Every finding on record at Wesley Health Care Center Inc

Based on record review and interviews during survey, the facility failed to ensure that resident records were complete and accurately documented for one (Resident #6) of nine residents reviewed for resident-identifiable information. Specifically, Resident #6 had a suprapubic catheter (a hollow flexible tube that is used to drain urine from the bladder through a cut in the abdomen), and was ordered to have urine output recorded every shift. The output was not consistently documented in March through June of 2026. Findings include:A facility policy titled Urinary Catheter Policy, effective date 10/27/2025, documented that during emptying the urine drainage bags, staff should note the amount of urine in the bag and report and record the quantity and quality of the urine in the resident's chart. Additionally documented under emptying of urine leg bag was note the amount of urine in the bag and if accurate measurement of urine was needed, to use a graduated container, and report quantity and quality of urine to staff nurse. A facility policy titled Clinical Care Documentation Policy, effective date 8/12/2025, documented the electronic chart was a means of communicating exact information among those caring for the resident. It was a permanent record and a legal document that was admissible in court, therefore, it must always be up-to-date and accurate. Resident #6 Resident #6 was admitted with the diagnoses of urinary tract infection (an infection caused by bacteria in the urinary system), obstructive and reflux uropathy (structural or functional blockage of urine flow causing urine to back up into the kidneys leading to swelling and potential kidney damage), Alzheimer's disease (a progressive neurological disorder that gradually destroys memory, thinking skills, and the ability to carry out simple daily tasks), and severe protein-calorie malnutrition (a life-threatening condition caused by a severe, prolonged deficiency of nutrients, primarily protein). The Minimum Data Set (an assessment tool) dated 3/11/2026 documented the resident was sometimes able to be understood, sometimes was able to understand others, and was so significantly cognitively compromised they were unable to complete the assessment. The Treatment Administration Record for March 2026 documented the resident was to receive toileting assistance and document their output every shift. There was no documentation of toileting assistance or output amounts on the following dates and shifts: Day shift (7 AM to 3 PM) on 3/08/2026, 3/09/2026, 3/15/2026, and 3/24/2026.Evening shift (3 PM to 11 PM) on 3/05/2026, 3/12/2026, 3/13/2026, 3/16/2026, 3/17/2026, 3/20/2026, 3/25/2026, 3/27/2026, 3/29/2026, 3/30/2026, and 3/31/2026.Night shift (11 PM to 7 AM) on 3/08/2026, 3/10/2026, 3/14/2026, 3/15/2026, 3/17/2026, 3/28/2026, and 3/31/2026. The Treatment Administration Record for April 2026 documented the resident was to receive toileting assistance and document their output every shift. There was no documentation of toileting assistance or output amounts on the following dates and shifts: Day shift (7 AM to 3 PM) on 4/02/2026, 4/03/2026, 4/05/2026, 4/06/2026, 4/10/2026, 4/14/2026, 4/15/2026, and 4/25/2026.Evening shift (3 PM to 11 PM) on 4/02/2026, 4/04/2026, 4/05/2026, 4/06/2026, 4/13/2026, 4/14/2026, 4/23/2026, 4/24/2026, and 4/26/2026.Night shift (11 PM to 7 AM) on 4/10/2026, 4/18/2026, and 4/30/2026. The Treatment Administration Record for May 2026 documented the resident was to receive toileting assistance and document their output every shift. There was no documentation of toileting assistance or output amounts on the following dates and shifts: Day shift (7 AM to 3 PM) on 5/01/2026, 5/03/2026, and 5/21/2026.Evening shift (3 PM to 11 PM) on 5/03/2026, 5/08/2026, and 5/17/2026.Night shift (11 PM to 7 AM) on 5/23/2026, 5/24/2026, 5/26/2026, 5/28/2026, and 5/31/2026. The Treatment Administration Record for June 2026 documented the resident was to receive toileting assistance and document their output every shift. There was no documentation of toileting assistance or output amounts on the following dates and shifts:Day shift (7 AM to 3 PM) on 6/02/2026, 6/03/2026, 6/09/2026, and 6/15/2026.Evening shift (3 PM to 11 PM) on 6/13/2026, and 6/18/2026.Night shift (11 PM to 7 AM) on 6/02/2026, and 6/19/2026. During an interview on 6/30/2026 at 10:34 AM, Certified Nurse Aide #2 stated they had handheld tablets on which they documented the tasks like emptying foley catheters. During an interview on 6/30/2026 at 10:46 AM, Registered Nurse #3 stated Foley catheters were typically emptied with morning and evening care. The staff did make an agreement with the family that Resident #6 would have their bag emptied before lunch. Registered Nurse #3 stated that because Resident #6's family would only allow use of leg bag, the staff had to be educated that it needed to be emptied more often than the other bags. During an interview on 6/30/2026 at 12: 48 PM, Certified Nurse Aide #3 stated that they marked output on their tablet. They stated that sometimes tasks did not get documented until the end of the day, at the end of their shift, but they always made sure they documented before they went home. When asked what missing marks on the records would mean, Certified Nurse Aide #3 stated that if it was not documented it meant it probably was not done. During an interview on 6/30/2026 at 12:51 PM, Registered Nurse #4 stated that blank documentation or missing documentation would mean that it was not documented or was not done. If the treatment administration records or medication administration records were blank, that meant that it was not done or was not documented that it was done. When asked if little to no output had occurred, would the documentation be noted or blank, Registered Nurse #4 stated that it would have been documented as zero not be blank. During an interview on 7/01/2026 at 11:17 AM, Director of Nursing #1 stated if intake and/or output was ordered to be monitored by the provider, it should have been documented that it was done. Registered Nurses were responsible for checking to see that the documentation was done. If it was not marked, it likely was not done. The facility had been working on improving their documentation issues. 10 New York Code of Rules and Regulations 483.70 (h)(1)

Based on observations, interviews, and record reviews conducted during survey, the facility failed to ensure residents' right to be free from abuse. Specifically, between 06/29/2025 and 06/14/2026, staff witnessed and documented Residents #1, 3, 5 and 10 verbally and/or physically abusing other residents but did not take action to prevent residents from further abuse. This resulted in actual harm (psychosocial and physical) to Resident #4 that was Immediate Jeopardy and had likelihood to place other vulnerable residents at risk for serious harm, serious injury, serious impairment, or death. Findings include:The facility policy titled Resident Abuse Prevention Policy and Procedure effective 06/02/2022 and last updated 07/01/2025, documented all employees will report suspicion of or actual occurrences of resident abuse committed by anyone. Additionally, the policy defines verbal abuse as, including any action that creates fear or psychological harm for the resident, examples include a threatening tone of voice, angry gesture, or any action that creates fear, intimidation, or humiliation. Resident #1 was admitted to the facility with diagnoses of Alzheimer's disease (a progressive, irreversible brain disorder impacting memory and cognitive skills), generalized anxiety disorder (a mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life), and dementia (loss of cognitive abilities, such as thinking, remembering, and reasoning severe enough to interfere with daily life). The Minimum Data Set (a resident assessment tool) dated 06/25/2025 documented that the resident could be understood, could understand others, and had severe cognitive impairment for decisions of daily living.A progress note dated 07/14/2025 documented Resident #1 was having a verbal altercation with another (unidentified) resident and they began hitting each other. Resident #1's Comprehensive Care Plans included, potential to abuse others, was initiated on 02/24/2025 with interventions including; assist to set realistic goals, explore sources of dissatisfaction or agitation, offer diversional activities, and provide positive feedback. The care plan was updated on 07/14/2025 to include the interventions; keep away from resident (unidentified resident initials) and resident (unidentified resident initials), and behavior charting every shift.There was no documented evidence of behavior charting being completed every shift. Resident #3 was admitted to the facility with diagnoses of anxiety disorder (a group of mental health conditions characterized by excessive fear, worry, or apprehension that is persistent, difficult to control, and interferes with daily functioning), major depressive disorder (a mood disorder characterized by persistent sadness, loss of interest or pleasure, and a range of emotional, cognitive, and physical symptoms), and dementia. The Minimum Data Set, dated [DATE], documented the resident could be understood, could usually understand others, and had intact cognition for decisions of daily living.A Progress Note dated 07/13/2025 documented Resident #3 grabbed Resident #4's arm, exposed themselves, made sexually explicit comments, and blocked Resident #4's path of travel. Resident #3's Comprehensive Care Plan included potential to abuse others related to behavioral changes due to dementia, initiated 02/26/2025, with interventions including: assist to set realistic goals, offer diversional activities, provide with positive feedback, and provide verbal and physical cues as needed. The Care Plan was updated on 07/16/2025 to include, evaluate medication regime, explore sources of dissatisfaction or agitation, provide positive feedback, and notify medical provider of changes in mood or behavior.Resident #3's Comprehensive Care Plan included I have behaviors of antagonizing peers, yelling at staff, initiated 02/27/2025, with goal of my behaviors that cause distress to self or others will be reduced through the review date. The Care Plan was updated on 07/14/2025 to include interventions of, will not display sexually inappropriate behaviors in residential shared spaces. Will respect other residents use of shared spaces by not engaging in inappropriate social sexual conversations in shared areas.There was no documented evidence of measures taken, including care plan updates with person-centered interventions aimed at preventing further recurrences. Resident #4 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe), diverticulosis (a condition characterized by the formation of small pouches in the colon), and generalized anxiety disorder. The Minimum Data Set, dated [DATE], documented the resident could be understood, could understand others, and had intact cognition for decisions of daily living.A progress note dated 07/05/2025 documented Resident #4 was involved in an altercation with Resident #10 (Resident #10 attempted to push Resident #4 out of the chair) which resulted in Resident #4 having bruises and red marks on both arms.Progress notes 07/06/2025 and 07/07/2025 documented Resident #4 was scared and had anxiety after the incident, had requested anti-anxiety medication, reported difficulty sleeping, appeared anxious and reported racing thoughts.There was no documented evidence of medical provider notification or of the incident being investigated by the facility, resident assessments being completed after the incident, or measures taken, including care plan updates with person-centered interventions aimed at preventing further recurrences.Resident #5 was admitted to the facility with diagnoses of Parkinson's disease (a progressive disease of the nervous system), anxiety disorder, and major depressive disorder. The Minimum Data Set, dated [DATE], documented the resident usually could be understood, usually could understand others, and had severe cognitive impairment for decisions of daily living. Resident #5's Comprehensive Care Plan included potential to abuse others, initiated on 03/05/2025 with interventions including; assist to set realistic goals, explore sources of dissatisfaction or agitation, and maintain personal space. The Care Plan was updated on 07/14/2025 to include the interventions; keep separated from residents (two unidentified resident initials) and tap bell in dining room for safety and comfort.A Progress Note dated 06/14/2026 documented Resident #5 was yelling and telling other residents that they were going to kill them. There was no documented evidence of medical provider notification or of the incident being investigated by the facility, resident assessments being completed after the incident, or measures taken, including care plan updates with person-centered interventions aimed at preventing further recurrences. Resident #10 was admitted to the facility with diagnoses of dementia with severe agitation, anxiety disorder, and adult failure to thrive (a condition characterized by a substantial decline in overall health and functional abilities). The Minimum Data Set, dated [DATE], documented the resident could sometimes be understood and could sometimes understand others, and had severe cognitive impairment for decisions of daily living.Resident #10's Comprehensive Care Plans included, psychosocial well-being risk/problem related to history of agitation and being combative during care or when being redirected; language barrier with inability to utilize/understand virtual translator initiated on 03/12/2025. Some of the interventions listed were to discuss hobbies and passions, include in activities that support psychosocial needs.A progress note dated 06/11/2025 documented Resident #10 was extremely agitated and walking around the unit banging on the tables and chairs, was also in the dining room attempting to flip multiple tables. Staff were able to distract for a short period of time, but the resident continued to show signs of aggression. As needed medication was given, but the resident did not calm down until two hours later.A progress note dated 06/24/2025 documented Resident #10 was in another resident's room, dis-robing and attempting to get into another resident's bed. Resident #10 became physically abusive with staff, punching, pinching, and yelling. Other residents were found to be alarmed and were moved into the dining room. Progress note documented Resident is most agitated at this time of the day. Resident was given medications with little resolve.A progress note dated 06/29/2025 documented Resident #10 was in Resident #11's bathroom while they were toileting. Resident #10 was combative and would not leave.Care plan was updated on 08/18/2025 potential to abuse others with interventions including, explore sources of dissatisfaction or agitation, maintain personal space, offer diversional activities, and provide verbal and physical cues as needed.A Progress Note dated 11/02/2025 documented Resident #10 was in the hallway without pants, verbally taunting and frightening other (unidentified) residents. Several residents appeared visibly upset.There was no documented evidence of medical provider notification or of the incident being investigated by the facility, resident assessments being completed after the incident, or measures taken, including care plan updates with person-centered interventions aimed at preventing further recurrences. During an interview on 06/29/2026 at 12:15 PM, Nurse Practitioner #1 stated that Resident #1 had incidents of slapping other residents. They could not recall specifically when the incidents occurred. During an interview on 06/29/2026 at 12:15 PM, Director of Nursing #1 stated that Resident #1 was known to be very violent towards other residents. During an interview on 06/30/2026 at 1:55 PM, Registered Nurse #2 stated incident reports were not made if the incident was not severe, such as involving a hospital visit or physical injury, but they still documented the incident in the resident's chart.During an interview on 07/01/2026 at 11:17 AM, Director of Nursing #1 stated the policy for reporting incidents that involve verbal altercations was that a report was made when a resident was visibly upset or expressed emotional distress after the altercation.During an interview on 07/02/2026 at 11:58 AM, Licensed Practical Nurse #2 stated Resident #4 appeared very distraught and was fearful of being harassed again by Resident #3 after the incident on 07/13/2025. Licensed Practical Nurse #2 stated that Resident #4 had been targeted by Resident #3 on more than one occasion and that Resident #4 stated they no longer have any peace. During an interview on 07/09/2026 at 11:15 AM Registered Nurse #1 stated that Resident #10 did not speak English and was unable to use the translator due to cognitive deficits. Staff that speak Spanish say the resident speaks mostly gibberish and non-sensical words.During an interview on 07/09/2026 at 12:35 PM and 3:30 PM, Administrator #1 stated the staff should report incidents of possible abuse, including verbal abuse, to the supervisor. The supervisor should start an investigation and then report to Administrator #1 or Director of Nursing #1, who would then report to the Department of Health. Abuse that should be reported included verbal (swearing or threatening that affects the resident) or physical contact. Administrator #1 stated they were aware of multiple incidents of verbal abuse that were not reported. Administrator #1 stated they believed there have been so many incidents involving resident verbal altercations that staff had accepted it as normal baseline behavior and did not think of the altercations as abuse and therefore did not report or investigate the incidents. They stated that after the State Survey team arrived, the facility hired a consultant to help them address the issues and created a team to identify and address the problem.During an interview on 07/20/2026 at 1:44 PM, Medical Director #1 stated if residents were being verbally aggressive to other residents, in order to determine if it was abuse, it depended on the incident, what was being said, how it was said, and the mood they were in. Medical Director #1 stated, you need to analyze the situation and follow the protocol. If it was out of the normal, follow the protocol, separate them, report to higher up staff, New York State Department of Health, etcetera to take action. You cannot say every single incident should be treated the same. If the resident felt threatened, you would investigate and take action according to what happened during the incident and report it. Immediate Jeopardy was issued to the Administrator #1 on 07/13/2026.During an interview on 07/13/2026 at 8:05 PM, Administrator #1 stated that since 7:00 PM, they had Registered Nurse supervisors round every hour and would ask the Licensed Practical Nurses and Certified Nurse Aides if there were any agitated residents or any concerns from the staff if residents were escalating in their behaviors. Administrator #1 stated a resident roster for each unit would be generated to include high-risk residents with behaviors or altercation history and would be given to unit staff to be aware of the heightened awareness for those residents.On 07/14/2026, hourly rounding sheets were reviewed for the evening and night shift on 07/13/2026. Sheets did not document how many or which staff were interviewed. There were no problems documented on the rounding sheets.On 07/14/2026, progress notes for the evening and night shift on 07/13/2026 were reviewed and documented the following: Resident #5 was combative and yelling, Resident #22 was combative with staff and refusing care, and Resident #23 was wandering into other resident's rooms, placed on one-to-one supervision.During an interview on 07/14/2026 at 12:47 PM, Administrator #1 stated they were unaware of incidents documented in progress notes on 07/13/2026. Stated if a resident was care planned for them to be aggressive, the incident is not reported because it is their normal baseline.During an interview on 07/14/2026 at 1:50 PM, Director of Nursing #1 stated the nurse supervisor completed hourly rounds the previous night (07/13/2026) and should have spoken with all staff on each unit to determine if there were any behavioral issues.Progress notes for the evening and night shift on 07/13/2026 were reviewed with Director of Nursing #1. At the time of review, Director of Nursing #1 stated the surveyor-noted incidents were not captured on the rounding sheets and should have been.During an interview on 07/14/2026 at 4:59 PM, Administrator #1 stated facility staff would report up allegations of resident-to-resident abuse, regardless if it was repetitive or normalized.Facility Immediacy Removal Plan submitted on 07/14/2026 was approved.Immediate Jeopardy was lifted effective 07/16/2026. The facility's immediacy removal actions included the following: An additional certified nurse aide was added as a roamer to monitor the floor and specifically residents identified by surveyors (resident roster provided by surveyors).One registered nurse supervisor worked on Unit 2 Springs for added observation.A second registered nurse supervisor conducted hourly rounding on all units.The facility ceased admissions to Units 2 and 3 Springs until the facility reassessed all residents and their care plan interventions related to behaviors.As of 07/16/2026 at 6:30 AM, 337 staff (90%) received education on reporting suspected abuse, including resident to resident verbal abuse, and de-escalation techniques. The remaining employees to be educated upon arrival for their next shift. 10 New York Codes, Rules, and Regulations 415.4(b)(1)(i)

Based on record review and interviews during a survey, the facility failed to ensure alleged violations involving abuse, were reported immediately, but not later than two (2) hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to officials (including to the State Agency) for three (Residents #s 4, 5, and 10) of 10 residents reviewed for abuse. Specifically, on 07/05/2025, Resident #10 had a physical altercation with Resident #4, resulting in Resident # 4 having bruises; on 06/14/2026, Resident #5 threatened to kill other residents; and on 11/02/2025, Resident #10 was noted to taunt and threaten other residents causing distress. These incidents were not reported to the State Survey Agency.Findings include:Cross reference to F-600.The facility policy titled Resident Abuse Preventions Policy effective 06/02/2022, last reviewed 06/08/2026 documented, Alleged violations and injuries of unknown source: Must be reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Not later than 24 hours if the allegation does not involve abuse and does not result in serious bodily injury, to the administrator of the facility and to other officials (i.e., State Survey Agency and adult protective services) The policy defined the following: Physical Abuse: Includes, but is not limited to, hitting, slapping, pinching, kicking. It also includes controlling behavior through corporal punishment. And Verbal Abuse: Use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Includes any action that creates fear or psychological harm for the resident. Examples may include a threatening tone of voice, angry gesture, or any other action that creates fear, intimidation, or humiliation.A progress note dated 07/05/2025 documented Resident #4 was involved in an altercation with Resident #10 (Resident #10 attempted to push Resident #4 out of the chair) which resulted in Resident #4 having bruises and red marks on both arms.A progress note dated 11/02/2025 documented Resident #10 was in the hallway without pants, verbally taunting and frightening other (unidentified) residents. Several residents appeared visibly upset. A progress note dated 06/14/2026 documented Resident #5 was yelling and telling other residents that they were going to kill them.A review of the Internet Quality Improvement & Evaluation System (iQIES) revealed no facility submissions related to these incidents were received by the New York State Department of Health.During an interview on 06/30/2026 at 1:55 PM, Registered Nurse #2 stated incident reports were not made if the incident was not severe, such as involving a hospital visit or physical injury, but they still documented the incident in the resident's chart.During an interview on 07/01/2026 at 11:17 AM, Director of Nursing #1 stated the policy for reporting incidents that involve verbal altercations was that a report was made when a resident was visibly upset or expressed emotional distress after the altercation.During an interview on 07/09/2026 at 12:35 PM, Administrator #1 stated they were aware of multiple incidents of verbal abuse that were not reported. During an interview on 07/09/2026 at 3:30 PM, Administrator #1 stated they believed there had been so many incidents involving resident verbal altercations that staff have accepted it as normal baseline behavior and did not think of the altercations as abuse and therefore did not report the incidents.10 New York Codes, Rules, and Regulations 483.12(c)(1)(4)

