Resident #1 expressing pain to LPN #2, but again, CNA #4 was not sure how LPN #2 responded to Resident #1. During an interview on 12/4/14 at 4:00 pm, LPN #2 stated that at no time did anyone report that Resident #1 complained of pain. LPN #2 stated that she applied a treatment to the resident at approximately 5:15 am but Resident #1 did not complain of pain at that time. During an interview on 12/8/14 at 10:30 am, LPN #1 stated that CNA #2 had advised him of Resident #1's pain, however, he was in the middle of his medication pass, assumed Resident #1 was just anxious, and told CNA #2 to tell the supervisor. During a follow-up interview on 12/17/14 at 3:30 pm, the DON stated that not all resident's require leg rests when being moved about in a wheelchair and typically the registered nurse (RN) will make the recommendation. The DON stated that the RN will add the need for leg rests to the residents care card to communicate the need to CNAs. Resident #2 This resident was admitted to the facility on [DATE] diagnosed with [REDACTED]. Resident #2's Brief Mini Mental Status (BIMS) dated 9/10/14 assessed the resident with moderate cognitive impairment. Resident #2's care card last updated October 2014 documented that when Resident #2 was non-ambulatory, Resident #2 required adaptive equipment including a wheelchair with right side leg rest. Observation on 11/3/14 at 11:20 am Resident #2 watching television seated in his wheelchair. There was no leg rest on the right side of the Resident #2's wheelchair. During an interview on 11/3/14 at 11:25 am, CNA #5 stated she routinely assists Resident #2 and was asked if Resident #2 required a leg rest on his wheelchair. CNA #5 stated that Resident #2 did not. CNA #5 reviewed Resident #2's care card, noted the need for a right leg rest, stated she was unaware of it and immediately looked about Resident #2's room. CNA #5 located a leg rest in the top, back of Resident #2's closet. 10NYCRR 415.12

Based on medical record review and staff interviews during a complaint investigation (Case # NY 383), it was determined that the facility did not ensure that a resident who enters the facility without pressure sores, does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable. Specifically, the facility did not ensure for one (Resident #1) of two residents reviewed, that adequate interventions were put in place to prevent breakdown of the resident's heels after the resident was assessed by a registered nurse during the week of 12/30/11 -1/5/12 to be "at risk" for developing pressure ulcers. On 2/8/12, the resident's left heel was noted to have a Stage II pressure ulcer which progressed to a Stage III area on 3/15/12. This was actual harm that is not immediate jeopardy. This is evidenced by the following: The Lippincott Nursing Center Web page defines staging in pressure ulcers on the heel "A Stage I Pressure Ulcer on the heel appears red, generally nonblanchable, and is often painful. This injury has the potential to recover if off-loaded continuously. A Stage II heel Pressure Ulcer often appears as a blister or a shallow skin tear, whereas a full-thickness (Stage III-IV) pressure ulcer appears open and deeper. A heel pressure ulcer caused by friction generally appears red and often is blistered from friction to tissue." In the "Pressure Ulcer Prevention Quick Reference Guide" the National Pressure Ulcer Advisory Panel (NPUAP) documents, "...ensure that the heels are free from the surface of the bed...use a pillow under the calves so that the heels are elevated (i.e. free floating). NPUAP extended guidelines advise that "Pillows are appropriate for short-term use in alert and cooperative individuals. Heel suspension devices may be preferable for long-term use or with individuals who are not likely to keep their legs on the pillows. Boot selection should be based upon the individual's clinical condition, the plan of care, the individual's tolerance of the device, and the manufacturer's guidelines." Resident #1 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having severe cognitive impairment. The MDS also assessed that the resident required extensive assistance for bed mobility. A facility form titled "Pressure Ulcer Potential Assessment" documented during the week 12/30/11-1/5/12 that the resident was assessed to be a number "11" for pressure ulcer risk. The key on this form documented that a score of 10-18 places the resident at "moderate risk" for developing pressure ulcers. On the reverse side of this form, a checkmark is placed next to additional pieces of equipment to be used on the resident for pressure ulcer prevention. There is one checkmark in the " moderate risk list of equipment next to " side lying wedge." There are a number of pressure relieving heel protectors are listed (prompting the care planner), they are not checked. A review of the at risk for skin breakdown section of Resident #1's care plan revealed that " pillow under heels in bed is written in the " approach/plan" column. There is no date for this intervention. On 