Based on observation, record review, and interviews conducted during survey, the facility failed to ensure allegations of abuse were investigated for two (Resident #5, and 10) of two residents reviewed. Specifically, staff witnessed and documented in Progress Notes Resident #'s 5, and 10 verbally and/or physically abused other residents. There was no documented evidence of investigations of these incidents.Findings include:Cross reference to F-600.Facility Policy titled Investigation of Suspected Resident Abuse Neglect Mistreatment effective 06/08/2026, documented the facility would conduct a thorough investigation of allegations of abuse, suspected abuse, neglect, mistreatment, injuries of unknown origin. Reports of abuse were promptly and thoroughly investigated. The investigation was the process used to try to determine what happened. Designated facility personnel would begin the investigation immediately and a root cause investigation and analysis would be completed with gathered information given to the administration. The investigation would include who was involved, resident statements and roommate statements if applicable, involved staff and witness statements, description of resident behavior and environment at the time of incident. A resident assessment by a registered nurse for possible physical and psychosocial harm, observation of resident and staff behaviors during the investigation, and environmental considerations.Resident #5:Resident #5 was admitted to the facility with diagnoses of Parkinson's disease (a progressive disease of the nervous system), anxiety disorder (a group of mental health conditions characterized by excessive fear, worry, or apprehension that is persistent, difficult to control, and interferes with daily functioning), and major depressive disorder. The Minimum Data Set, dated [DATE], documented the resident usually could be understood, usually could understand others and had severe cognitive impairment for decisions of daily living.A progress note 06/14/2026 documented Resident #5 was yelling and telling other residents that they were going to kill them.Resident #10:Resident #10 was admitted to the facility with diagnoses of dementia, anxiety disorder, and adult failure to thrive (a condition characterized by a substantial decline in overall health and functional abilities). The Minimum Data Set, dated [DATE], documented the resident could sometimes be understood and could sometimes understand others, and had severe cognitive impairment for decisions of daily living.A progress note dated 06/29/2025 documented Resident #10 was in another resident's bathroom while they were toileting, they were combative and would not leave.A progress note dated 07/05/2025 documented Resident #10 was witnessed by facility staff to attempt to push Resident #4 out of their wheelchair. A progress note dated 11/02/2025 documented Resident #10 was ambulating in the hallway without pants, verbally taunting and frightening other residents, several residents appeared visibly upset.There was no evidence of incident reports or investigations conducted for any of the incidents documented.Interviews:During an interview on 06/30/2026 at 1:55 PM, Registered Nurse #2 stated incident reports were not made if the incident was not severe, such as involving a hospital visit or physical injury, but they still documented the incident in the resident's chart.During an interview on 07/01/2026 at 11:17 AM, Director of Nursing #1 stated the policy for reporting incidents that involve verbal altercations was that a report was made when a resident was visibly upset or expressed emotional distress after the altercation.Director of Nursing #1 stated if an incident is not reported (an incident report completed), then most likely it was not investigated.During an interview on 07/09/2026 at 12:35 PM, Administrator #1 stated the staff should report incidents of possible abuse, including verbal abuse to the supervisor, the supervisor should start investigation and report to Administrator or Director of Nursing, who would then report to the Department of Health. Abuse that should be reported includes verbal (swearing or threatening that affects the resident(s) or physical contact. Administrator #1 stated they were aware of multiple incidents of verbal abuse that were not reported. Administrator #1 stated they believed there have been so many incidents involving resident verbal altercations that staff had accepted it as normal baseline behavior and did not think of the altercations as abuse and therefore did not report or investigate the incidents. New York Codes, Rules and Regulations 483.12(c)(2 - 4)

Based on observations, record review, and interviews during the Recertification Survey, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. Specifically, (a) the facility had an outbreak of COVID 19 that started 7/11/2024 and continued through the survey with 174 (6 admitted w/Covid) resident positives and 100 staff positives and positive residents located in all units throughout the facility; during this time the facility kept COVID negative roommates in the same room with COVID positive roommates, specifically Resident #627 was left in the room with Resident #266 when they were COVID positive, Resident #73 was left in the room with Resident #66 when they were COVID positive, and Resident #55 was left in the room with Resident #265 when they were COVID positive. Resident #627, Resident #73, and Resident #55 all became COVID positive after being left in the room with positive roommates. (b) Doors to COVID positive rooms were kept open with a plastic barricade in front of the door to restrict access. In addition, (c) mechanical lifts were contaminated on 2 Springs, 3 Springs, and 5 Springs units. This is evidenced by: The facility policy titled Infection Control Plan, last revised 11/15/2022, documented that all equipment and surfaces are cleaned and decontaminated after contact with blood or potentially infectious material and when surfaces are overtly contaminated. It further documented that Transmission Based Precautions would be initiated when a resident has a communicable infectious disease. Reusable equipment that is visibly contaminated is not used for the care of another resident until it has been cleaned and disinfected properly. Enhanced Droplet Precautions documented that a private room for infected residents if available, if not cohort the resident with another resident with the same single infection. The door is kept closed and the resident remains in the room. Centers for Medicare and Medicaid Services QSO-20-39-NH, revised 5/8/2023 documented that face coverings were to be used in accordance with CDC guidelines, effective appropriate staff use of personal protective equipment per CDC guidelines, and the core principles that are consistent with CDC guidelines should be adhered to at all times (bold/underlined in QSO). CDC's Infection Control Guidance: SARS-CoV-2 website stated, When used solely for source control, any of the options listed above could be used for an entire shift unless they become soiled, damaged, or hard to breathe through. If they are used during the care of patient for which a NIOSH Approved respirator or facemask is indicated for personal protective equipment (PPE) (e.g., NIOSH Approved particulate respirators with N95 filters or higher during the care of a patient with SARS-CoV-2 infection, facemask during a surgical procedure or during care of a patient on Droplet Precautions), they should be removed and discarded after the patient care encounter and a new one should be donned. Found at the following website: https://www.cdc.gov/covid/hcp/infection-control/index.html. State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities (Rev. 225; Issued 08-08-2024) documents that the infection prevention and control plan must follow accepted national standards and guidelines; it further documents that facilities must implement appropriate use of transmission-based precautions. It documented that a facility should take the appropriate steps to diagnose and manage cases, implement appropriate precautions, and prevent further transmission of the disease. Mechanisms to prevent and control transmission of infectious organisms through direct and indirect contact include standard and transmission-based precautions; for droplet precautions the resident should be placed in a private room, but if a private room was not available, the resident could be cohorted with a resident with the same infectious agent. Resources are available for current recommendations on standard and transmission-based precautions, such as: Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007) https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html . (a) Resident #627 and Resident #266 Resident #266 was admitted with diagnoses of diabetes, high cholesterol and hip fracture; the Minimum Data Set (an assessment tool), dated 10/03/2024, documented that the resident had moderately impaired cognition. Resident #627 was admitted with diagnoses of diabetes, high cholesterol and hip fracture. The Minimum Data Set, dated dated [DATE], documented that the resident was cognitively intact. According to the facility line list, Resident #266 tested positive for COVID on 10/21/2024. Resident #627 was negative for COVID on 10/21/2024, but remained in the same room with Resident #266 and Resident #627 became COVID positive on 10/28/2024. Resident #73 and Resident #66 Resident #66 was admitted with diagnoses of dementia, anxiety, and depression. The Minimum Data Set, dated dated dated [DATE], documented that the resident had severely impaired cognition. Resident #73 was admitted with diagnoses of dementia, depression, and high blood pressure.The Minimum Data Set, dated dated dated [DATE], documented that the resident had severely impaired cognition. According to the facility line list, Resident #66 tested positive for COVID on 11/01/2024. Resident #73 was negative for COVID on 11/01/2024, but remained in the same room with Resident #66 and Resident #73 became COVID positive on 11/05/2024. Resident #55 and Resident #265 Resident #265 was admitted with diagnoses of high blood pressure, diabetes, and dementia.The Minimum Data Set, dated dated dated [DATE], documented that the resident had moderately impaired cognition. Resident #55 was admitted with diagnosis of high blood pressure, dementia, and depression; the Minimum Data Set, dated dated dated [DATE], documented that the resident had severely impaired cognition and could not complete the test. According to the facility line list, Resident #265 tested positive for COVID on 10/30/2024. Resident #55 was negative for COVID on 10/30/2024, but remained in the same room with Resident #265 and Resident #55 became COVID positive on 11/01/2024. During an interview on 11/12/2024 at 3:17 PM, the Infection Preventionist stated that COVID negative roommates were left in the room with COVID positive roommates because they were already exposed to COVID. (b) An observation on 11/13/2024 at 9:39 AM revealed a sign on the ground floor of the Springs Building in front of the elevator that stated masks were required for all staff and visitors. An observation on 3 Springs unit on 11/12/2024 at 11:20 AM revealed that the door to room [ROOM NUMBER] was open and had a COVID sign on a plastic barricade in front of the door, the resident in the room was COVID positive; the door to room [ROOM NUMBER] was open and had a COVID sign on the plastic barricade in front of the door, the resident in the room was COVID positive. An observation on 5 Springs unit on 11/12/2024 at 11:30 AM revealed that the doors to the following rooms with COVID positive residents were open and a plastic barricade was in front of the door: room [ROOM NUMBER], 510, 513, 515, 521, and 523. (c) An observation on 2 Springs unit on 11/12/2024 at 1:47 PM revealed a mechanical lift with a cushion and chunks of unknown brown and yellow material approximately the size of a dime and fluid that appeared sticky and red on the mechanical lift stored between room [ROOM NUMBER] and 206. An observation on 2 Springs unit on 11/13/2024 at 9:41 AM revealed a clean linen storage bin that was uncovered and open. An observation on 2 Springs unit on 11/13/2024 at 10:02 AM revealed a gray mechanical lift observed the prior day in a different position with more chunks of unknown substance on the lift and the top to the cleaning wipes was open to the air. The lift was stored between rooms [ROOM NUMBERS]. An observation on 11/13/2024 at 10:04 AM revealed Certified Nurse Aide #3 walked into a resident room with the surgical mask below the nose; unable to interview the staff member. An observation on 11/13/2024 at 10:19 AM revealed the mechanical lift between room [ROOM NUMBER] and 320 on Springs unit 3 had visible dirt and red sticky substance on the lift and the floor in front of the lift. An observation and interview on 11/15/2024 at 9:54 AM revealed Licensed Practical Nurse #4 donning an N-95 with only 1 strap fastened and a surgical mask on top and entering a COVID isolation room; the nurse said they only had to change the surgical mask and not the N-95. An observation on 11/15/2024 at 10:24 AM revealed a newly placed infection control cart outside of room [ROOM NUMBER] [NAME] without signage to explain which transmission-based precaution. During an interview on 11/19/2024 at 8:15 AM, Infection Preventionist #1 stated that housekeeping was responsible for putting out carts of personal protective equipment and appropriate signage. They also said that staff that used the mechanical lift were responsible for cleaning the lift after each use and when visibly soiled. All staff should ensure the clean linen was covered at all times. Infection Preventionist #1 stated that N-95 masks should only be changed if wet or soiled and not changed after caring for a COVID positive resident, usually they were only changed after each shift, and that they recommended putting a surgical mask over the n-95 and changing that when caring for COVID positive residents. Infection Preventionist #1 stated they were not aware of the CDC guidance requiring removal of the N-95 after caring for a COVID positive resident. The Infection Preventionist stated that roommates of COVID positive residents were already exposed to COVID, so even if they test negative they leave them in the room with the COVID positive roommate and test the negative roommate on days 1, 3 and 5. For staff that test COVID positive at home, the staff member would then drive to the facility to test in the parking lot to confirm the positive result. During an interview on 11/19/2024 at 12:29 PM, Director of Nursing #1 stated that infection control was discussed at all meetings and Infection Preventionist #1 was responsible for following policies and procedures. New York Codes Rules and Regulations 415.19(a)(1-3)

Based on observation and interviews during the recertification survey, the facility did not ensure that food was stored, prepared, distributed, or served in accordance with professional standards for food service safety in 8 of 8 resident unit kitchenettes. Specifically, the area of the resident kitchenettes was not clean, and open containers were not appropriately labeled when they were opened. This is evidenced by: The facility policy titled Area and Equipment Cleaning revised January 2024 documented that the kitchen staff have procedures in place for daily and weekly cleaning of all areas and equipment and documenting on the equipment cleaning log and master cleaning schedule. During an observation on 11/15/2024 at 10:15 AM, the [NAME] 3 unit resident kitchenette toaster had food particles on the catch tray, the counters had food particles on them, the sink area had substance in the basin of the sink, and the microwave shelving unit had food particles on them. None of the areas were appropriately cleaned. Within the refrigerator, there were containers of milk, cranberry juice, and prune juice that were opened with no open date. During an observation on 11/15/2024 at 10:24 AM, the [NAME] 2 unit resident kitchenette juice and coffee machines were covered with dirt and grime and not appropriately cleaned. Within the refrigerator, there were containers of milk, cranberry juice, prune juice, and three containers of blueberries that were opened with no open date. During an observation on 11/15/2024 at 10:48 AM, the Springs 2 unit resident kitchenette juice machine, coffee machine, top of the resident refrigerator, and seals of the resident refrigerator were covered with dirt and grime and not appropriately cleaned. During an observation on 11/15/2024 at 11:00 AM, the Springs 3 unit resident kitchenette juice and coffee machines were covered with dirt and grime and not appropriately cleaned. The resident freezer had significant ice build-up and was not cleaned appropriately. During an observation on 11/15/2024 at 11:08 AM, the Springs 2 unit resident kitchenette juice and coffee machines were covered with dirt and grime and not appropriately cleaned. The resident freezer had significant ice build-up and was not cleaned appropriately. During an observation on 11/15/2024 at 11:21 AM, the [NAME] 2 unit resident kitchenette juice machine, coffee machine, counters, the top of the resident refrigerator, and seals of the freezer and refrigerator were covered with dirt and grime and not appropriately cleaned. Within the resident's refrigerator, a plate of food was not labeled or covered. During an observation on 11/15/2024 at 11:31 AM, the [NAME] 3 unit resident kitchenette juice machine, coffee machine, counters, the top of the resident refrigerator, and seals of the freezer and refrigerator were covered with dirt and grime and not appropriately cleaned. Within the refrigerator, there was a container of milk that was opened with no open date. During an observation on 11/15/2024 at 11:40 AM, the [NAME] 4 unit resident kitchenette juice machine, coffee machine, counters, the top of the resident refrigerator, and seals of the freezer and refrigerator were covered with dirt and grime and not appropriately cleaned. A review of dining room cleaning logs dated from 11/11/2024 through 11/17/2024 documented that all units were cleaned by staff assigned to that unit. Cleaning logs documented that the inside and tops of juice, ice, and coffee machines were checked off and cleaned by staff. During an interview on 11/15/2024 at 10:10 AM, Nutritional Services Manager #1 stated that the kitchenette food service staff should be cleaning the kitchenettes every day after meal service and signing off when done. They stated that a weekly deep cleaning was performed with audits conducted. In reviewing findings with the Nutritional Services Manager #1 they stated that they were not sure whether it was their responsibility or the housekeeping staff who clean the tops of the machines in the kitchenette areas. They stated that they would have to talk with the Director of Environmental Services and work something out depending on whose responsibility it was. Nutritional Services Manager #1 stated that all items should have an open date on them. They do not necessarily place an expiration date on the fluids as they refer to the best-used date on the packaging. They stated that they do not pour liquids for residents, and it is the nursing staff that performs that task. They stated that they would have to follow up with the nursing department to make sure they place open dates on the items. During an interview on 11/15/2024 at 12:40 PM, Director of Environmental Services #1 stated that they believed it was the Kitchen staff that was responsible for the cleaning of the tops of the machines and refrigerators and not that of the environmental services team. They stated that they did not believe it had been one of the environmental services teams' responsibilities. They stated they would need to have to work out something with the kitchen staff to get them cleaned on a regular basis. 10 New York Codes, Rules, and Regulations 415.14(h)

Based on observation, record review, and interviews during the recertification survey and abbreviated survey (NY00356338), the facility did not ensure each resident was treated with respect and dignity and cared for in a manner and in an environment that promoted maintenance or enhancement of their quality of life, recognizing each resident's individuality for 2 (Resident #s 6 and 33) of 7 residents reviewed for dignity. Specifically, for (a.) Resident #6 was left to soil themselves because staff did not attend to the resident in a timely fashion, leaving the resident feeling humiliated on more than one occasion. Resident #33 was not assisted with the consumption of their observed meal in a dignified manner. This is evidenced by: A facility policy titled Promoting Dignity and a Safe Environment Guidelines, dated 03/12/2024 documented it was designed to provide a safe, respectful, and dignified environment for all residents. A facility policy titled Feeding a Resident, dated 11/12/2024 documented under section 2. Feeding a resident: c. staff should sit not standing over residents. Resident conversation should be engaging and resident-appropriate, keep private staff conversations for break time. A facility policy titled Resident Rights, dated 03/2024, documented that the facility would ensure residents had the right to a dignified existence, self-determination, respect, full recognition of their individuality, consideration and privacy in treatment and care for personal needs, and communication with and access to persons and services inside and outside the facility. Resident #6 Resident #6 was admitted to the facility with diagnoses of chronic kidney disease, dependence on renal dialysis (a treatment that removes waste and excess fluid from the blood when the kidneys are no longer functioning properly), and difficulty walking. The Minimum Data Set (an assessment tool) dated 10/16/2024 documented the resident was able to be understood, understand others, was cognitively intact and required significant assistance with activities of daily living. Resident #6's Comprehensive Care Plan for incontinence, undated, documented the resident's goals included remain free of odor and moisture associated skin damage. Interventions were check for incontinence; clean and dry skin if wet or soiled and dress in clothing that is easily removed for toileting. During an interview on 11/18/2024 at 2:29 PM, Resident #6 stated that the facility was short on staff. They stated few days ago they called for medications and for the restroom around 7:00 PM, staff did not come until 10:00 PM. This happened at least one time per week but usually several times per week. On a good day they answer the call light in 3 hours and on a bad day no one comes after turning their light off. Resident #6 stated several times they were left to the point that they soiled themselves and were embarrassed by this. They stated they were left soiled until the urine was up to the resident's belly area without assistance. During an observation on 11/19/2024 at 9:48 AM, the call light was engaged for room [ROOM NUMBER]; the call light was answered 27 minutes later at 10:15 AM. During an interview on 11/19/2024 at 12:28 PM, Registered Nurse #4 stated they were alone on the unit without other nurses and could not interview at that time. Resident #33 Resident #33 was admitted to the facility with diagnoses of dysphagia (difficulty swallowing), hemiplegia, and hemiparesis (muscle weakness or partial paralysis on one side). The Minimum Data Set, dated dated dated [DATE], documented the resident was usually able to make themselves understood, usually able to be understood by others, and severely cognitively impaired. During an observation 11/12/2024 at 12:29 PM, Resident #33 sat in the wheelchair at the dining room table on the third floor of Springs tower. Staff asked and placed a clothing protector. Licensed Practical Nurse #1 assisted Resident #33 with the noon meal, they turned to converse with other staff at the table of six residents with six staff assisting and four staff were engaged in the conversation, not paying attention to the residents they were assisting. Resident #33 was seen during this time chewing/sucking on her clothing protector. One resident was leaning towards the fork the staff was holding out of reach while their head was turned away from the resident. One resident was reaching for the food on the plate while the staff was paying attention to the conversation of other staff. During an observation and interview on 11/12/2024 at 12:29 PM, Certified Nurse Aide #1 stated residents should be assisted at meals when needed and the staff should pay attention and keep their concentration on the resident, they were assisting. This was a dignity issue for the resident. During an interview on 11/12/2024 at 12:29 PM, Licensed Practical Nurse #1 stated they should keep their attention on the resident they were assisting with meals through the entire meal. They apologized for their behavior during the meal. They confirmed it was a dignity issue. During an interview on 11/12/2024 at 12:43 PM, Director of Nursing #1 and Assistant Director of Nursing #1 stated all residents that required assistance with eating should receive it with dignity. This would be the staff assisting them would pay attention to them and not to participate in outside conversations with other staff, in doing this was a resident dignity issue. 10 New York Code Rules and Regulations 415.5(a)