2/14/12, gel heel float boots for the left heel only was added to the care plan. A review of the Resident #1's resident care flow sheet ( the form that instructs certified nursing assistants on what specific care each resident requires) for January and February 2012 revealed that CNA's were instructed to place a " pillow under (the resident's) heels in bed. " (Note: the form does not instruct staff to " float " or " off-load " the heels.) An addition of a gel heel float boot was made on 2/14/12 to the left foot only, one week after the resident's Stage II heel ulcer was discovered on 2/8/12. On the flow sheet dated April 2012 the confusing instructions for the CNA's read as follows, "Foam boots off for care only with gripper bottoms. " Dates next to this entry are 4/1/12 and 4/6/12 (with nothing crossed off). Written under those instructions, " L gel float boot with gripper off for care only, changed 4/9/12 " and under that instruction, " bilateral gelfloat boots with gripper in bed changed 4/9/12. " Nothing is crossed out to indicate that one boot has replaced the other and it is difficult to determinel what the current instructions are. Nurse's notes chronicle the progression of the pressure ulcer. A nurse's notes dated 2/8/12 documented a Stage II pressure ulcer was found on the resident's left heel during hygiene rounds. There was no drainage and the pressure ulcer measures 1.4 X 1.7cm and treatment was initiated. On 2/14/12, a nurses note documented that the resident's heel pressure ulcer was assessed and measured 1.6 X 1.8 cm with no depth or drainage. The surrounding tissue is pink and wound bed is brown and dry. The author goes on to document, "she continues to have foot elevated off bed with pillow but removes it at times. Will issue gel heel float boot plus." A note dated 2/21/12 documented the wound is unstageable, measuring 1.6 X 1.8 cm with a small amount of bloody drainage. On 2/28/12 the wound is measured at 2.5 X 2.7cm and the treatment is changed due to the worsening condition of the wound. On 3/6/12 the wound is measured at 1.6 X 1.6cm with yellow drainage and on 3/13/12 the author writes the skin team assessed the resident and the heel wound is larger and measured 2.0 X 2.0 cm with a moderate amount of brown drainage with slight odor. The doctor is aware of the worsening condition of the wound and ordered a wound care evaluation. Documentation on Resident # 1's wound care flow sheet describes the left heel ulcer on 2/8/12 as a Stage II with measurements of 1.4 X 1.7cm with wound bed red and dry, no pain and adaptive equipment listed as a pressure relieving mattress, side turning wedge and pillow under heels, on 2/1412 the wound is described as unstageable, measured to be 1.6 X 1.8cm, wound bed brown, painful to touch, progress of wound called slightly larger and adaptive equipment described as " the same " (as 2/8/12); on 2/21/12 again the wound is described as a unstageable, measured at 1.6 X 1.8cm, wound bed brown/softer, painful to touch, progress is noted as no change and adaptive equipment the same; on 2/28/12 the wound is described as " pressure unstageable " measured 2.5 X 2.7cm, wound bed brown painful to touch, progress "worse" and adaptive equipment described as pressure reduction mattress, side lying wedge and pillow under heels; 3/6/12 the wound is described as a Stage II, measures 1.6 X 1.6cm wound bed brown, painful to touch, adaptive equipment the same and improved. There is no entry for 3/13/12. On 3/15/12 a wound care specialist physician writes on his consult that the resident has a Stage III pressure ulcer on the left heel. Peripheral pulses are not palpable; doppler signals are absent; very loose necrotic eschar was removed. During an interview on 4/10/12 at approximately 4:30pm the Registered Nurse Manager (RNM) stated that the resident was admitted on [DATE] and at that time there were no skin integrity issues. In January and early February she was care-planned to have a pillow placed under her heels. On occasion she would kick the pillow out. There were boots available in the facility but a gel boot was not added to the resident's care plan until after the PU developed and it appeared to be worsening. During an interview on 4/10/12 at approximately 4:00pm a CNA#1 stated that she had cared for Resident # 1 a number of times and when the resident was in bed, she would place a pillow under the resident's heels because that's what was written on the care plan. CNA #1 stated that the resident didn't always leave the pillow in place and at times would kick the pillow out. The CNA did not recall there being any other protective device used on the residents heels until after the resident developed a pressure ulcer on the heel. The NYSDOH surveyor took two pillows off of Resident # 1's bed and a pillow off of the resident's roommates bed. The surveyor placed an arm across each of the pillows, applying minimum pressure. Each of the pillows flattened out and could not support the surveyors arm off of the mattress. 10 NYCRR 415.12(c) (1)(2)