Based on record review and interviews during the recertification survey, the facility did not ensure that each resident was screened for a mental disorder or intellectual disability prior to admission for 1 (Resident #243) of 35 residents reviewed. Specifically, there was no documentation that a Preadmission Screening and Resident Review (PASARR, New York State Department of Health form 695) was completed for Resident #243 by a qualified screener prior to admission to the facility. This is evidenced by: Resident #243 was admitted to the facility with diagnoses of malignant neoplasm of prostate (prostate cancer that spread to other parts of the body), secondary malignant neoplasm of bone (cancer that spread to the bone from the prostate), and difficulty walking. The Minimum Data Set (an assessment tool) dated 8/29/2024 documented that the resident was able to be understood, understand others, and was somewhat cognitively impaired. There was no documented evidence that Residents #243 had a Preadmission Screening and Resident Review completed prior to admission to the facility as required. During an interview on 11/19/2024 at 8:54 AM, Admissions Coordinator #1 stated that there was no Preadmission Screening and Resident Review for Resident #243 and that they were not aware there was not one done until the survey team asked for it. Resident #243 was admitted through hospice from home. The Hospice admission person was supposed to send the screen and never did. Admissions Coordinator #1 stated they reached out to the Hospice team to have it sent over upon discovery that it had not been. Hospice was unable to find the Preadmission Screening and Resident Review in question. Admission Coordinator #1 stated they would complete the screen as soon as possible. During an interview on 11/19/2024 at 12:54 PM, Administrator #1 stated there would be a Performance Improvement Plan for addressing Resident #243's missing Preadmission Screening and Resident Review. Administrator #1 stated the facility usually did not have an issue with having completed Preadmission Screening and Resident Reviews or making sure they were completed before residents were admitted . Administrator #1 stated that Admissions Coordinator #1 was very stressed at the time Resident #243 was admitted and Resident #243's missing Preadmission Screening and Resident Review was a one-off situation. 10 New York Code of Rules and Regulations 415.11(3)

Based on observations, record review, and interviews conducted during a recertification survey, the facility did not ensure Comprehensive Care Plans were reviewed after each assessment and revised based on changing goals, preferences, and needs of the resident and in response to current interventions for 1 (Resident #68) of 39 residents reviewed. Specifically, for Resident #68, the Comprehensive Care Plan for Respiratory Therapy was not reviewed and revised to include changes in the resident's respiratory status when resident was not using oxygen. This is evidenced by: A review of the facility policy titled Respiratory Therapy Program dated 4/18/2023 documented the facility was to provide respiratory therapy assessment and treatment to those residents with deficiencies or abnormalities of pulmonary function, for whom a provider's order has been written. Resident #68 was admitted to the facility with diagnoses of sepsis (a life-threatening condition that occurs when the body's immune system has an extreme response to an infection that may lead to organ failure or death), rhabdomyolysis (a serious condition when muscle fibers die and release their contents into your bloodstream), and paroxysmal atrial fibrillation (a condition of having an irregular heartbeat). The Minimum Data Set (an assessment tool) dated 10/23/2024 documented that the resident could be understood, and usually understand others, and had intact cognition for daily living decisions. During an observation on 11/12/2024 at 12:49 PM, Resident #68 was not receiving oxygen, and a nasal cannula was connected to an oxygen concentrator as well as one attached to the portable oxygen tank in their wheelchair. During an observation on 11/15/2024 at 10:27 AM, the resident was not receiving oxygen, and a nasal cannula was connected to the portable oxygen tank in their wheelchair. There was no oxygen tubing on the resident concentrator, and it was unplugged. During an observation on 11/18/2024 at 10:12 AM, the resident was not receiving oxygen, and a nasal cannula was connected to the portable oxygen tank in their wheelchair. There was no oxygen tubing on the resident concentrator, and it was unplugged. A review of the Treatment Administration Record on 11/15/2024 for November 2024, documented that Resident #68 was to be on continuous oxygen therapy at 2 liters per minute via a nasal cannula and was to be changed once weekly. The nasal cannula tubing was documented as last being changed on 11/10/2024. The record further documented that staff ensured residents' oxygen was in place and functioning every four hours. The Treatment Administration Record documented that staff was signing off that the resident's oxygen was in place consistently for November 2024 A review of Resident #68 Care Plans dated 10/17/2024 documented resident had the potential for respiratory complications due to prolonged hospitalization , pain, and a new need for oxygen. The care plan further documented the resident was to have oxygen administered per the Medical Director's order. A review of the physician order sheet documented Resident #68 was to be on continuous oxygen at 2 liters per minute via nasal cannula. During an interview on 11/12/2024 at 12:49 AM, Resident 68 stated that they only wore the oxygen at night. They mentioned that they came to the facility with oxygen on and the facility had placed it on them but believed they did not require it as they did not wear it at home and had no issues with breathing. During a follow-up interview on 11/18/2024 at 10:12 AM, Resident #68 stated that they were not on oxygen over the weekend. They stated that they had not been on oxygen in quite some time. They stated they were not sure why there was oxygen as they feel they do not require it. Resident #68 stated that they had never used the portable oxygen tank that was located in their wheelchair. During a subsequent interview on 11/19/2024 at 9:40 AM, Resident #68 stated that they had not been on oxygen much since they had been at the facility. The resident was not on oxygen during their morning physical therapy session. During an interview on 11/19/2024 at 9:50 AM, Registered Nurse #2 stated that Resident #68 had an order for oxygen but stated they hardly wore it. They stated that they have had conversations with the team about discontinuing the oxygen for the resident but had not heard from the physician at all. They stated that the resident had not been on oxygen for approximately 5-6 days and their oxygen saturation was above 95%. Mentioned findings to Registered Nurse #2 and they verified that the staff have been verifying resident was wearing their oxygen and documenting it in the Treatment Administration Record. They stated that staff should be documenting that the resident was not on oxygen. 10 New York Code of Rules and Regulations 483.21 (b)(2)(iii)

Based on observations, record review, and interviews during a recertification survey, the facility did not ensure that it provided an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 1 (Resident # 80) of 2 residents reviewed for activities. Specifically, Resident #80 was not provided with activities that met the residents' preferences and cognitive abilities. This is evidenced by: The Policy titled General Activity/Life Enrichment Program Guidelines dated 03/01/2024 document the facility would provide activities, social events, and schedules that were compatible with the resident's interests, physical and mental assessment, and overall plan of care. The Policy documented activities were offered 7 days a week and should provide ongoing supportive program of the resident's psychosocial needs. Resident #80 was admitted to the facility with diagnoses of dementia, anxiety, and major depressive disorder. The Minimum Data Set (an assessment tool) dated 10/16/2024 documented the resident was severely cognitively impaired, could be sometimes understood, and sometimes understand others. The Comprehensive Care Plan documented that staff were to help Resident #80 with all activities of daily living. Care Plan lacked documentation of any activity preferences for Resident #80. During an observation on 11/15/2024 at 09:14 AM, Resident #80 was tucked under the dining room table, had breakfast in front of them. Received no assistance and had spilled eggs on her lap, bacon directly on the table, and no staff around for assistance. During an observation on 11/18/2024 at 7:54 AM, Resident was tucked under the dining room table facing the corner of the dining room and calling out help me. No staff noted nearby. During an observation on 11/18/2024 at 10:54 AM, Resident #80 was at the dining room table, tucked under the table, was resting with eyes closed. Resident had nothing in front of them. During an observation on 11/19/2024 at 9:46 AM, Resident #80 was sitting in their wheelchair in the hallway. No activity/interaction, tearful, calling out again help me. During an observation on 11/19/2024 at 12:08 PM, Resident #80 was sitting at the dining room table tucked in and calling I want to go home, help me, mother please help. During an interview 11/19/2024 at 12:28 PM, Registered Nurse #4 stated they were alone on the floor so did not have time interview. During an interview 11/19/2024 at 12:29 PM, the Director of Nurses #1 stated that life enrichment should provide activities for all residents. During an interview on 11/19/2024 at 3:20 PM, Life Enrichment director #1 stated the life enrichment staff assigned to Spring tower floor 2, was out sick on this date. The interdisciplinary team meets regularly and discuss each resident. 10 New York Codes, Rules, and Regulations 415.5(f)(1)h

Based on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that each resident received the necessary respiratory care and services that were following professional standards of practice, for 3 (Residents #'s 49, 53, and 68) of 6 residents reviewed for oxygen administration. Specifically, (a) for Residents #49, 53, and 68, their supplemental oxygen tubing was not dated and labeled to reflect when the tubing was changed; and (b) supplemental oxygen was not provided as ordered by the physician for Resident #68. This is evidenced by: A review of the facility policy titled Respiratory Therapy Program dated 4/18/2023 documented the facility was to provide respiratory therapy assessment and treatment to those residents with deficiencies or abnormalities of pulmonary function, for whom a provider's order had been written. Resident #49 was admitted to the facility with diagnoses of chronic respiratory failure (a condition where you do not have enough in the tissues), dependence on supplemental oxygen, and chronic systolic (congestive) heart failure (a chronic condition in which the heart does not pump blood as well as it should). The Minimum Data Set (an assessment tool) dated 9/06/2024, documented the resident had severe cognitive impairment, could be understood, and understand others. It documented the resident received oxygen therapy while in the facility. During an observation on 11/12/2024 at 11:16 AM, the resident was receiving oxygen at 2 liters via a nasal cannula that was connected to an oxygen concentrator. There was no date on the oxygen tubing when it was changed. During an observation on 11/15/2024 at 3:29 PM, the resident was receiving oxygen at 2 liters via a nasal cannula that was connected to an oxygen concentrator (a device that provides a continuous supply of oxygen). The oxygen tubing was dated 11/12/2024. During an observation on 11/18/2024 at 10:11 AM, the resident was not in their room. The oxygen tubing was connected to the oxygen concentrator and was dated 11/18/2024. The Treatment Administration Record dated November 2024, documented the resident received oxygen at 2 liters per minute via nasal cannula (a device that gives additional oxygen through the nose) for chronic respiratory failure. The oxygen tubing (nasal cannula) was to be changed one time weekly and was documented as being changed on 11/08/2024. The Treatment Administration Record dated November 2024, documented the oxygen tubing was last changed on 11/08/2024. There was no documentation on the record that the tubing was changed on 11/12/2024. The Treatment Administration Record dated November 2024, documented the oxygen tubing was last changed on 11/15/2024. There was no documentation on the record that the tubing was changed on 11/18/2024. During an interview on 11/18/2024 at 10:31 AM, Registered Nurse #1 stated the oxygen tubing change was usually done weekly during the 11 PM - 7 AM shift. The surveyor discussed their findings dated 11/12/2024, 11/15/2024, and 11/18/2024. Registered Nurse #1 stated that on 11/12/2024, they made sure the oxygen tubing was dated. When asked if they personally changed the oxygen tubing on 11/12/2024, they stated no, and said it was done on 11/12/2024 during the night shift. They stated when the tubing was changed, it was documented on the Treatment Administration Record. Resident #53 Resident #53 was admitted to the facility with diagnoses of chronic respiratory failure, essential hypertension (high blood pressure), and heart failure. The Minimum Data Set, dated dated dated [DATE] documented that the resident could be understood and understand others and had moderately impaired cognition for daily living decisions. During an observation on 11/12/2024 at 01:38 PM, the resident received oxygen at 3 liters via a nasal cannula connected to an oxygen concentrator. There was no date on the oxygen tubing. During an observation on 11/15/2024 at 10:22 AM, the resident received oxygen at 3 liters via a nasal cannula connected to an oxygen concentrator. There was no date on the oxygen tubing. During an observation on 11/18/2024 at 10:28 AM, the resident was receiving oxygen at 3 liters via a nasal cannula that was connected to an oxygen concentrator and was dated 11/17/2024. A review of the Treatment Administration Record on 11/15/2024 for November 2024, documented that the resident received oxygen at 3 liters per minute via nasal cannula when placed on the oxygen concentrator. The oxygen tubing (nasal cannula) was to be changed once weekly and was documented as last being changed on 11/10/2024. A review of the Treatment Administration Record on 11/18/2024 for November 2024, documented that the oxygen tubing (nasal cannula) was to be changed on 11/17/2024. During an interview on 11/18/2024 at 10:44 AM, Licensed Practical Nurse #2 stated residents' oxygen tubing was to be changed every Sunday during the overnight 11- 7 shift. They stated they were unsure why the tubing was not labeled as they stated it should have been by the nurse changing it. During an interview on 11/18/2024 at 12:03 PM, Licensed Practical Nurse #3 stated residents' oxygen tubing was to be changed every Sunday during the overnight 11- 7 shift. They stated they were unsure why the tubing was not labeled as they stated it should have been by the nurse changing it. During an interview on 11/19/2024 at 9:50 AM, Registered Nurse #2 stated the oxygen tubing change was usually done weekly during the 11 PM - 7 AM shift. The surveyor discussed their findings dated 11/12/2024, 11/15/2024, and 11/18/2024. Registered Nurse #2 stated that the tubing should have been labeled with the last date changed before the 11/18/2024 date. When asked if the oxygen tubing was changed before 11/18/2024, Registered Nurse #2 stated that they would assume that it was but have no proof as it was not labeled, but stated it was documented on the Treatment Administration Record. During an interview on 11/19/2024 at 11:45 AM, the Director of Nursing #1 stated that nursing staff should be changing the oxygen tubing once a week. They stated that staff should be labeling the oxygen tubing as it was the policy of the facility to do so. Mentioned the labeling observations with the Director of Nursing #1 and they stated that the tubing should not be unlabeled. Resident #68 Resident #68 was admitted to the facility with diagnoses of Sepsis (a life-threatening condition that occurs when the body's immune system has an extreme response to an infection that may lead to organ failure or death), Rhabdomyolysis (a serious condition when muscle fibers die and release their contents into your bloodstream), and paroxysmal atrial fibrillation (a condition of having an irregular heartbeat). The Minimum Data Set, dated dated dated [DATE] documented that the resident could be understood and usually understand others and had intact cognition for daily living decisions. During an observation on 11/12/2024 at 12:49 PM, the resident was not receiving oxygen, and a nasal cannula was connected to an oxygen concentrator as well as one attached to the portable oxygen tank in their wheelchair. There were no dates on either oxygen tubing. During an observation on 11/15/2024 at 10:27 AM, the resident was not receiving oxygen, and a nasal cannula was connected to the portable oxygen tank in their wheelchair. There were no dates on the oxygen tubing. There was no oxygen tubing on the resident concentrator, and it was unplugged. During an observation on 11/18/2024 at 10:12 AM, the resident was not receiving oxygen, and a nasal cannula was connected to the portable oxygen tank in their wheelchair. There were no dates on the oxygen tubing. There was no oxygen tubing on the resident concentrator, and it was unplugged. A review of the Treatment Administration Record on 11/15/2024 for November 2024, documented that the oxygen tubing (nasal cannula) was to be changed once weekly and was documented as last being changed on 11/10/2024. Staff were to ensure residents' oxygen was in place and functioning every four hours. A review of the Treatment Administration Record on 11/15/2024 for November 2024, documented that Resident #68 was to be on continuous oxygen therapy at 2 liters per minute via a nasal cannula and was to be changed once weekly. The nasal cannula tubing was documented as last being changed on 11/10/2024. The record further documented that staff ensured residents' oxygen was in place and functioning every four hours. The Treatment Administration Record documented that staff was signing off that the resident's oxygen was in place consistently for November 2024 A review of the Treatment Administration Record on 11/18/2024 for November 2024, documented that the oxygen tubing (nasal cannula) was to be changed on 11/17/2024. During an interview on 11/18/2024 at 10:44 AM, Licensed Practical Nurse #2 stated residents' oxygen tubing was to be changed every Sunday during the overnight 11- 7 shift. They stated they were unsure why the tubing was not labeled as they stated it should have been by the nurse changing it. During an interview on 11/18/2024 at 12:03 PM, Licensed Practical Nurse #3 stated residents' oxygen tubing was to be changed every Sunday during the overnight 11- 7 shift. They stated they were unsure why the tubing was not labeled as they stated it should have been by the nurse changing it. During an interview on 11/19/2024 at 09:50 AM, Registered Nurse #2 stated the oxygen tubing change was usually done weekly during the 11 PM - 7 AM shift. The surveyor discussed their findings dated 11/12/2024, 11/15/2024, and 11/18/2024. Registered Nurse #2 stated that the tubing should have been labeled with the last date changed before the 11/18/2024 date. When asked if the oxygen tubing was changed before 11/18/2024, Registered Nurse #2 stated that they would assume that it was but have no proof as it was not labeled, but stated it was documented on the Treatment Administration Record. During an interview on 11/19/2024 at 1145 PM, the Director of Nursing #1 stated that nursing staff should be changing the oxygen tubing once a week. They stated that staff should be labeling the oxygen tubing as it was the policy of the facility to do so. Mentioned the labeling observations with the Director of Nursing #1 and they stated that the tubing should not be unlabeled. During an interview on 11/12/2024 at 12:49 AM Resident 68 stated that they only wear the oxygen at night. They mentioned that they came to the facility with oxygen on and the facility had placed it on them but believed they did not require it as they did not wear it at home and had no issues with breathing. During a follow-up interview on 11/18/2024 at 10:12 AM, Resident #68 stated that they were not on oxygen at all over the weekend. They stated they were not sure why there was oxygen as they felt they did not require it. Resident #68 stated that they has never used the portable oxygen tank that is located in their wheelchair. During a follow-up interview on 11/19/2024 at 9:40 AM, Resident #68 stated that they had not been on oxygen much since they have been at the facility. The resident was not on oxygen during their morning physical therapy session. During an interview on 11/19/2024 at 9:50 AM, Registered Nurse #2 stated Resident #68 had an order for oxygen but stated they hardly wore it. They stated that they have had conversations with the team about discontinuing the oxygen for the resident but have not heard from the physician at all. They stated the resident had not been on oxygen for approximately 5-6 days and their oxygen saturation was above 95%. Mentioned findings to Registered Nurse #2 and they verified that the staff have been verifying resident was wearing their oxygen and documenting it in the Treatment Administration Record. They stated that staff should be documenting that the resident was not on oxygen. 10 New York Code of Rules and Regulations 415.12(k)(6)

Based on observation, record review, and interviews during the recertification survey, the facility did not maintain medical records in accordance with accepted professional standards and practices that were accurately documented and completed for 1 (Resident #68) of 39 residents reviewed. Specifically, for Resident #68 staff was observing and verifying every four hours that the resident's oxygen nasal canula was in place and the resident was using the oxygen as prescribed by the physician. This is evidenced by: A review of the facility policy titled Respiratory Therapy Program dated 4/18/2023 documented the facility was to provide respiratory therapy assessment and treatment to those residents with deficiencies or abnormalities of pulmonary function, for whom a provider's order has been written. Resident #68 was admitted to the facility with diagnoses of sepsis (a life-threatening condition that occurs when the body's immune system has an extreme response to an infection that may lead to organ failure or death), rhabdomyolysis (a serious condition when muscle fibers die and release their contents into your bloodstream), and paroxysmal atrial fibrillation (a condition of having an irregular heartbeat). The Minimum Data Set (an assessment tool) dated 10/23/2024 documented that the resident could be understood and usually understand others and had intact cognition for daily living decisions. During an observation on 11/12/2024 at 12:49 PM, the resident was not receiving oxygen, and a nasal cannula was connected to an oxygen concentrator as well as one attached to the portable oxygen tank in their wheelchair. During an observation on 11/15/2024 at 10:27 AM, the resident was not receiving oxygen, and a nasal cannula was connected to the portable oxygen tank in their wheelchair. There was no oxygen tubing on the resident concentrator, and it was unplugged. During an observation on 11/18/2024 at 10:12 AM, the resident was not receiving oxygen, and a nasal cannula was connected to the portable oxygen tank in their wheelchair. There was no oxygen tubing on the resident concentrator, and it was unplugged. A review of the Treatment Administration Record on 11/15/2024 for November 2024, documented that Resident #68 was to be on continuous oxygen therapy at 2 liters per minute via a nasal cannula and was to be changed once weekly. The nasal cannula tubing was documented as last being changed on 11/10/2024. The record further documented that staff ensured residents' oxygen was in place and functioning every four hours. The Treatment Administration Record for November 2024 documented from 11/01/2024 through 11/15/2024 that the staff was observing and verifying every four hours that the resident's oxygen nasal canula was in place and the resident was using the oxygen as prescribed by the physician. A review of Resident #68 care plans dated 10/17/2024 documented they had the potential for respiratory complications due to prolonged hospitalization , pain, and a new need for oxygen. The care plan further documented the resident to have oxygen administered per the Medical Director's order. A review of the physician order sheet dated 11/01/2024 documented Resident #68 was to be on continuous oxygen at 2 liters per minute via nasal cannula. During an interview on 11/12/2024 at 12:49 AM, Resident #68 stated that they only wore the oxygen at night. They mentioned that they came to the facility with oxygen on and the facility had placed it on them but believed they did not require it as they did not wear it at home and had no issues with breathing. During a follow-up interview on 11/18/2024 at 10:12 AM, Resident #68 stated that they were not on oxygen over the weekend. They stated that they had not been on oxygen in quite some time. They stated they were not sure why there was oxygen as they feel they did not require it. Resident #68 stated that they had never used the portable oxygen tank that was located in their wheelchair. During a follow-up interview on 11/19/2024 at 9:40 AM, Resident #68 stated that they had not been on oxygen much since they had been at the facility. The resident was not on oxygen during their morning physical therapy session. During an interview on 11/19/2024 at 09:50 AM, Registered Nurse #2 stated that Resident #68 had an order for oxygen but stated they hardly wore it. They stated that they have had conversations with the team about discontinuing the oxygen for the resident but have not heard from the physician at all. They stated that the resident had not been on oxygen for approximately 5-6 days and their oxygen saturation was above 95%. Mentioned findings to Registered Nurse #2 and they verified that the staff have been verifying resident is wearing their oxygen and documenting it in the Treatment Administration Record. They stated that staff should be documenting that the resident is not on oxygen. 10 New York Code of Rules and Regulations 483.70 (h)(2)(ii)

Based on record review and interviews during an abbreviated survey (Case #NY00241321), the facility did not ensure that a resident with a pressure ulcer received the necessary treatment and services consistent with professional standards of practice for 1 (Resident #1) of 3 residents reviewed. Specifically, for Resident #1, who was assessed with open areas on the right and left coccyx/inner buttock upon admission on 5/2/2019, the facility did not implement their policy and procedure for the prevention and treatment of skin issues that included weekly pressure injury assessment and tracking for a stage 2 pressure ulcer on the residents coccyx/buttocks, as documented on the 48 Baseline Care Plan dated 5/2/2019. The electronic medical record (EMR) did not include documentation of weekly assessments and monitoring the characteristics and measurements of the wound(s) and did not ensure a care plan was developed that included intervention and treatment strategies for the healing of and prevention of infection in the wounds through the resident's date of discharge on 7/24/2019. This is evidenced by: Resident #1: Resident #1 was admitted to the facility with diagnoses of routine healing of a closed fracture of unspecified part of neck of right femur (hip), chronic lymphocytic leukemia (CLL; cancer of the blood and bone marrow) not in remission, and diabetes with diabetic neuropathy (nerve damage caused by diabetes). The Minimum Data Set (MDS - an assessment tool) dated 5/9/2019, documented the resident was cognitively intact. The Policy and Procedure (P&P) titled Prevention and Treatment of Skin Issues reviewed 1/2018, documented the purpose of the policy was to provide a means to assure that skin issues were prevented when possible and treated if they occur. The facility's system for the prevention of pressure ulcers included the following policy statements: the facility was committed to pressure injury (PI) prevention and management; the facility required that each resident receive a comprehensive skin inspection and risk assessment by a Registered Nurse (RN) at the time of admission or readmission and at set intervals; pressure injuries were tracked weekly with PI characteristics identified by a RN on the wound assessment in the EMR ; residents with PIs identified as non-healing by the interdisciplinary team were assessed by a Certified Wound Nurse or sent to a specialist for further workup as appropriate (ex: vascular, wound clinic). General comments documented the Unit Coordinator directed an interdisciplinary approach towards care planning for the prevention and treatment of skin issues per guidelines; residents who had skin issues were assessed by a RN weekly and per judgment of the RN, tracked on the STCP (short-term care plan) or a wound tracking sheet with input from Therapy and Nutritional Services. The Progress Note dated 5/2/2019 at 10:40 PM by the RN, documented an open area on the right and left coccyx/inner buttock that measured 0.8 x 0.5 cm and 2 x 0.5 cm, respectively. The Skin Inspection report dated 5/2/2019, documented an open area on the right and left coccyx/inner buttock that measured 0.8 x 0.5 cm and 2 x 0.5 cm, respectively. The anatomical drawing included in the report did not document the location of the wounds. The 48 Hour Baseline Care Plan dated 5/2/2019, documented the resident had a current pressure ulcer that was stage 2 (partial thickness skin loss with exposed dermis (middle layer of skin) presenting as a shallow open ulcer) on the coccyx/buttock. The wound's characteristics and measurements were not documented. It was not documented that the resident had two wounds. Review of the MDS Section M; Skin Conditions dated 5/9/2019, documented the resident was at risk of developing pressure ulcers/injuries and had no unhealed pressure ulcers/injuries. Other skin problems included moisture associated skin damage (MASD). The Comprehensive Care Plan (CCP) for At Risk for Skin Breakdown and Pressure Ulcers, created and last revised on 5/10/2019, documented the resident had 2 opens areas on their coccyx/buttocks. CCP interventions did not include treatment strategies for the healing of the wounds and prevention of infection. Review of the Treatment Administration Record (TAR) dated 5/2/2019 through 7/24/2019, documented treatment to the coccyx and inner buttocks was administered as ordered. The EMR did not document weekly assessments of the stage 2 PI on the resident's coccyx that included staging; description of the PIs characteristics; progress toward healing; if infection was present; and a description of the treatments provided through the discharge date [DATE]. The undated report titled Pressure Ulcer Tracking 2019 by the former Director of Nursing (DON) #2, documented Resident #1 had a stage 2 pressure injury (PI) on their coccyx that started in the hospital. It documented the PI had an origin date of 5/2/2019; was measured on 7/3/2019 and was stable; and there was a care plan for the PI. The measurements were not documented on the report or in the EMR. It documented a meeting was held on 7/5/2019. The facility could not provide any prior or additional Pressure Ulcer Tracking records. Review of the Progress Notes for all disciplines, including Medical dated 5/3/2019 through 7/24/2019, did not document the status of the wound. During an interview on 6/29/2023 at 10:10 AM, the Director of Nursing (DON) #1 stated the Nursing assessment note documented there were 2 open areas on the right and left inner buttocks. The DON #1 stated there was a treatment order and it was done as ordered. The DON #1 stated the treatment ordered was typically used for stage 1 and stage 2 pressure ulcers (PUs). The DON #1 stated wound assessments for Resident #1 were not done weekly as they were supposed to be per their policy. The DON #1 stated the RN Unit Coordinator (UC) would have been ultimately responsible for wound assessments. The DON #1 stated that in 2019, the former DON (#2) would hold a meeting and discuss the (PUs) that were on each unit. The DON #1 stated a PU should be on the MDS. The DON #1 stated that currently they have weekly meetings that the ADON was in charge of and tracks the wounds. The DON #1 stated all UCs and Charge nurses attend the meeting. During an interview on 7/5/2023 at 3:05 PM, the MDS Coordinator (MDS) stated they could not recall the resident. The MDS #1 stated the facility's staff had changed since 2019. The MDS #1 stated they did their assessment for skin condition by reviewing the EMR for Nursing progress notes and wound assessments. The MDS #1 stated the facility's system for wound tracking and treatment has changed since 2019. The MDS #1 stated all wounds were currently being monitored daily and a daily skilled note was written. The MDS #1 stated the CWOCN comes once a week, and all wounds were being monitored. The MDS #1 stated the Charge nurse now completes a wound form with the identification of a wound and documents the measurements, treatments, and progression of the wound. The MDS #1 stated the updating of the CCP was a team effort between the MDS Coordinators, Nursing, Nurse Managers, and the Charge Nurse. During an interview on 7/5/2023 at 3:28 PM, the Assistant Director of Nursing (ADON) stated they worked as (UC) in 2019. The ADON stated the facility's system in 2019 was for the RN to do a head-to-toe skin assessment upon admission and then document the findings in a Nursing Note and a wound assessment in the EMR. The ADON stated that after admission, the wound would be assessed weekly by the RN (UC) and documented. The ADON stated the Licensed Practical Nurse (LPN) would provide wound treatments as ordered. The ADON stated that in 2019, the facility had (PU) meetings with the DON #2 and the DON #2 had a paper wound tracker that they would review at the meeting. The ADON stated that they currently run the PU meetings and review all PUs in the facility. The ADON stated they also did audits by looking at the wound documentation, CCP, interventions and the Certified Nurse Aide (CNA) care cards. The ADON stated the facility identified a problem with the management of PUs and the CWCON provided training to all RNs in February 2023 and incorporated it into QAPI. The ADON stated that currently the wound trackers are being sent to the MDS Coordinators. The ADON stated if a wound was identified, a CCP for the actual wound would be developed with interventions for healing of the wound and prevention of new wounds. The ADON stated that the resident's wounds should not have been documented on the risk care plan. In a subsequent interview on 7/5/2023 at 4:02 PM, the DON #1 stated each PU should have its own care plan with its own interventions for healing and should not be on the risk care plan. The DON #1 state the resident did not have a CCP for the PU. During an interview on 7/12/2023 at 11:01 AM, the DON #2 stated they did not recall the resident or their Pressure Ulcer Tracking 2019 report. The DON #2 stated the facility had an EMR and any wound assessments should have been documented in the EMR. The DON #2 could not recall the facility's process for wound tracking and stated the Administrator (ADMIN) #1 should know what the process for wound tracking was back then. During an interview on 7/14/2023 at 1:33 PM, the Medical Director (MD) #3, stated that if the PU was a stage 2 when the resident was first admitted and the wound was being treated, it should have been gone on 7/3/2019, two months later. The MD #3 stated the facility has made improvements with wound management since 2019. 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: -In August 2022, the facility identified pressure ulcers as a trigger for quality measures (QM). -On 9/26/2022, the Prevention and Treatment of Skin Issues policy was reviewed and updated. -On 12/7/2022, the Prevention of Skin Issues due to Pressure, Moisture, Shear, Friction, and Trauma policy was reviewed and updated. -In December 2022, the facility met with the Certified Wound Ostomy Continence Nurse (CWOCN) to discuss a pressure ulcer performance improvement plan (PIP) and incorporated into Quality Assurance and Performance Improvement (QAPI). The CWOCN completed a full-house assessment of all current pressure ulcers for prevention measures and treatment recommendations. Plans were developed to initiate training as supported by the CWOCN related to prevention, identification, and treatment. -In January 2023, the facility identified pressure ulcers in QAPI as high priority with steps presented for improvement in the committee meeting. -From 2/6/2023 through 2/27/2023, all RNs were assigned mandatory training for the Annual NDNQI (National Data of Nursing Quality Indicators) pressure injury training. -From 2/28/2023 through 3/16/2023, a mandatory 6-hour live training course titled Wound care Training; Systems in Place for Prevention and Early Detection of Wounds was presented by the CWOCN for all RNs. -From 3/16/2023 through 4/28/2023, a mandatory makeup training course was assigned on the electronic training platform for all remaining RNs. -On 4/28/2023, wound care training was completed by 100% of all RNs. 10 NYCRR 415.12(c)(1)

Based on record review and interviews during an abbreviated survey (Case # NY00241321), the facility did not ensure it promptly notified the ordering physician of results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner for 1 (Resident #1) of 5 residents reviewed. Specifically, for Resident #1 who was admitted for rehabilitation following a fall with a right hip fracture, the facility did not promptly notify the physician (MD) #1 of x-ray results dated 5/21/2019, that documented the possibility of interval development of fracture until 6/6/2019. This is evidenced by: Resident #1: Resident #1 was admitted to the facility with diagnoses of routine healing of a closed fracture of unspecified part of neck of right femur (hip), chronic lymphocytic leukemia (CLL; cancer of the blood and bone marrow) not in remission, and diabetes with diabetic neuropathy (nerve damage caused by diabetes). The Minimum Data Set (MDS - an assessment tool) dated 5/9/2019, documented the resident was cognitively intact. The Policy and Procedure (P&P) titled Physician Visits Policy updated on 5/30/2023, documented residents experiencing an acute change in condition would be communicated to a provider. The P&P documented (Refer to Change in Condition Policy). Upon receiving test results (ex; x-rays/labs), results would be placed in the provider book for review upon daily provider rounds. The provider would review the results and indicate signature directly on the test results. Provider would give order changes as necessary verbally or by entering directly into the EMR (electronic medical record). The results would be scanned into the resident's EMR. During off-hours, test results received that are identified to be abnormal, would be verbally communicated to the on-call provider. The (P&P) titled Nursing Guidelines Communication for Change in Condition initiated 4/2019, documented the objective of the policy was to ensure the facility staff made appropriate notification to the nurse or provider and when there was a change in the resident's condition or an accident that may require provider interventions. A change in condition was defined as the sudden deviation from a resident's baseline in physical, cognitive, behavioral, or functional health, that without intervention may result in resident harm. The nurse would contact the medical provider of a need to alter treatment significantly or to commence a new form of treatment. The nurse would document the notification including those notified, any intervention initiated and the resident's response to those interventions, and any new provider orders received. The Comprehensive Care Plan (CCP) for At Risk for Falls related to status post right hip fracture, last updated on 7/13/2019, documented that on 5/21/2019 the resident was found on the floor and had slid out of the recliner. The Nursing Progress Note dated 5/21/2019 at 8:20 AM, documented the resident complained of 6 of 10 pain to the right hip and had limited range of motion related to pain. The MD #1 was made aware and ordered an x-ray of the right hip to rule out further injury. The Portable Diagnostic Imaging result dated 5/21/2019 at 1:04 PM, documented views of the right hip were done for pain following a fall. The result impression documented clinical correlation and imaging follow-up for the possibility of interval development of fracture in this region recommended as indicated. Review of Progress Notes for all disciplines, including Medical dated 5/21/2019 did not document the MD #1 was notified of the x-ray results. A screenshot (electronic image) of the resident's EMR documented an x-ray of the right hip was captured (scanned) into the EMR on 5/22/2019 at 2:01 PM. Review of Progress Notes for all disciplines, including Medical dated 5/22/2019 through 6/5/2019, did not document the MD #1 was notified of the x-ray results. The MD Visit Note dated 6/6/2019 by the MD #1, documented the resident returned from a visit with the Orthopedist. An x-ray was done in the office to follow up on the device placement from their surgery. A new fracture stemming through the subtrochanteric (below the area of the original hip fracture) hip region was seen, which was not seen on post operative x-rays in the hospital. The MD #1 documented they did a follow up x-ray in the facility on 6/6/2019, which described the stable appearance of the open reduction internal fixation (hip fracture surgery) with incomplete healing. The resident was in no distress. During an interview on 6/29/2023 at 10:10 AM, the DON #1 stated that on 5/21/2019 at 1:50 AM, the resident slid out of the recliner and fell on to the floor. The resident had complained of 2/10 pain in the right hip and was assessed by the Registered Nurse with no injuries. The DON #1 stated there was a note at 8:00 AM on 5/21/2019, that the resident had complaint of 6/10 pain to the right hip. MD #1 was made aware and ordered an x-ray of the right hip. The DON #1 stated there was no documentation in the EMR that MD #1 was made aware of the results that showed a fracture to the right hip that was not previously there. The DON #1 stated MD #1 was informed of the fracture on 6/6/2019. The DON #1 stated MD #1 made a note about the fracture after they read the orthopedic consult report. The DON #1 stated the MD #1 should have been notified on 5/21/2019, when the results were available. During an interview on 7/14/2023 at 1:33 PM, the Medical Director (MD) #3 stated there should have been communication by Nursing staff to MD #1 when the results were made available on 5/21/2019. The MD #3 asked the surveyor to read the results and stated they would not have changed the management of the resident's original fracture. The MD #3 stated the treatment for the original fracture was rehabilitation and it would have remained the same for the new fracture. The MD #3 stated they would have ordered weightbearing as tolerated, follow up with orthopedics, and medication for pain if needed. During an interview on 8/11/2023 at 10:18 AM, the Assistant Director of Nursing (ADON) stated the facility had policies in place for notifying the provider of abnormal x-ray results. The ADON stated a fracture was an acute change in condition and the provider should have been notified on 5/21/2019 when the facility received the results. The ADON stated abnormal test results were to be verbally reported to the provider and then placed in the provider book. The ADON stated there was an in-house provider in the facility Monday through Friday. The ADON stated the results were scanned into the EMR. 10 NYCRR 415.21

Based on observation, record review and interviews during an abbreviated survey (Case #NY 433), the facility did not ensure that the resident representative was notified of a change in condition for 1 (Resident #12) of 16 residents reviewed. Specifically, the facility did not notify Resident # 12's representative when they began to limp, express pain and was ordered to have Xray imaging completed. Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- an assessment tool) dated 9/15/2021, documented the resident had severely impaired cognition, sometimes understand others and could sometimes make themself understood. The Policy and Procedure (P&P) titled Communication for Change in Condition dated 7/12/2022, documented the facility staff was to make appropriate notification to the nurse or provider and that notification is given to the resident and/or the resident representative when there is a change in the resident's condition or an accident that may require provider interventions. A Clinical Note dated 9/11/2021 at 2:48 PM, documented that Resident #12 had abruptly started limping, was grimacing and expressed being in pain. A Clinical Note dated 9/11/2021 at 4:38 PM, documented that upon nursing assessment, there was no bruising, swelling or obvious abnormality observed. Resident #12 was assessed for ambulation and noted pain with weight bearing on left side. The on-call provider was notified, and a new order was obtained for an Xray of the pelvis, left hip and femur. A Clinical Note dated 9/12/2021 at 4:17 AM, documented that Resident #12 continued to express pain with repositioning and was rounded on frequently by nursing staff. A Clinical Note dated 9/12/2021 at 4:19 AM, documented that Xray imaging results had been received and no acute abnormalities were found. A Clinical Note dated 9/12/21 at 1:41 PM, documented that Resident #12 continued to have difficulty standing and ambulating due to complaints of left hip pain; no bruising or swelling was observed. A new order for a local anesthesia patch to be applied to the left hip for 12 hours until the resident could be seen by the physician. A Clinical Note dated 9/13/21 at 3:00 AM, documented that the resident had no complaints of hip pain and was able to self-ambulate during the night. Review of the resident electronic medical record revealed no documentation of the resident representative having been notified of the change in condition on 9/11/21. During an interview on 8/4/2022 at 12:48 PM, Registered Nurse Manager (RNM) #1 stated that the resident representative should be notified of any change in condition immediately after the provider is notified and any needed interventions are provided to the resident. During an interview on 8/4/2022 at 1:03 PM, RNM #4 stated that a resident representative should be notified as soon as possible if any change in a resident's condition or anything that was not considered to be baseline for the resident occurred. During an interview on 8/4/2022 at 3:24 PM, the Director of Nursing (DON) stated that the resident representative should be notified immediately of any change in resident condition. She said when Resident #12 presented with pain, they were assessed by a nurse and ordered to have an Xray completed of the hip and femur. The DON said the nurse supervisor working on the unit at the time had intended to notify the family once the results of the Xray were received, however, the results were not received before the end of the nurse supervisor's shift and the on-coming nurse supervisor did not notify the representative of the change after the Xray results were received. 10 NYCRR 513.3(e)(2)(ii)(b)

Based on record review and interviews during an abbreviated survey (Case #s NY 744, NY 016, and NY 158), the facility did not maintain complete medical records for 4 residents (Resident #s 1, 2, 3, and 4) of 4 residents reviewed for Certified Nursing Assistant (CNA) documentation of care provided. Specifically, the facility did not ensure CNAs consistently documented the care they provided to Resident #s 1, 2, 3, and 4 on every shift. This was evidenced by: The undated Policy and Procedure titled Activities of Daily Living, documented the staff were to document throughout their shift as care was provided instead of waiting until the end of the shift. If a task was provided more than once, it could be entered again. Each staff person was to complete their documentation by the end of their shift. Resident #2 Resident #2 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- an assessment tool) dated 1/3/2022, documented the resident was cognitively intact, could usually be understood, and could sometimes understand others. The Comprehensive Care Plan (CCP) for At Risk for Constipation with a goal date of 4/22/2022 , documented to assist the resident with toileting and provide incontinence care as needed. The CCP for Activities of Daily Living (ADLs), with a goal date of 4/22/2022, documented to assist the resident with activities of daily living and encourage the resident to participate as able. The CCP for At Risk for Incontinence due to limited mobilitywith a goal date of 4/22/2022 , documented staff were to check for incontinence and to clean and dry skin if wet or soiled. The CNA Care Card dated 10/18/2021, documented the resident was to have assistance from 1 staff person for AM and PM care in the bathroom, turn and position every 2 hours, offer the bathroom regularly. The ADL Verification Worksheet dated 12/30/2021, had no documentation of care provided to the resident on the day or evening shifts. The ADL Verification Worksheet dated 12/31/2021, had no documentation of care provided to the resident on the day or evening shifts. The ADL Verification Worksheet dated 1/1/2022, had no documentation of care provided to the resident on the day or evening shifts. The ADL Verification Worksheet dated 1/2/2022, had no documentation of care provided to the resident on the day or evening shifts. The ADL Verification Worksheet dated 1/2/2022, had no documentation of care provided to the resident on the day or evening shifts. Resident #3 The CCP with a goal date of 6/8/2022 for Self Care Deficit, documented to assist the resident with ADLs (bathing, grooming, toileting, feeding, walking) it the resident was unable to complete. The CCP for At Risk for Incontinence due to limited mobility with a goal date of 6/8/2022 , documented staff were to check for incontinence and to clean and dry skin if wet or soiled. The CNA Care Card as of 5/31/2022, documented the assistance of 1 staff for AM and PM care at bed side or in bed, the assistance of 2 staff for toileting, oral care, and shaving facial hair. Resident #3 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE], documented the resident had severe cognitive impairment, could be understood, and could usually understand others. The ADL Verification Worksheet dated 5/6/2022, had no documentation of care provided to the resident on the night or evening shifts. The ADL Verification Worksheet dated 5/7/2022, had no documentation of care provided to the resident on the night or evening shifts. The ADL Verification Worksheet dated 5/8/2022, had no documentation of care provided to the resident on the day shift. The ADL Verification Worksheet contained no documentation for 5/9/2022 from the night, day, or evening shifts of the care provided to the resident. The ADL Verification Worksheet dated 5/10/2022, had no documentation of care provided to the resident on the day or evening shifts. Resident #4 Resident #4 was admitted to the facility with a stroke that affected their right side, loss of ability to speak, and need for assistance with personal care. The MDS dated [DATE], documented the resident had moderate cognitive impairment, could usually be understood, and could usually understand others. The Comprehensive Care Plan (CCP) with a goal date of 7/8/2022 for ADLs, documented to assist the resident with ADLs. The Comprehensive Care Plan (CCP) with a goal date of 7/8/2022 for At Risk for Incontinence due to limited mobility, documented staff were to check for incontinence and to clean and dry skin if wet or soiled. The CNA Care Card as of 5/13/2021, documented the resident was to have assistance from 1 staff person for AM and PM care in the bathroom, and assistance of 1 for dressing. The ADL Verification Worksheet dated 5/6/2022, had no documentation of care provided to the resident on the night or evening shifts. The ADL Verification Worksheet dated 5/7/2022, had no documentation of care provided to the resident on the night or evening shifts and only one entry on the day shift at 12:03 PM that the resident was not bathed. The ADL Verification Worksheet dated 5/8/2022, had no documentation of care provided to the resident on the day or evening shifts. The ADL Verification Worksheet contained no documentation for 5/9/2022 from the night, day, or evening shifts of the care provided to the resident. The ADL Verification Worksheet dated 5/10/2022, had no documentation of care provided to the resident on the day or evening shifts. During an interview on 5/11/2022 at 2:28 PM, CNA #3 stated they were supposed to finish their documentation prior to the end of their shift. During an interview on 5/11/2022 at 2:52 PM, Registered Nurse Charge Nurse #1 (RN Charge Nurse) stated the CNAs were expected to document all care provided during their shift. RN Charge Nurse #1 stated the CNAs were required to complete their documentation prior to the end of their shift. If it was not complete, the CNA was supposed to tell their team leader (the medication nurse) that it was not done. RN Charge Nurse #1 stated the nurses were supposed to be checking the CNAs' documentation throughout the shift to ensure they were. During an interview on 5/11/2022 at 3:14 PM, Registered Nurse Unit Coordinator #2 (RNUC) stated the CNAs were supposed to document each time they completed care for a resident. RNUC #2 stated they checked the CNAs' documentation prior to the end of their shift and came in on off shifts to check documentation and provide education if needed. The RNUC stated the CNAs were required to complete their documentation by the end of their shift. During an interview on 5/17/2022 at 2:07 PM, the Director of Nursing (DON) stated the CNAs were supposed to document after providing care to each resident; however, a lot of them documented at the end of their shift. The CNAs were supposed to have completed their documentation prior to leaving their shift. 10 NYCRR 415.22(a)(1-4)

Based on interviews and record review, during an abbreviated survey (NY 744, NY 016, NY 158), the facility failed to develop and implement policies and procedures (P&P) to ensure proper precautions to prevent the spread of COVID-19 by unvaccinated staff. Specifically, the facility did not ensure Policy and Procedures included a process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who were not fully vaccinated for COVID-19. This was evidenced by: The facility P&P titled, COVID Vaccination Policy dated 4/29/2022, documented employees and non-employee members of the staff were required to be up to date with the COVID vaccination (fully vaccinated and boosted or fully vaccinated but not eligible for the booster dose or have received their first COVID-19 vaccine dose and be on track to becoming up to date). The P&P documented all new staff would be required to receive their first dose of vaccination prior to starting their first shift or must show proof they had started their vaccination series prior to their first day of work. The P&P documented those personnel with approved medical exemptions should comply with all applicable requirements for personal protective equipment, including enhanced masking with use of a KN95 or N95 mask. During an interview on 5/11/2022 at 4:46 PM, the Administrator stated anyone coming on board was required to have at least one dose of vaccine before starting their shift. The staff, if they were eligible for their 2nd shot, they must have it prior to starting employment. The employee, if not eligible for 2nd dose yet would be brought on but would be required to wear a mask, either a KN95 or an N95. The Administrator stated staff not fully vaccinated were tested twice a week. The staff testing was based on community transmission level. The Administrator stated the community was currently in the red zone, so that meant the employee needed to be tested twice a week. 10 NYCRR 415.19(a)(1-3)

Based on record review and interviews during an abbreviated survey (NY 653), the facility did not ensure each resident's right to a dignified existence for 1 (Resident #3) of 5 residents reviewed. Specifically, Resident #1 was observed to have their hand under Resident #3's shirt. Resident #3 had severe cognitive impairment and was nonverbal while Resident #1 had moderate cognitive impairment. This was evidenced by: Resident #3: Resident #3 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- an assessment tool) dated 6/6/2021, documented the resident was rarely or never understood, and could rarely or never understand others. A Nursing Note dated 7/16/2021 at 10:00 PM, written by a Registered Nurse Supervisor (RNS), documented Resident #1 had their hand under Resident #3's shirt in the chest area. The residents were separated. A Nursing Note dated 7/17/2021 at 1:00 AM, documented the medical provider, Administration and the local Police Department had been notified of the incident. A voice mail message was left for the family. Resident #1: Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE], documented the resident had moderate cognitive impairment, could be understood, and could understand others. A Nursing Note dated 7/16/2021 at 10:00 PM, written by an RNS, documented they were notified by the floor Licensed Practical Nurse (LPN) that Certified Nurse Aide (CNA) #1 witnessed that Resident #1 had their hand in Resident #3's shirt. CNA #1 separated the residents and told the floor LPN. Interviews: During an interview on at 2:49 PM, CNA #1 stated that on 7/16/2021, between 8:00 PM and 9:00 PM, when they came around the corner, they saw that Resident #1 had their hand inside Resident #3's dress in the chest area. CNA #1 asked Resident #1 what they were doing. CNA #1 stated Resident #1 quickly withdrew their hand from Resident #3's dress. Resident #3 had no facial expression at that time. During an interview on 7/20/2021 at 1:59 PM, the Director of Nursing (DON) stated a CNA witnessed Resident #1 touching Resident #3's breast. Resident #3 remained at their baseline and did not seem upset after the incident. The DON stated Resident #3 had advanced dementia and was nonverbal most of the time. 10 NYCRR 415.3(c)(1)(i)

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 when an irregularity that requires urgent action to protect the resident is identified. This is evidenced by: On 9/29/2021, the facility Administrator provided a policy titled; Medication Regimen Review, revised on 5/2019 and reviewed on 6/2021. The policy documented; If in the professional judgment of the Pharmacist, there is an irregularity that requires immediate action, the Pharmacist will report the irregularity to the Unit Charge Nurse and Attending Physician immediately. The policy did not include the steps to be taken or timeframes for the Unit Charge Nurse and Attending Physician's response to the reported irregularity requiring immediate action. During an interview on 10/05/21 at 1:59 PM, the Facility Administrator was asked to review the policy for the steps and timeframes. The Administrator was unable to find the information and stated, I don't know how we missed that, but we did. 10 NYCRR415.18(c)(2)

Based on observation, record review, and staff interview during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety. A test kit is to be provided that accurately measures the parts per million (ppm) concentration of the chemical solution used to sanitize equipment, and dishwashing machines are to be operated in accordance with the manufactures' instructions. Specifically, an accurate test kit was not provided, and the automatic dishwashing machine was not operating according to the manufacturer's instructions. This is evidenced as follows. The main kitchen was inspected on 09/29/2021 at 9:57 AM. The bottle label of chemical concentrate used to sanitize food equipment in the 3-compartment sink stated the dilution is to be between 200 ppm and 400 ppm; the test kit used to measure the sanitizer did not provide color graduations to indicate if the solution is too concentrated. The automatic dishwashing machine final rinse water pressure was 12 pounds per square inch (psi); the manufacturer's instructions require the final rinse water pressure to be between 15 psi and 25 psi. The Dining Services Director stated in an interview on 09/30/2021 at 1:24 PM, that the dishwashing machine has been adjusted and is now rinsing at 20 psi, the dishwashing machine temperature log now includes the water pressure, and all staff have been in-serviced to record the water pressure and what to do if out of range. The Administrator stated in an interview on 10/01/2021 at 2:35 PM, that the facility will monitor the dishwashing machine water pressure and will contact the chemical manufacturer about the test papers. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.112(c), 14-113(a)

Based on medical record review and interviews during an abbreviated survey (Case #NY 222) the facility did not ensure one (Resident #4) of 9 residents reviewed, received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, for Resident #4, the facility did not ensure: the resident was provided with the interventions documented in the resident's Care Plan titled Risk for constipation due to use of narcotic pain relief ; did not ensure physicians orders were followed when the resident did not receive Milk of Magnesia every third and fourth day if no BM; did not ensure facility staff followed the policy titled Bowel Management dated ,[DATE]; and did not ensure the estimated amount of fluids necessary to meet the resident's daily needs were provided from [DATE] through [DATE], when facility staff were not aware of who was responsible for monitoring intake and the facility policy did not include the name or title or position of the person responsible. Additionally, a facility investigation into the resident's hospitalization was not thorough when it did not identify that the facility did not ensure any of the above. The resident's lack of a BM from [DATE] through [DATE] (12 days) and inadequate fluid intake from [DATE] through [DATE] resulted in the resident's transfer and admission to the hospital where the resident's [DIAGNOSES REDACTED]. The resident expired on [DATE]. This resulted in harm with the potential for more than minimal harm that is not immediate jeopardy. This was evidenced by: Resident #4: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) dated [DATE], assessed the resident to have no cognitive impairment. A review of the Nurse's notes documented the following: [DATE] 3:15 pm, the resident is admitted , quite weepy. [DATE] 1:07 am, self transferred three time without using the call light. [DATE] 9:25 pm, found on floor attempting to ambulate to bathroom, complained about increasingly severe back pain, sent to emergency room [DATE] 1:59 am, resident returned new order for [MEDICATION NAME]. [DATE], 5:48 pm [MEDICATION NAME] given with positive effects. 8:50 pm still having severe pain, physician notified and increased [MEDICATION NAME] to every four hours. [DATE] 2:36 pm, requested [MEDICATION NAME] with positive effect. [DATE] 2:08 pm, medicated for pain per physician's orders [REDACTED]. 10:04 pm requesting [MEDICATION NAME] for pain with effect. [DATE] 4:26 am, self transferred to bathroom, complained of pain, medicated with [MEDICATION NAME]. 3:11 pm found attempting to self transfer. 5:47 pm remains non-compliant with getting up on own. [DATE] 9:55 pm, requested [MEDICATION NAME] without positive effect. [DATE] 6:48 pm, found self ambulating to bathroom. [DATE] 6:56 am, medicated for pain twice with little effects, states terrible right side rib pain. 3:01 pm continues to self transfer. Asked to be toileted within five minutes of toileting, when toileted, not voiding. [DATE] 10:13 am, resident restless, agitated, unsafely self-transferring. 2:46 pm anxious and agitated this shift. Resident has attempted to self transfer this shift. Complained of pain and anxiety, given [MEDICATION NAME] and antianxiety medication without effects. [DATE] 12:10 pm, resident continues to refuse to eat or drink. [DATE] 5:09 am, called to unit for protruding circular area on the center of abdomen, records indicate last bowel movement on [DATE]. Physician notified who orders a rectal digital exam and if is impacted to call back to send out. 6:42 am hard formed stool palpated in the lower sigmoid, physician ordered to send for evaluation. 7:46 am resident complained of pain, medicated with some relief. Noticed resident's abdomen to be distended and hard to touch. Resident stated it was painful. A review of hospital medical records titled History & Physical (H&P) dated [DATE], revealed the resident came to the emergency room with abdominal pain and an abdominal x-ray showed copious stool, large bowel. It documented the resident received multiple soap suds enemas and manual disimpaction, a large amount of stool was removed from her rectum. It documented that the resident continues to complain of abdominal pain. The resident did appear to be uncomfortable stating her abdomen hurt. Under the H&P section titled abdomen, documented bowel sounds were present and the resident seemed tender in the lower quadrants. The resident was noted to be dehydrated. The hospital laboratory results dated [DATE], revealed the following: Sodium level was 149 (normal ,[DATE]) BUN 67 (Blood Urea Nitrogen / reflects kidney function, heart failure, dehydration or a diet high in protein can make BUN higher) (normal ,[DATE]), Creatinine 1.54 (reflects kidney function, dehydration may cause abnormal BUN and creatinine levels) (normal 0.55 - 1.02). A review of a facility form titled Investigation dated [DATE], documented that despite being constipated it was found that a documented BM was noted on ,[DATE] and MOM was given [DATE]. Interview with the UC (Unit Coordinator) resident did toilet herself and did not report to staff when she went. Staff had found her walking back to bed or chair from the bathroom and were not sure what she had done in the bathroom. The staff reported the family also toileted the resident. Resident received [MEDICATION NAME] (fiber) for constipation and MOM. Resident was on [MEDICATION NAME]. No abuse, neglect or mistreatment or failure to follow the careplan occurred. Investigation dated [DATE], documented that despite being constipated it was found that a documented BM was noted on ,[DATE] and MOM was given [DATE] During an interview with the RN/UC (Registered Nurse/Unit Coordinator) on [DATE] at 3:30 pm, the RN/UC stated the aides are usually very good about documenting BMs. The medication nurses review the BMs and report to the ,[DATE] medication nurse which residents need MOM. When the RN/UC was asked about the resident not receiving MOM after no documented bowel movements from ,[DATE] to [DATE], the RN/UC stated it was probably a mistake. The resident always toileted herself and the family also would toilet the resident. When the RN/UC was asked why that was not care planned, the RN/UC stated it should have been. When questioned about the documentation on the ADL Verification Worksheet the RN/UC stated the facility had changed to an electronic medical record and some things may have been missed. When questioned about who is responsible for monitoring the intakes, the RN/UC stated that the RD (Registered Dietician) is responsible. The RN/UC stated she was not able to find any additional documentation that the resident had a BM during that time period. During an interview with the DON (Director of Nursing) on [DATE] at 4:30 pm, the DON stated she completed an investigation in the resident's need for transfer to the hospital. When questioned about the resident not having a bowel movement in twelve days, the DON stated that the resident would toilet herself as well as the family. The DON was not able to provide a care plan for self toileting. During an interview with the physician on [DATE] at 3:00 pm, the physician stated he would expect to be notified that the resident had no BM in twelve days and usually the facility is good about notifying him. When the physician was asked about the lack of documentation regarding fluid intake, the physician stated he would expect dietary to be notified. The RD was interviewed on [DATE] at 3:30 pm and stated nursing will usually alert dietary via email or verbally of a concern with a residents intake. The RD stated the intake is reviewed only quarterly. When questioned if the RD had been notified she stated she was never notified that the resident had poor intake and would expect notification after the first week of poor intake. When asked who was responsible for reviewing the intake on the ADL Verification Worksheet, the RD stated the RN/UC would be responsible. Finding #1: The facility did not ensure the resident was provided with the interventions documented in the resident's Care Plan titled for Risk for constipation due to use of narcotic pain relief . A review of the resident's Care Plan dated [DATE], titled risk for constipation due to use of narcotic pain relief documented the following interventions: assist with toileting; encourage fluids: record bowel pattern via the electronic medical record: follow the bowel protocol: provide incontinence care and pads as needed; and help with pain using other methods than narcotics including repositioning, diversional activities and calming techniques. A facility form titled Nutritional Assessment dated [DATE], documented that the resident's estimated fluid needs were 1530 cc (cubic centimeters) per day. A review of a facility form titled ADL Verification Worksheet (used by the aides to document fluid intake) was reviewed from [DATE] to [DATE]. Twenty of forty-eight meals did not include documentation of fluid intake. Daily total intake from [DATE] to [DATE] (16 days) did not meet the recommended fluid intake by the RD (Registered Dietician). A facility policy titled Bowel Management dated ,[DATE], documented; if the resident has not had a bowel movement in three (3) days give first dose of Milk of Magnesia 30 cc (cubic centimeters) by mouth on the day shift. If no results repeat Milk of Magnesia on the fourth day. If no results by the fifth morning, give [MEDICATION NAME] suppository before getting the resident out of bed in the morning. If no results from the suppository follow-up with Fleets enema after breakfast. If the resident does not respond to this protocol, notify the RN (Registered Nurse) and make a MD (medical doctor) referral. It is the responsibility of the CNA (Certified Nursing Assistant) to notify the RN of no bowel movement for three consecutive days by documenting on the daily bowel results of the resident. A review of Bowel records for the period of time from [DATE] to [DATE], revealed no documented evidence that the resident had a BM from ,[DATE] through [DATE]. A review of facility records revealed no documented evidence that MOM was administered (other than on [DATE] and [DATE]), or that a CNA informed an RN of no BM for 3 days, or that a [MEDICATION NAME] suppository or a Fleets enema was administered, or that an MD referral was made. During an interview on [DATE] at 3:30 pm, with the RN/UC, the RN/UC stated the resident always toileted herself and the family also would toilet the resident. When the RN/UC was asked why that was not care planned, the RN/UC stated it should have been. There was no documented evidence that interventions to monitor the resident's BMs when the resident self toileted or the family toileted the resident were in place. Finding #2 The facility did not ensure physicians orders were followed when the resident did not receive Milk of Magnesia every third and fourth day if no BM. A review of Physician orders [REDACTED]. A review of the Bowel Records for the period of time [DATE] to [DATE], revealed the resident did not have a BM documented from ,[DATE] to [DATE]. A review of the form titled [DATE] Medications documented MOM was administered once on [DATE]. A review of the form titled [DATE] Medications documented that MOM was administered on [DATE] at 7:35 and Not Administered on [DATE] at 7:42 Order On Hold. Finding #3: The facility did not ensure that the policy titled Bowel Management dated ,[DATE], was followed by facility staff. A facility policy titled Bowel Management dated ,[DATE], documented; if the resident has not had a bowel movement in three (3) days give first dose of Milk of Magnesia 30 cc (cubic centimeters) by mouth on the day shift. If no results repeat Milk of Magnesia on the fourth day. If no results by the fifth morning, give [MEDICATION NAME] suppository before getting the resident out of bed in the morning. If no results from the suppository follow-up with Fleets enema after breakfast. If the resident does not respond to this protocol, notify the RN (Registered Nurse) and make a MD (medical doctor) referral. It is the responsibility of the CNA (Certified Nursing Assistant) to notify the RN of no bowl movement for three consecutive days by documenting on the daily bowel results of the resident. The policy does not document who is responsible for reviewing the daily bowel results. The ADL Verification Worksheet form included spaces to document the following; BM, BM where evacuated, BM continency, BM size, BM consistency and BM incontinence care. The ADL Verification Worksheet printed form for the time period of [DATE] through [DATE], revealed a documented response of No in the area for BM's from ,[DATE] to [DATE]. Review of the [DATE] MAR (Medication Administration Record) revealed the resident received MOM on [DATE] at 10:00 am. The MAR indicated [REDACTED]. Review of the [DATE] MAR indicated [REDACTED]. Additionally, it documented that the medication was not administered. There was no other documentation related to this medication administration or bowel movements. Finding #4: The facility failed to ensure that the resident received the estimated amount of fluids necessary to meet her daily needs from [DATE] through [DATE], when facility staff were not aware of who was responsible for monitoring intake and the facility policy did not include the name or title or position of the person responsible. A facility form titled Nutritional Assessment dated [DATE], documented that the resident's estimated fluid needs were 1530 cc (cubic centimeters) per day. A review of a facility form titled ADL Verification Worksheet (used by the aides to document fluid intake) reviewed from [DATE] through [DATE] revealed that twenty of forty-eight meals did not include documented evidence of fluid intake. Also, the daily total intake for the time period from [DATE] through [DATE] (16 days) did not meet the estimated fluid needs of 1530 cc as recommended by the RD (Registered Dietician). During an interview with the RN/UC (Registered Nurse/Unit Coordinator) on [DATE] at 3:30 pm, RN/UC stated that the RD (Registered Dietician) was responsible for monitoring the intakes. During an interview with the RD on [DATE] at 3:30 pm, the RD stated the RN/UC was responsible for reviewing the intake on the ADL Verification Worksheet. 10NYCRR415.12

Based on observation, record review and staff interview during an abbreviated extended survey (NY 766), the facility failed to ensure that systems were in place to administer, monitor and supervise residents who required respiratory care to ensure residents received the proper treatment and care. Specifically, 10 (Resident #s 1, 2, 3, 4, 7, 9, 10, 11, 13 and 14) of 14 residents reviewed did not have physician's orders [REDACTED]. This resulted in Immediate Jeopardy and Substandard Quality of Care. This is evidenced by: Policy and Procedure titled Oxygen Therapy Administration last revised 10/14, documented that the purpose of the policy is to safely administer oxygen therapy to those residents requiring it. The policy statement documented that Oxygen is a drug, therefore physician orders [REDACTED]. Emergency O2 standing orders need to address protocols that govern oxygen and allow the nurse to begin therapy independently. Essential steps documented in the procedure include: physician's orders [REDACTED].) and the condition of the resident. It further documented the specific oxygen orders will be documented on the blue oxygen medex (where oxygen administration is documented by Licensed Practical Nurses (LPN) and Registered Nurses (RN) and will included the liters per minute, oxygen saturation (O2 sat) frequency and physician orders. The policy documented that a nurse may obtain a discretionary O2 sat, can administer oxygen at 2 liters per minute if the O2 sat is less than 90% and follow-up physician's for routine oxygen orders need to be obtained within 24 business hours. Further, based on the resident's condition and O2 sat, the RN can increase the liters per minute and update the physician. Emergency Standing Orders last revised 10/14, documented that medication and procedures may be initiated by the RN supervisor with the immediate notification of the physician. A nurse may obtain a discretionary O2 sat after observing air hunger, shortness of breath, cyanosis or change in mental state. Nursing Guidelines Resident Admission / Readmission last reviewed 12/14, documented that the nurse will take off physician's orders [REDACTED]. Resident #1: The resident was readmitted to the facility from the hospital on [DATE], diagnosed with [REDACTED]. The resident was documented with moderate cognitive impairment upon readmission. physician's orders [REDACTED].#1 as telephone orders from the resident's physician. Comprehensive Care Plan, Potential for Respiratory Complications due to [MEDICAL CONDITION] documented that on 9/8/15, the resident returned from the hospital on oxygen continuous at 2 lpm. The care plan documented administer O2 per MD order. Nurse's Note dated 9/8/15 at 5:00 pm, signed by RNS #1, documented that the resident returned from the hospital at 4:40 pm, alert, in good spirits, and in no respiratory distress. RN #1 documented that the hospital discharge [DIAGNOSES REDACTED]. RN #1 documented that telephone orders were received by Physician #2, and that the resident's O2 sat was 95%. There is no documentation of the administration or use of oxygen for the resident. Nurse's note dated 9/8/15 at 10:00 pm, signed by LPN #1, documented the resident's O2 sat at 95% on 2 lpm. Nurse's note dated 9/9/15 at 3:00 am, signed by RN #1, documented the resident on oxygen at 2 lpm via nasal cannula. Nurse's note dated 9/9/15 at 4:00 am, signed by LPN #2, documented the resident's O2 sat of 96% on room air. Nurse's note dated 9/9/15 at 3:00 pm, signed by the Director of Nursing (DON), documented that physical therapy noted resident with oxygen out of resident's nose and a low O2 sat. Oxygen at 3 lpm was applied and Physician #1 notified ordered nebulizer treatment and O2 sat up to 88%. Chest x-ray ordered for 9/10/15. Resident did not appear short of breath when assessed by the unit coordinator, no cyanosis noted lips or nails. Continue O2 at 2 lpm on concentrator. physician's orders [REDACTED]. There are no changes in liter per minute by the physician after the 9/9/15 3:20 pm. Nurse's note dated 9/9/15 at 7:20 pm, LPN #1 documented the resident's O2 sat at 6:55 pm read 93% on 3 liters of oxygen per minute. Nurse's note dated 9/9/15 at 10:00 pm, RNS #1 documented the resident's O2 sat was 93% on 3 liters of oxygen. September 2015 Medex documented O2 via nasal cannula or mask at 2 liters per minute to maintain O2 sat greater than 90% was initiated and initialed 9/9/15 the 3pm - 11pm shift. Nurse's note dated 9/10/15 at 2:45 am, RN #1 documented the resident was on 3 liters of oxygen per minute and her O2 sat was 97%. September 2015 Medex documented O2 via nasal cannula or mask at 2 liters per minute to maintain O2 sat greater than 90% was initialed 9/10/15 the 11:00 pm - 7:00 am shift. Nurse's note dated 9/10/15 at 8:45 am, Registered Nurse Unit Coordinator (Unit Coordinator) documented that the resident's O2 sat was 95% on room air. Nurse's note dated 9/10/15 at 11:00 am, Unit Coordinator documented that the resident's physician was in to see resident, reviewed chest x-ray and ordered the resident to the hospital for evaluation and treatment. Nurse's note dated 9/10/15 at 11:30 am, Unit Coordinator documented the resident's transfer to the hospital for continued increase in respirations and difficulty breathing worsening prior to leaving, O2 sat at 92% 3 liters via nasal cannula. September 2015 Medex documented O2 via nasal cannula or mask at 2 liters per minute to maintain O2 sat greater than 90% was initialed 9/10/15 the 7:00 am - 3:00 pm shift. During an interview on 9/22/15 at 4:10 pm, Physician #2 stated that the role of nursing staff is to report to the physician if there is a resident with a new need for oxygen. Physician #2 stated that the physician will investigate whether the need is acute, will give an oxygen order and will specify the liters per minute to administer the oxygen to the resident. Physician #2 stated that in the case of residents diagnosed with [REDACTED]. When questioned if nursing staff could increase the oxygen rate for a resident with [MEDICAL CONDITION] without a physician's orders [REDACTED]. Physician #2 stated that nursing staff can assess a resident's change in condition, but they need to obtain a physician's orders [REDACTED]. During an interview on 9/23/15 at 12:30 pm, the DON stated the resident returned from the hospital on 2 liters of continuous oxygen and on 9/8/15 and was observed on 9/9/15 unresponsive with her nasal cannula attached to an empty oxygen tank. The DON stated that she investigated the incident to determine root cause, which was determined to be that the resident's nasal cannula was attached to an empty portable oxygen tank. The DON was asked to review the resident's physician's orders [REDACTED]. The DON reviewed the physician's orders [REDACTED]. The DON was asked to review the oxygen monitoring medex. The DON stated that the oxygen monitoring was not initiated until 9/9/15 on the 3 :00 pm - 11:00 pm shift, after the incident. The DON stated that RNS #1 got readmission orders [REDACTED]. When asked how RNS #1 responded when the DON asked her why there were no orders, the DON stated I didn't talk to the nurse yet, so I don't know why the order is not there. The DON stated that she thought there were oxygen orders somewhere in the emergency standing orders and that nurses were within their scope of practice when they placed oxygen on a resident. The DON was asked if a readmission would be considered an emergency, and the DON stated no. The DON stated that you went beyond my investigation, I hadn't gotten to the point of looking at the protocols. The DON stated that she reviewed all of the oxygen orders for all resident's last night (9/22/15) and felt as though some of the oxygen orders written by the physician's were setting the nursing staff up to fail because they did not include the liters per minute. The DON stated that communication had been sent to the Medical Director to discuss the problem. The DON stated that the RNs can increase the oxygen, they should write it in the physician's orders [REDACTED]. The DON stated that the physician orders [REDACTED]. During an interview on 9/24/15 at 12:00 pm, RNS #1 stated that she was the RNS that readmitted the resident to the facility on [DATE]. RNS #1 stated that when a resident arrives back to the facility, the RNS get the readmission orders [REDACTED]. RNS #1 stated that when she called the resident's physician she just read off the orders as they were written. RNS #1 stated that she will typically review the discharge summary from the hospital for her own knowledge and should have seen that the resident was on continuous oxygen therapy. RNS #1 stated that she knew that the resident was on continuous oxygen, so if the oxygen order is not there, I missed it. During an interview on 9/24/15 at 1:15 pm, Unit Coordinator #1 stated that often times when a resident is going to be readmitted to the facility, she will obtain the medication list from the hospital and prepare the physician readmission orders [REDACTED]#1 had prepared. The Unit Coordinator stated that she does not recall if she informed RNS #1 that O2 orders were not included and needed to be obtained from the physician. Unit Coordinator #1 stated that the physician had seen the resident on the morning of 9/9/15 and she knows that the resident had oxygen on throughout the day. Unit Coordinator #1 stated that after the incident, she is not aware of who picked up the fact that there was no oxygen order, but it was identified and the physician wrote an oxygen order after the incident. During an interview on 9/23/15 at 4:00 pm, the Medical Director stated that when a resident comes to the facility after being discharged from a hospital, the facility will get a discharge summary with the resident's course of treatment and medications and treatments as ordered in the hospital. The Medical Director stated when the resident arrives to the facility, nursing staff review the discharge summary and orders, contacts the physician and requests the physician orders. The Medical Director stated that orders should be obtained and the physician should provide the range or reference as necessary for medications and treatments, including the flow of liters per minute for oxygen orders. The Medical Director stated that oxygen use requires an immediate physician's orders [REDACTED]. The Medical Director stated that monitoring orders for oxygen should be consistent with the physician's orders [REDACTED]. Resident #2: The resident was readmitted from the hospital on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident's cognition in Brief Interview Mental Status (BIMS ) as 15/15, no cognitive impairment. Observation of the resident on 9/22/15 at 12:10 pm: lying in bed with Oxygen (O2) 4 liters per minute (lpm) via nasal cannula (nc) via O2 concentrator. Comprehensive Care Plan, Potential for Respiratory Complications due to [MEDICAL CONDITION] documented that on 6/18/15, the resident had the potential for respiratory complications due to [MEDICAL CONDITION] and documented administer O2 per MD order. physician's orders [REDACTED]. August 2015 Medex initiated on 8/3/15 3pm-11pm shift, documented O2 via nc or mask at 2 lpm, and a number 4 is written over the number 2, to maintain O2 sat greater than 90%. The medex is initialed daily, on each shift, with the exception of 8/20/15 and 8/21/15, 3pm - 11pm shift. September 2015 Medex documented O2 via nc or mask at 4 lpm to maintain O2 sat greater 90%. The medex is initialed daily, on each shift, from September 1st 7:00 am -3:00 pm shift through September 22nd, 7:00 am - 3:00 pm shift. Renewal Physician order [REDACTED]. physician progress notes [REDACTED].#2, documented resident's O2 sat was 92% on two liters. During an interview on 9/22/15 at 12:00 pm, LPN #1 reviewed the physician's orders [REDACTED]. LPN #1 escorted the surveyor to the resident at 12:10 pm, observed the resident's oxygen concentrator, and stated that the resident was receiving oxygen at 4 lpm. During an interview on 9/22/15 at 12:20 pm, RN #2 was asked to review the resident's medical record and locate the physician's orders [REDACTED]. RN #2 stated that the O2 order dated 9/8/15 which documented wean and d/c O2 as tolerated to keep O2 sat at 90% or greater. RN #2 stated that there was no order for O2 at 4 lpm. During an interview on 9/22/15 at 1:20 pm, Physician #1 stated that oxygen orders are written by any of the facility physician's and can be changed by any other physician, but nursing staff cannot change an oxygen order on their own. Physician #1 stated that the nursing staff may try to taper a resident's oxygen by lowering the liters per minute every 4 hours to maintain a saturation rate above 90%. The physician stated while the nursing staff are attempting to taper oxygen, they may wait to get a physician's orders [REDACTED]. During an interview on 9/23/15 at 4:00 pm, the Medical Director stated that orders should be obtained and the physician should provide the range or reference as necessary for medications and treatments, including the flow of liters per minute for oxygen orders. The Medical Director stated that oxygen use requires an immediate physician's orders [REDACTED]. Resident #4: The resident was admitted to the facility on [DATE] and readmitted from the hospital on [DATE], with a [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident''s cognition in Brief Interview Mental Status (BIMS) as 14/15; no cognitive impairment. Observation on 9/22/15 at 12:40 pm; resident was in bed on oxygen at 4 liters via nasal cannula through a concentrator. Comprehensive Care Plan, Potential for Respiratory Complications due to [MEDICAL CONDITION] documented on 7/27/15, the resident had the potential for respiratory complications due to lung disease and documented administer O2 per MD order. physician's orders [REDACTED]. Nurse's note dated 9/14/15 at 3:00 am, LPN #3 documented an O2 sat of 86%-88% on 3 liters. Next entry of Nurse's note (no date documented) timed 8:30 pm, LPN #3 documented an O2 sat of 95 % on 3 liters. Nurse's note dated 9/15/15 at 3:45 am, LPN #3 documented an O2 sat of 96% on 3 liters. Nurse's note dated 9/15/15 at 2:30 pm, RN # 2 documented an O2 sat of 95% on 3 liters. Nurse's note dated 9/15/15 at 8:50pm, LPN #3 documented an O2 sat of 95% on 3 liters. Nurse's note dated 9/17/15 at 4:00 am, LPN #4 documented an O2 sat of 94% on 3 liters. Nurse's note dated 9/17/15 at 4:35 am, LPN #4 documented an O2 sat of 95% on 3 liters. Nurse's note dated 9/18/15 at 7:45 pm, LPN #5 documented an O2 sat of 94%, continues on 3 liters. Nurse's note dated 9/19/15 at 3:50 am, LPN # 3 documented an O2 sat of 93% 2 liters. Asleep in bed denies discomfort, O2 cont at 3l via nc. Nurse's notes dated 9/19/15 - 9/21/15 at 4:30 am, document the resident on oxygen at 3 lpm. Nurse's note dated 9/21/15 at 6:15 pm, RNS #2 documented an O2 sat of 79% on 3 lpm. Nurse's note dated 9/21/15 at 7:00 pm, RNS #3 documented oxygen therapy increased to 4 lpm, O2 sat to 84%, new physician order [REDACTED]. physician's orders [REDACTED]. Nurse's note dated 9/21/15 at 11:00 pm, RNS #2 documented that the resident was returned from the hospital with an O2 sat at 95% on 4 liters. on-call provider notified of return, no new orders received. There are no additional physician's orders [REDACTED]. September 2015 Medex documented O2 via nasal cannula or mask at 4 next to a 2 that is X over, 2 liters per minute to maintain O2 sat greater than 90% and handwritten in *prn for comfort*. The medex is initialed daily, on each shift, from September 14th 11:00 pm - 7:00 am shift through September 22nd, 7:00 am - 3:00 pm shift, with the exception of blanks on 9/16, 9/17, 9/19 3:00 pm - 11:00 pm, 9/18 7:00 am - 3:00 pm, and 9/20/15 11:00 pm - 7:00 am. During an interview on 9/22/15 at 1:10 pm, Registered Nurse Unit Coordinator (Unit Coordinator) #1 reviewed the resident's medical record and stated that the current order is the 9/14/15 order Oxygen (O2) at 2 liters per minute (lpm) via nasal cannula to maintain O2 sat at greater than 90%. The Unit Coordinator accompanied the surveyor to the resident's room, observed the resident's oxygen concentrator and stated oh, its on 4 liters, I am not sure why, I will have to check. During an interview on 9/22/15 at 1:15 pm, LPN #1 stated that she had checked the resident at around 12:00 pm and the resident's O2 sat was 98% on 4 liters of oxygen. During an interview on 9/22/15 at 1:20 pm, Physician #1 stated that oxygen orders are written by any of the facility physician's and can be changed by any other physician, but nursing staff cannot change an oxygen order on their own. Physician #1 stated that the nursing staff may try to taper a resident's oxygen by lowering the liters per minute every 4 hours to maintain a saturation rate above 90%. The physician stated while the nursing staff are attempting to taper oxygen, they may wait to get a physician's orders [REDACTED]. During a follow-up interview on 9/22/15 at 1:50 pm, the Unit Coordinator stated that the resident came back from the hospital last night on 4 liters of oxygen, however, there is no order in the chart. The Unit Coordinator stated that she would have the physician review the chart and update the orders. During an interview on 9/23/15 at 4:00 pm, the Medical Director stated that orders should be obtained and the physician should provide the range or reference as necessary for medications and treatments, including the flow of liters per minute for oxygen orders. The Medical Director stated that oxygen use requires an immediate physician's orders [REDACTED]. The Immediate Jeopardy identified on 9/23/15 was removed on 9/24/15, when the facility took the following measures: O2 issues were discussed with the attending physician and an email sent to the Medical Director; O2 administration policy reviewed and revised as necessary; 7-3 RN Supervisor and RN Unit Coordinators reviewed each resident's O2 order for accuracy and clarity. Any order identified as a concern was reviewed with the physician; O2 orders were compared to the MAR for accuracy and any discrepancies were corrected; Ninety percent of the RN ' s and LPN ' s were in serviced on changes to the O2 Guidelines; Each resident on O2 MAR and Care Plan were reviewed by the ADNS (Assistant Director of Nursing Services) and Unit Coordinator to ensure that the MAR, and Care plan reflected the number of oxygen liters ordered by the physician. 10 NYCRR 415.12 (k) (6)

Based on record review, observation and interviews during an abbreviated survey, (Case # NY 766), it was determined that the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently. The facility failed to ensure that systems were in place to administer, monitor and supervise residents who required respiratory care, to ensure residents received the proper treatment and care. Specifically, 10 of 14 residents reviewed did not have physician's orders [REDACTED]. This resulted in Immediate Jeopardy to Resident Health and Safety and Substandard Quality of Care. This was evidenced by: Refer to F Tag 328 Scope/Severity K Quality of Care Policy and Procedure titled Oxygen Therapy Administration last revised 10/14 documented that the purpose of the policy is to safely administer oxygen therapy to those residents requiring it. The policy statement documented that Oxygen is a drug, therefore physician orders [REDACTED]. Emergency O2 standing orders need to address protocols that govern oxygen and allow the nurse to begin therapy independently. Essential steps documented in the procedures included; that the physician's orders [REDACTED].) and the condition of the resident. It is further documented that the specific oxygen orders will be documented on the blue oxygen medex (where oxygen administration is documented by Licensed Practical Nurses (LPN) and Registered Nurses (RN) and will included the liters per minute, oxygen saturation (O2 sat) frequency and physician orders. The policy documented that a nurse may obtain a discretionary O2 sat, can administer oxygen at 2 liters per minute if the O2 sat is less than 90% and follow-up physician's for routine oxygen orders need to be obtained within 24 business hours. Further, based on the resident's condition and O2 sat, the RN can increase the liters per minute and update the physician. Emergency Standing Orders last revised 10/14 documented that medication and procedures may be initiated by the RN supervisor with the immediate notification of the physician. A nurse may obtain a discretionary O2 sat after observing air hunger, shortness of breath, cyanosis or change in mental state. Nursing Guidelines Resident Admission / Readmission last reviewed 12/14 documented that the nurse will take off physician's orders [REDACTED]. During an interview on 9/23/15 at 12:30 pm, the Director of Nursing (DON) stated that Resident #1 returned from the hospital on 2 liters of continuous oxygen and on 9/8/15 and was observed on 9/9/15 unresponsive with her nasal cannula attached to an empty oxygen tank. The DON stated that she investigated the incident to determine root cause, which was determined to be that the resident's nasal cannula was attached to an empty portable oxygen tank. The DON was asked to review the resident's physician's orders [REDACTED]. The DON reviewed the physician's orders [REDACTED]. The DON was asked to review the oxygen monitoring medex. The DON stated that the oxygen monitoring was not initiated until 9/9/15 on the 3pm - 11 pm shift, after the incident. The DON stated that RNS #1 got readmission orders [REDACTED]. When asked how RNS #1 responded when the DON asked her why there were no orders, the DON stated I didn't talk to the nurse yet, so I don't know why the order is not there. The DON stated that she thought there were oxygen orders somewhere in the emergency standing orders and that nurses were within their scope of practice when they placed oxygen on a resident. The DON was asked if a readmission would be considered an emergency, and the DON stated no. The DON stated that you went beyond my investigation, I hadn't gotten to the point of looking at the protocols. The DON stated that she reviewed all of the oxygen orders for all resident's last night (9/22/15) and felt as though some of the oxygen orders written by the physician's were setting the nursing staff up to fail because they did not include the liters per minute. The DON stated that communication had been sent to the medical director to discuss the problem. The DON stated that the RNs can increase the oxygen, they should write it in the physician's orders [REDACTED]. The DON stated that the physician orders [REDACTED]. During an interview on 9/24/15 at 1:15 pm, Unit Coordinator #1 stated that often times when a resident is going to be readmitted to the facility, she will obtain the medication list from the hospital and prepare the physician readmission orders [REDACTED]. The Unit Coordinator stated that she does not recall if she informed RNS #1 that O2 orders were not included and needed to be obtained from the physician. Unit Coordinator #1 stated that the physician had seen the resident on the morning of 9/9/15 and she knows that the resident had oxygen on throughout the day. Unit Coordinator #1 stated that after the incident, she is not aware of who picked up the fact that there was no oxygen order, but it was identified and the physician wrote an oxygen order after the incident. During an interview on 9/23/15 at 4:00 pm, the Medical Director stated that when a resident comes to the facility after being discharged from a hospital, the facility will get a discharge summary with the resident's course of treatment and medications and treatments as ordered in the hospital. The Medical Director stated when the resident arrives to the facility, nursing staff review the discharge summary and orders, contacts the physician and requests the physician orders. The Medical Director stated that orders should be obtained and the physician should provide the range or reference as necessary for medications and treatments, including the flow of liters per minute for oxygen orders. The Medical Director stated that oxygen use requires an immediate physician's orders [REDACTED]. The Medical Director stated that monitoring orders for oxygen should be consistent with the physician's orders [REDACTED]. During an interview on 9/24/15 at 10:15 am, the Administrator stated that he was aware of an investigation into an incident in which Resident #1 was found without oxygen and was informed by the DON that the resident was connected to an empty portable oxygen tank. The Administrator stated that it wasn't until after the surveyor identified the lack of an oxygen order that the the facility began to review lack of or inconsistent oxygen orders as a concern. The Administrator stated that the facility has reviewed all resident's with oxygen and determined that some of the physician's orders [REDACTED]. The Administrator stated, we are working on clarifying and correcting all of the orders. 10 NYCRR 415.26

Based on medical record review and staff interviews during an abbreviated survey, (Case # NY 766), the facility failed to provide a Quality Assessment and Assurance (QAA) Program that readily and effectively identified issues with the potential to cause serious harm to the health and safety of residents. Specifically, the facility failed to ensure that systems were in place to administer, monitor and supervise residents who required respiratory care to ensure residents received the proper treatment and care. This resulted in Immediate Jeopardy to Resident Health and Safety and Substandard Quality of Care. This was evidenced by: Refer to F Tag 328 Scope/Severity K Quality of Care During an interview on 9/24/15 at 9:45 am, the Associate Administrator (AA) stated that she was the Quality Assurance Process Improvement (QAPI) Coordinator for the facility. The AA stated that she is involved in quality initiatives, however, is not that involved with nursing department and would be brought into issues as needed by the Administrator. The AA stated that she was not aware of any systems issues related to resident's on oxygen therapy until last night (9/23/15). During an interview on 9/24/15 at 10:15 am, the Administrator stated that not all nursing issues being audited are brought to the QAPI and was not aware of any identified concerns regarding residents on oxygen. The Administrator stated he is now aware that nursing staff may have had concerns about the way physician's orders [REDACTED]. The Administrator stated that for the most part he thought that nurses sought clarification as needed with physician's, but in this situation, it didn't appear to be so. 10 NYCRR 415.27(a-c)

Based on observation, record review, and staff interviews during an abbreviated survey (Complaint #NY 870), the facility did not consult with the physician or notify the family representative when one (Resident #2) of five residents reviewed for falls, sustained falls resulting in injury and had the potential for requiring physician intervention. Specifically, Resident #2's physician was not consulted nor the family representative notified when the resident, who was receiving anticoagulant therapy (xarelto, a blood thinner), had a fall on 6/3/14 at 5:00 am, was transferred to the emergency department (ED) at 1:00 pm, diagnosed with [REDACTED]. This resulted in actual harm that was not Immediate Jeopardy. This was evidenced by: Resident #2 The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident # 2 had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 4 according to the Minimum Data Set ((MDS) dated [DATE]. The Resident Incident Report (Fall #1) dated 5/5/14 at 2:25 am, signed by a Registered Nurse Supervisor (RNS #1) documented the resident was found sitting on the floor at the side of his bed, and sustained the following injuries; left knee abrasion, left elbow abrasion, left back abrasion measuring 5 centimeter (cm) by 1 cm, and a left eye top of lid abrasion. It was documented that there was no witness to the fall and that the medical doctor (MD) and family representative was not notified of these injuries. The facility Policy & Procedure (P&P) titled "Accident/Incident Reporting " dated as revised January 2009 documented "for unwitnessed falls or for striking the head, to notify the doctor for further recommendations." Nursing progress note dated 5/5/14 at 2:25 am and signed by RNS #1 documented that the resident was found on the floor next to his bed he sustained a small abrasion to the left elbow, left knee with some bruising, left eyebrow and a larger abrasion 5 cm by 1 cm to the left side of back. There was no documentation that the MD or the family representative were notified of the fall or injuries. Review of the 24 hour shift report dated 5/5/14 and 5/6/14 revealed no documentation in regards to notifying the MD of the unwitnessed fall with injury. The Resident Incident Report (fall #2) dated 5/24/14 at 1:10 pm was signed by a registered nurse (RN) and documented the resident was found sitting on the floor in front of his dresser facing his closet, no injury sustained. The Resident Incident Report documented that the physician was not notified. Nursing progress note dated 5/24/14 at 1:30 pm and signed by an RN documented, unwitnessed fall in bedroom next to bed, said he fell on his bottom. Denies hitting his head, no apparent head injury, blood pressure (BP) 180/113. There was no documentation of the MD being consulted about the unwitnessed fall or the elevated BP. A physician telephone order dated 5/3/14 at 3:15 pm documented "Call MD if BP greater than 170/100". Nursing progress note dated 5/24/14 at 2:30 pm and signed by an licensed practical nurse (LPN) documented the resident has positive range of motion (ROM) all four extremities, ambulating with walker, assist, and gait belt with no problems noted. BP rechecked after fall and noted to be 161/91. There was no documentation of the MD being consulted about the unwitnessed fall. Review of 24 hour shift report dated 5/24/14 and 5/25/14 revealed there was no documentation in regards to notifying the MD of the unwitnessed fall or the elevated BP. The Resident Incident Report (fall #3) dated 5/31/14 at 7:50 am documented the resident fell and was found in his room near the closet, no injury sustained, there was no witness to the fall. The section of this form for MD notification was blank. Nursing progress note dated 5/31/14 at 7:50 am and signed by an RNS documented, the resident found on floor sitting in front of closet door. No complaints of pain, neuro exam-pupils constrict to light. No lacerations, hematomas or abrasions noted. Family aware of incident. There was no documentation regarding consulting the MD of the unwitnessed fall. Review of 24 hour shift report dated 5/31/14 and 6/1/14 revealed no documentation in regards to notifying the MD of the unwitnessed fall. The facility's form titled "Resident Incident Report" signed by RNS dated 6/3/14 and initiated at 5:00 am documented the resident fell and was found in bathroom with wheeled walker backwards on toilet, and wheelchair outside bathroom, no injury sustained, stating "he hit his head on the bridge of his neck" and had a crescent shaped red mark on his back below his shoulder. The section on the I&A form for MD notification included a check for MD not notified. The section on the I&A form for family notification was checked no. The "physician's review" section of this report documented at 2:10 pm on 6/3/14 that the resident had developed elevated blood pressure, vomiting with headache and was sent to the emergency department (ED) at 1:00 pm. The ED report documented that a CT (computerized tomography) scan showed a left subdural hematoma with a significant midline shift, possible herniation. Nursing progress note dated 6/3/14 at 5:05 am and signed by an RNS documented, Resident found sitting on bathroom floor. Resident hit his head on the toilet as he tried to turn around. There are no bruises or open areas. He did have a small crescent shaped red line just below right shoulder. He said he hit the bridge of his neck where his head meets his neck. The nursing progress note did not have documented evidence that the MD or family were notified. Nursing progress note dated 6/3/14 at 1:00 pm and signed by the RN Charge Nurse documented, the resident complained of headache and wanting to go back to bed, Resident states headache 10/10. Vital signs checked 179/119 manual BP lying, pulse 69, respirations 19, O2 sat 97%. Pupils are bilateral equal and responsive, answer question appropriately, no trouble with vision, denies dizziness/lightheadedness. Resident made comfortable in bed, cold cloth place on forehead, gave Resident Tylenol 650 mg, Xarelto, and [MEDICATION NAME] (treats BP). Resident swallowed with no difficulty, then began to vomit, MD notified and ordered to send to emergency room . CT scan report dated 6/3/14 from the hospital documented, large acute on chronic left subdural hemorrhage with significant midline shift of greater than 11 millimeters (mm). Possible developing uncal (a condition in which the medial part of the temporal lobe protrudes over the tentorial edge as a result of increased intracranial pressure. If uncorrected, the progressive disorder causes pressure on the brainstem after first impinging on the third cranial nerve. A dilated pupil on the side of the herniation is a diagnostic sign of the disorder) herniation. Facility investigation revealed a statement written by RN Nurse Manager (RNM) and dated 6/3/14 documented that vital signs stable throughout shift until 1:00 pm when Resident complained of headache, which he described as 10/10 pain asking to go to bed. Manual BP was obtained at 179/114. We had Resident for evaluation in the MD book for the sebaceous cyst on the right shoulder area, but sent him to emergency room per MD. Facility investigation revealed a statement written by the RN Charge nurse and dated 6/4/14 that a note was placed on Resident's orders for MD to reassess skin area while seeing Resident for status [REDACTED]. BP taken manually and was 179/119, pupils were bilaterally equal, re-active, and responsive. Team leader informed that she had given Tylenol for headache and scheduled medications. This writer went to page MD to inform of condition, shortly after leaving room approximately at 1:15 pm Resident began to vomit. MD notified of Resident's change in condition was quick onset and status [REDACTED]. During an interview on 7/2/14 at 12:30 pm the RN Charge Nurse stated that when a resident falls and there is an actual head injury or suspicion the Medication Administration Record [REDACTED]. During an interview on 7/2/14 at 2:30 pm the Attending MD stated that the nurses usually notify him of falls. MD did not recall getting any phone calls in regards to Resident # 2's falls. During an interview on 7/10/14 at 8:25 am LPN # 3 stated that the MD should have been notified of the fall, did not know why MD was not notified. Usually a conversation would take place between the Supervisor and the LPN and decide who would call the MD, the conversation did not take place for the fall of 6/3/14. During an interview on 7/10/14 at 9:50 am RN UC (Unit Coordinator) who started employment at the facility on 6/3/14, stated that going forward the MD will be called for all Residents on anticoagulant therapy and who have a fall. RN will assess the residents when they fall and determine who will call the MD. During an interview on 7/10/14 at 10:10 am RN Charge Nurse stated that on 6/3/14 during morning report he heard that Resident # 2 fell and MD was not notified for all four falls that Resident # 2 had, and should have been notified for all of them. During an interview on 7/17/14 at 1:50 pm the Medical Director stated he knew about the last fall on 6/3/14 and that the physician should have been notified. The first fall when the resident sustained [REDACTED]. The last fall on 6/3/14 with no evidence of injury, he was not sure if he would have sent him to the ER. During an interview on 7/17/14 at 1:40 pm RNS #2 stated that the Resident having a high BP 180/113 during the fall assessment, would not call the MD, he would monitor for a short time to see if it came down. Having a blood pressure one hour later of 161/91, RNS # 2 was not sure if he would call the MD. During an interview on 7/17/14 at 8:48 am RNS #1 stated that the MD would be called if a hip was out of alignment, there was discomfort in the legs or eyes, or if stitches were required. Don't usually send to hospital unless resident requested. RNS # 1 was working the day of the 5/5/14 fall and the 6/3/14 fall, was not aware that the resident was on Xarelto until the last fall. The P&P documents to call the MD, if they hit their nose or eye. RNS # 1 would have documented if the MD was called. 10NYCRR 415.3(e)(2)(ii)(b)

Based on observation, record review, and staff interviews during an abbreviated survey (complaint #NY 870), the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one ( Resident #2) of three residents reviewed for standards of care for residents on anticoagulants (blood thinner) who have had unwitnessed falls with suspected head injury. Specifically, Resident #2 who was receiving an anticoagulant Xarelto, had four unwitnessed falls in a 30 day period. The first unwitnessed fall resulted in several abrasions including a head abrasion. The second and third fall were unwitnessed with no injury documented. The fourth fall documentation included no visible injury, however, the resident stated he had hit his head. The resident subsequently complained of headache and vomited, was transferred to the emergency room and diagnosed with [REDACTED]. The resident expired the following morning. The physician was not notified following all four unwitnessed falls and neurological assessments for this resident receiving a blood thinner were not performed consistently. This resulted in actual harm which was not Immediate Jeopardy. This was evidenced by: Resident #2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #2 had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 4 according to the Minimum Data Set ((MDS) dated [DATE]. Resident #2 had four unwitnessed falls on [DATE], [DATE], [DATE] and [DATE]. The first fall resulted in several abrasions including a head abrasion. The second and third fall were unwitnessed with no injury documented. The fourth fall was documented as no visible injury. The resident stated he had hit his head. During the following shift the resident complained of a headache, had an elevated blood pressure (BP), vomited, was subsequently transferred to the emergency room and diagnosed with [REDACTED]. The Resident expired the following morning. Care plan entitled Potential for side effects from anticoagulant use, and dated [DATE] documented Resident has the potential for side effects from the need of anticoagulant secondary to AFib, flutter, uses Xarelto. Update dated [DATE] documented no signs/symptoms (s/s) of bleeding. Approaches included; monitor and report s/s of side effects such as smokey urine, hematuria, bruising. Care plan entitled At risk for complications from Cardiovascular Disease and dated [DATE] documented, at risk for complications from cardiovascular disease due to the following diagnosis; Afib, flutter, Hypertension (HTN), [MEDICAL CONDITION] HTN. Approaches included; monitor and report s/s such as chest pain, one sided weakness, diaphoresis, and change in vital signs. A physician telephone order dated [DATE] documents Call MD (medical doctor) if BP>,[DATE] or HR (heart rate) less than 50. Resident Incident Report dated [DATE] at 2:25 am and signed by a Registered Nurse Supervisor (RNS) documented Resident #2 who was receiving Xarelto (anticoagulant) was found sitting on the floor at the side of his bed, and had sustained the following injuries; left knee abrasion, left elbow abrasion, left back abrasion measuring 5 centimeter (cm) by 1 cm, and a left eye top of lid abrasion. There was no documented evidence that the MD was notified of the unwitnessed fall. Nursing progress note dated [DATE] at 2:25 am and signed by the RNS documented Resident #2 was found on the floor next to his bed sustaining a small abrasion to the left elbow, left knee with some bruising, left eyebrow and a larger abrasion (5 centimeter (cm) by 1 cm) to the left side of back. Blood pressure (BP) was ,[DATE], pulse 61, respirations 22. There was no documented evidence in this progress note that the MD was notified of the unwitnessed fall. Review of 24 hour shift report dated [DATE] on the 11:00 pm to 7:00 am shift did not include documented evidence that the MD had been notified of the unwitnessed fall. Neuro Check Flow Sheet dated as reviewed ,[DATE] documented in bold letters, "If resident is on anticoagulation therapy continue neuro checks every 4 hours until discontinued by the MD/Nurse Practitioner (NP). The frequency of neuro checks may be increased per RN judgement. Neuro checks were initiated for all four falls and none were performed completely as the neuro check forms contained blanks, and that resident was sleeping or eating. Review of the neuro check forms revealed that the forms either had blanks where neuro checks should have been done, documentation that the resident refused the neuro check, or that the neuro check was not done at the frequency that the facility form and policy indicated and finally that the neuro check was not done as the resident was sleeping or eating. For example: Review of the Neuro check flow sheet dated [DATE] at 2:25 am; documentation in the column for baseline neuro checks was incomplete. The remainder of the columns to complete for the neuro checks were as follows: First check did not include the time documented; blood pressure, pulse and respiration were also not completed. The second and third 15 minute checks were 30 minutes apart. The third and fourth 15 minute checks was 75 minutes apart with the fourth check documented as refused. The first 30 minute check following the 15 minute checks was one hour apart. There were no four hour neuro checks performed. During an interview on [DATE] at 8:48 am RNS #1 stated that neuro checks are done initially with a fall, range of motion is done, and a body check. MD would be called if a hip was out of alignment, there was discomfort in the legs or eyes, or if stitches were required. Don't usually send to hospital unless resident requested. RNS #1 was working the day of the [DATE] fall and the [DATE] fall, was not aware that the Resident was on Xarelto (anticoagulant) until the last fall. The P&P documents to call the MD, if they hit their nose or eye. RNS #1 stated she would have documented if the MD was called. RNS #1 stated she would initiate neuro checks, but does not follow-up that the neuro checks are being done by the Licensed Practical Nurse (LPN). The [DATE] neuro check list documented refusals for neuro checks on three occasions and the LPN should have notified the Supervisor. The neuro checks should be done every 15 minutes for two hours, every 30 minutes for one hour then every four hours until MD is notified. Resident Incident Report dated [DATE] at 1:10 pm and signed by an RN documented Resident #2 was found sitting on the floor in front of his dresser facing his closet, no injury sustained. There was no witness to the fall, neuro checks were initiated. There was no documented evidence that the MD was notified. Neuro checks were not performed consistently. For example: Neuro check flow sheet dated [DATE] at 1:10 pm; documentation in the column for baseline neuro checks was incomplete. The remainder of the columns to complete for the neuro checks were as follows: Third and fourth 15 minute check had no time documented. First, second, third, 30 minute checks had no time documented. Fourth 30 minute check was documented as sleeping. Fifth 30 minute check was documented as eating. The next check was documented as supper and timed as 5:20 pm. There were no four hour checks completed. Nursing progress note dated [DATE] at 1:30 pm and signed by an RN documented, unwitnessed fall in bedroom next to bed, said he fell on his bottom. Denies hitting his head, no apparent head injury, blood pressure (BP) ,[DATE] (elevated). Will monitor for signs of injury, vital signs, and neuro signs. Will recheck BP and notify MD if BP does not resolve to normal parameters. There was no documentation in regards to neuro checks not being done due to sleeping or eating, or that the RNS was notified that neuro checks were not done. There was no documented evidence of the MD being called about the fall or the elevated BP in this note. The Nursing Care Plan entitled At risk for complications from Cardiovascular Disease and dated [DATE] documented monitor and report signs and symptoms such as chest pain, one sided weakness, diaphoresis, and change in vital signs. There was no documented evidence that the elevated BP was reported. Nursing progress note dated [DATE] at 2:30 pm and signed by an LPN documented the resident has positive range of motion (ROM) all four extremities, ambulating with walker, assist, and gait belt with no problems noted. BP rechecked after fall and noted to be ,[DATE] (elevated BP). There was no documented evidence of the MD being notified about the fall or the elevated BP in this note. Review of 24 hour shift report dated [DATE] and [DATE] revealed there was no documented evidence that the MD was notified of the unwitnessed fall or elevated BP. During an interview on [DATE] at 12:30 pm the RN Charge Nurse stated the [DATE] neuro check list did not follow the every four hour neuro checks, as directed by facility policy and procedure. The columns on the facility form include areas for entries for aspects of the neuro checks documented eating and sleeping indicating the neuro checks were not performed. During an interview on [DATE] at 9:00 am LPN #1 stated that for the [DATE] fall she did document sleeping in one column, eating in another column and supper in another column and did not notify the Supervisor of this. LPN #1 stated she knew the purpose of neuro checks was to make sure there was "no bleeding", and that "anticoagulants were blood thinners and could cause blood clots." During an interview on [DATE] at 1:40 pm RNS #2 who was the RNS on duty for the [DATE] fall stated when a fall occurs the RNS is called and completes an assessment. RNS #2 stated that neuro checks are done every 15 minutes until cleared from MD, not sure of P&P for those residents on anticoagulants. RNS #2 stated that the resident having a high BP ,[DATE] during the fall assessment he would monitor for a short time to see if it came down. Having a blood pressure one hour later of ,[DATE], RNS # 2 was not sure if he would call the MD. Regarding the neuro checks that are documented sleeping or eating, RNS #2 would have to check the P&P to determine what should be done and if he would have to do neuro checks. Resident I&A dated [DATE] at 7:50 am documented Resident #2 fell and was found in his room near the closet, no injury sustained, no witness to the fall. Neuro checks were initiated. No documented evidence that the MD was notified. Neuro checks were not completed as the forms had blanks and four hour checks were not initiated. For example: Review of the Neuro check flow sheet dated [DATE] at 7:50 am; documentation in the column for baseline neuro checks was incomplete. The remainder of the columns to be completed for the neuro checks were as follows: Column dated [DATE] for 3:00 pm to 11:00 pm shift left blank. Four hour checks were not initiated following the 30 minute checks. Nursing progress note dated [DATE] at 7:50 am and signed by an RNS documented, the resident found on floor sitting in front of closet door. No complaints of pain, neuro exam-pupils constrict to light. No lacerations, hematomas or abrasions noted. Family aware of incident. There was no documented evidence of notifying the MD. Review of 24 hour shift report dated [DATE] and [DATE] revealed there was no documented evidence regarding notifying the MD of this fall. Resident Incident Report dated [DATE] at 5:00 am and signed by RNS documented Resident #2 fell and was found in bathroom with wheeled walker backwards on toilet, and wheelchair outside bathroom, no injury sustained, has a crescent shaped red mark on his back below his shoulder. There was no witness to the fall, neuro checks were initiated, medication usage documented [MEDICATION NAME]/routine/as needed (prn). Section of I&A for MD notification checked "no" and section for notification of family documented "No-will call Later". Neuro check flow sheets indicate that neuro checks were not completed as follows: Review of the Neuro check flow sheet dated [DATE] at 5:00 am. The columns to be completed for the neuro checks were as follows: Baseline neuro check was completed, the fourth 15 minute check was not completed. The 30 minute checks were not completed, the only remaining neuro check was at 7:30 am. Four hour neuro checks were not initiated. Nursing progress note dated [DATE] at 5:05 am and signed by the RNS documented, Resident found sitting on bathroom floor. Resident hit his head on the toilet as he tried to turn around. There are no bruises or open areas. He did have a small crescent shaped red line just below right shoulder. He said he hit the bridge of his neck where his head meets his neck. There was no documentation of notifying the MD of the unwitnessed fall or that the resident had hit his head on the toilet at the bridge of his neck where his head meets the neck. Nursing progress note dated [DATE] at 10:20 am signed by LPN documented that the resident continues on 15 minute checks (visual check of resident). Denies pain or discomfort, temperature 97.4, BP ,[DATE], pulse 60, respirations (resp) 20, oxygen (O2) saturation(sat) (measures the saturation of oxygen in your blood) 97%. appetite good, resident encouraged to stay in dayroom or by nurses station. There was no documentation of neurological checks or documented evidence of notification to the MD that this resident who was receiving an anticoagulant had fallen and that he had hit his head. Nursing progress note dated [DATE] at 1:00 pm and signed by the RN Charge Nurse documented, the resident complained of headache and wanting to go back to bed, Resident states headache is ,[DATE]. Vital signs checked ,[DATE] (elevated) manual BP lying, pulse 69, resp 19, O2 sat 97%. Pupils are bilateral equal and responsive, answer question appropriately, no trouble with vision, denies dizziness/lightheadedness. Resident made comfortable in bed, cold cloth place on forehead, gave the resident Tylenol 650 mg, Xarelto, and [MEDICATION NAME] (treats BP). Resident swallowed with no difficulty, then began to vomit, MD notified and ordered to send to emergency room . Patient transfer form (used to provide information to the hospital) dated [DATE] documented, the resident fell [DATE] at 5:00 am unwitnessed. Neuro checks initiated because fall was unwitnessed. Neuro checks within normal limits. Facility investigation revealed a statement written by RN Nurse Manager (RNM) dated [DATE] documenting that neuro checks were initiated since the fall was un-witnessed, these were normal throughout shift. Vital signs stable throughout shift until 1:00 pm when Resident complained of headache, which he described as ,[DATE] pain asking to go to bed. Manual BP was obtained at ,[DATE]. The resident was sent to the emergency room per MD. Facility investigation revealed as documented on [DATE] at 1:00 pm the team leader reported that the resident was complaining of headache and wanted to lie down. BP taken manually and was ,[DATE], pupils were bilaterally equal, re-active, and responsive. Team leader informed that she had administered Tylenol for headache and scheduled medications. This writer went to page MD to inform of condition, shortly after leaving room approximately at 1:15 pm the resident began to vomit. MD notified of the resident's change in condition was quick in onset and status [REDACTED]. The computerized tomography (CT) scan report dated [DATE] documented large acute on chronic left subdural hemorrhage with significant midline shift of greater than 11 mm. Possible developing uncal (a condition in which the medial part of the temporal lobe protrudes over the tentorial edge as a result of increased intracranial pressure. If uncorrected, the progressive disorder causes pressure on the brainstem after first impinging on the third cranial nerve. A dilated pupil on the side of the herniation is a diagnostic sign of the disorder) herniation. Facility investigation summary documented the resident was transferred to the hospital for evaluation. A hospital CT scan detected a subdural hematoma. A rapid decline occurred and the resident expired. During an interview on [DATE] at 11:00 am the Director of Nursing (DON) stated the RN Charge Nurse was the second in command on the unit. She was responsible to receive daily report, review the nurse notes and fall documentation, and look at the resident. The neuro check list remains with the MAR (Medication Administration Record) and the Medication Nurse is responsible to complete the neuro checks. It would be prudent for the RN Charge Nurse to look at the neuro check list to ensure it was being done appropriately. During an interview on [DATE] at 12:30 pm the RN Charge Nurse stated that when a resident sustains a fall and there is an actual head injury or suspicion, the MAR indicated [REDACTED]. Neuro check list should have the resident baseline documented then a neuro check should be completed every 15 minutes for one hour, every 30 minutes for two hours then every four hours unless the RN feels they should be done more often. If the resident was on an anticoagulant the neuro checks would continue until the MD was notified and an order received to discontinue (d/c) the neuro checks. The Licensed Practical Nurse (LPN) would be responsible for completing the neuro checks and the RN Charge Nurse would be responsible to help if needed, and to check to see if the neuro checks are being done. RN Charge did verbal checks with the LPN and but did not do a visual check of the neuro check list (to confirm completion and the resident's stability). RN Charge stated he checked the resident on the morning of [DATE] for the cyst he had on his back and he did a mini assessment, he was not aware that the neuro checks were not being done. RN Charge stated he will verify the neuro check lists by looking at them in the future. During an interview on [DATE] at 12:15 pm the DON stated the neuro check sheets are collected by the RN Unit Coordinator and should be reviewed before filing in the chart. The four falls should have had the four hour checks completed after the 30 minute checks. The DON stated that if they had been reviewed and if she was notified that the check lists were not completed per policy there would have been remediation done with the nurses. During an interview on [DATE] at 12:50 pm the RN Unit Coordinator (RNUC) stated that for people on anticoagulant therapy their baseline neuro status should be entered in the first column of the neuro check list, then the 15 minute checks should follow. Neuro check sheets will be reviewed in the future by an RN before filing. During an interview on [DATE] at 1:30 pm LPN #2 stated a resident who is on anticoagulant therapy and hits their head the neuro checks are to be started with 15 minute checks for one hour, 30 minute checks for 2 hours, one check after an hour, then every four hours until the MD is notified and an order is received for discontinue the neuro checks. LPN stated this has been the policy for a long time. During an interview on [DATE] at 2:30 pm the attending MD stated that the nurses usually notify him of falls. He stated that neuro checks should be done following a fall with head injury or suspicion of head injury. MD did not recall getting any phone calls in regards to Resident #2's falls. During an interview on [DATE] at 8:25 am LPN #3 stated that the protocol for a fall would be to call the Supervisor to assess, start neuro checks for every 15 minutes for one hour, every 30 minutes for two hours, then one check an hour after, and every four hours after that. On [DATE] Resident #2 was found on the floor at 5:00 am. Between 6:00 am and 7:00 am he was sitting in comfy chair at the nurse station and she was keeping an eye on him. LPN # 3 was passing medications and did not complete the neuro checks she was responsible for during that time. LPN #3 did not call the Supervisor for assistance in completing the neuro checks. LPN #3 stated she should have done those neuro checks, and would never not do neuro checks again. The MD should have been notified of the fall, did not know why MD was not notified. Usually a conversation would take place between the Supervisor and the LPN and decide who would call the MD, this conversation did not take place at the time of the fall of [DATE]. LPN #3 reported off at 7:00 am to LPN #1 and reported that Resident # 2 fell in the bathroom and was on neuro checks. When the check lists are full they are turned into the RN Charge. During an interview on [DATE] at 9:00 am LPN #1 stated she had been working at the facility for one year. LPN #1 stated she did know the basics of the falls/neuro checks protocol prior to Resident # 2 falling. LPN #1 did not understand the top of the neuro check form for writing in the times for the checks, and asked for re-education on neuro checks. LPN #1 stated there should be 15 minute checks for one hour, 30 minute checks for two hours, then every four hours for residents on anticoagulants until the MD discontinues them. LPN # 1 stated she received morning report from LPN # 3 on the morning of [DATE] and was told Resident # 2 had fallen and thought he had hit his head. LPN #1 stated she asked LPN #3 where should she start the neuro checks and she was told to do a 7:00 am to 3:00 pm (day shift) check. LPN #1 stated that the RN Charge nurse was present for the report and heard LPN #1 ask for a second time, how to start the neuro checks and was told to do one day shift check. LPN #1 stated she understood the seriousness of completing neuro checks and that she was constantly going over to him having him follow her fingers, even though she did not fill out the neuro check list and only did one neuro check. During an interview on [DATE] at 10:10 am RN Charge Nurse stated that on [DATE] during morning report he heard that Resident #2 fell and was on neuro checks, he did not hear the night nurse say anything about doing one neuro check and that he sat through the entire report. They were told of the fall and the neuro checks had been started and were handed off to the day shift nurse. MD was not notified for all four falls that Resident #2 had and should have been notified for all of them. RN Charge Nurse had never been asked to re-educate any nurse on the neuro check process. During an interview on [DATE] at 8:48 am RNS #1 stated that neuro checks are done initially with a fall, range of motion is done, and a body check. MD would be called if a hip was out of alignment, there was discomfort in the legs or eyes, or if stitches were required. Don't usually send to hospital unless resident requested. RNS #1 was working the day of the [DATE] fall and the [DATE] fall, was not aware that the resident was on Xarelto until the last fall. The [DATE] fall the RNS #1 saw Resident 2 sitting on the bathroom fall with legs straight out and was able to move his legs, and an assessment was done. Resident # 2 said he hit his head, RNS #1 felt the head for no injuries. Resident #2 was gotten up in a comfy chair and placed at the nursing station. RNS #1 does not follow-up to see the neuro checks are completed, sometimes does not go back to unit. Remembers Resident #2 sustained a crescent shaped red mark on his back, was aware that the resident was on blood thinner Xarelto (contrary to previous comment). Did not recall in P&P about calling MD with resident falls who are on blood thinners. During an interview on [DATE] at 1:50 pm the Medical Director stated he knew about the last fall [DATE] and that the physician should have been notified. The first fall when the resident sustainined a bruise to his eye he would not necessarily have sent him out. The last fall on [DATE] with no evidence of injury, he was not sure if he would have sent him to the ER. The frequency of calls related to falls have noticeably increased. The facility's P&P entitled Accident/Incident Reporting (dated as revised [DATE]) under the section for procedure documented the following; a Registered Nurse (RN) will evaluate the situation, assess the resident and direct further care as indicated, In the case of a head injury, possible fracture, unconsciousness or serious laceration the resident's physician will be called by the Nursing Supervisor or designee and /or transferred to hospital via emergency transport, Unit Coordinators (UC) should evaluate the number of falls and discuss with the interdisciplinary team, neuro checks should be initiated for unwitnessed falls or for striking the head, doctor notified (MD), MD recommendations record any order received, the incident report will be left on the unit to be reviewed and signed by a physician as soon as possible. The P&P entitled Head Injury/Neuro Check Flow Sheet, (dated as reviewed [DATE]) documented, following a significant blow to the head or an unwitnessed fall the resident will be assessed to determine extent of injury. Documented under purpose was; to provide baseline data in the event of complications due to a head injury and to determine the extent of injury. Documented under definitions; Neurologic vital signs; level of consciousness (LOC), pupils equal, round, reacting to light; verbal response, oriented, confused, inappropriate words, incomprehensible sounds; motor responses, obeys commands, change in strengths, change in tone, normal power, complaints of (c/o) pain. Complete neuro checks at the following times, baseline, every 15 minutes times one hour, every 30 minutes times two hours, every shift times three days. The facility P&P entitled Anticoagulation Protocol (dated as reviewed ,[DATE]), included documentation regarding the administration of [MEDICATION NAME] (anticoagulant) and and did not include documentation regarding other anticoagulants such as Xarelto. 10 NYCRR 415.12