Every finding on record at Absolut Center for Nursing and Rehabilitation at A

Based on observation, interviews and record review conducted during survey, the facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection, and prevent new pressure ulcers from developing unless clinically unavoidable for two (Resident #37 and #9) of four residents reviewed for pressure ulcers. Specifically, Resident #37 was admitted with a stage 1 pressure injury (intact skin with localized non-blanchable redness) on the bilateral buttocks on 07/02/2026. Subsequently, on 07/16/2026, it was determined the wound deteriorated, becoming painful, and progressed to stage 2 (partial-thickness loss) and stage 3 (full-thickness tissue loss with subcutaneous fat visible). Deficient practices identified included inconsistent administration of physician ordered treatments, failure to monitor the wound progression daily, and delayed implementation of revised interventions. This resulted in actual harm to Resident #37 that is not Immediate Jeopardy. Additionally, though there was no decline in Resident #9's left buttock stage 4 pressure ulcer (full thickness tissue loss may expose muscle, tendons and bone), treatments were not documented as administered on multiple days between 07/02/2026 and 07/16/2026. The findings are:The facility policy and procedure titled Documentation of Pressure Ulcer and Chronic Wounds, revised June 2023 documented that pressure ulcers and chronic wounds were monitored closely to monitor effectiveness of treatment and change in risk factors. An ongoing inspection and assessment of all pressure sores and chronic wounds will be conducted weekly and as needed. All pressure ulcers and chronic wound dressing will be inspected daily. The provider will be updated on new skin issues and or change in condition. Pressure, stasis and chronic wounds will be monitored daily with documentation when a complication or change was identified, which should include observations of the area if no dressing present or status of the dressing signs and symptoms of possible complications and whether pain, if present was adequately controlled.1. Resident #37 had diagnoses of osteoarthritis (occurs when the protective cartilage on the end of bones gradually wears away) and orthopedic after care following a knee replacement. The Minimum Data Set (a resident assessment tool) dated 07/08/2026 documented Resident #37 was moderately cognitively intact, understands and was understood by others. Resident #37 had impaired mobility, was incontinent and required staff assistance. The Minimum Data set documented the resident had two stage 1 pressure ulcers. The Comprehensive Care Plan dated 07/05/2026 documented Resident #37 had an actual alteration in skin integrity which included stage 1 pressure ulcers to the bilateral buttocks. Interventions included weekly skin checks on shower days, encourage the resident to elevate their legs, frequent change in position, and apply Calmoseptine Ointment (moisture barrier and skin protectant) twice daily to buttocks. Resident #37 had a functional performance deficit related to total knee replacement and osteoarthritis, interventions included total transfer lift with a green sling and two staff assist. Offer incontinent care every two to three hours and as needed and provide peri care with each incontinence episode. Monitor and report on change in skin integrity. The Visual/Bedside Kardex Report (a guide used by staff to provide care) dated 07/17/2026 documented Resident #37 required a total mechanical lift and two staff members for transfers; maximum assistance of one staff member for bed mobility and to encourage resident to utilize trapeze and make small frequent changes in position; offer incontinent care every two to three hours and as needed, provide peri care with each incontinence episode, and to monitor and report on change in skin integrity. A Braden Scale Assessment (an assessment tool to predict a resident's risk of developing pressure injuries) dated 07/02/2026 documented that Resident #37 was at a high risk to develop pressure ulcers. The resident was chair fast (ability to walk is severely limited or non-existent), and their skin was moist. Mobility was very limited and required occasional slight changes in body or extremity position but unable to make frequent or significant changes independently, nutrition was adequate, friction and shear was documented as a problem and required maximum assistance to move. Complete lifting without sliding against sheets was documented as impossible. Resident #37 frequently slid down in bed or chair and required frequent reposition with maximum assistance. A weekly skin status note dated 07/02/2026, documented a left buttock stage 1 pressure ulcer that measured 7.25 centimeters in length and 5.50 centimeters in width and had no measurable depth. The skin was intact, color noted to be darker than surrounding area and was non-blanchable. A physician's order dated 07/02/2026 documented to apply Calmoseptine ointment to Resident #37's bilateral buttocks topically every morning and evening at bedtime for a stage 1 pressure ulcer. The order was discontinued on 07/16/2026. The Treatment Administration Record dated 07/01/2026 - 07/31/2026, documented Resident #37 was to receive Calmoseptine Ointment twice a day to bilateral buttocks topically every morning and at bedtime for stage 1 pressure injury and had a start date of 07/02/2026 and a discontinuation date of 07/16/2026. There was no documented evidence that the treatments were completed for two of 16 morning shifts (7:00 AM - 3:00 PM) and two of 16 evening shifts (3:00 PM - 11:00 PM) reviewed. A weekly skin tracking sheet dated 07/07/2026 documented that Resident #37 had a stage 1 pressure ulcer to left buttock (site 32) measuring 7.25 centimeters and 5.50 centimeters in width upon admission. The tracking sheet documented the pressure ulcer had no change. The treatment was documented as Calmoseptine twice a day. During a care observation on 07/16/2026 at 11:39 AM, Resident #37 was transferred into bed via a mechanical lift and provided with urinary and fecal incontinence care by Certified Nurse Aide #1 and Certified Nurse Aide #2. Resident #37 was noted to moan in pain during the transfer and incontinence care. The resident was observed to have four open pressure ulcers on their buttocks; two were noted on the resident's right buttock and two were noted on the resident's left buttock, one of which had a thin layer of slough (dead tissue). After care was provided, Certified Nurse Aide #2 left the room to get the Resident Care Coordinator Licensed Practical Nurse #2. They returned to the room along with the Wound Consultant. The pressure ulcers were measured by Resident Care Coordinator Licensed Practical Nurse #2. The Wound Consultant agreed with measurements. A weekly skin tracking sheet dated 07/16/2026 (completed after the observation) documented the following:Upper right buttock (site 31) - stage 2 pressure ulcer measured 3 centimeters in length by 0.75 centimeters in width by 0 depth. The tracking sheet documented the ulcer worsened and documented a treatment change to Silvasorb (antimicrobial wound gel) followed by a bordered gauze. Right middle buttock (site 31): stage 2 pressure ulcer measured 3. centimeters in length by 0.5 centimeter in width x 0 depth. The tracking sheet documented the ulcer worsened and documented a treatment change to Silvasorb followed by a bordered gauze. Upper left buttock cite (site 32): stage 3 pressure ulcer measured 1 centimeter in length and 2 centimeters in width. The tracking sheet documented the ulcer worsened and documented a treatment change to Silvasorb followed by a bordered gauze. Lower left buttock (site 32): stage 2 pressure ulcer measured 4 centimeters in length and 1 centimeter in width x 0 depth. The tracking sheet documented the ulcer worsened and documented a treatment change to Silvasorb followed by a bordered gauze. During an interview at the time of the observation on 07/16/2026 11:39 AM, Certified Nurse Aide #1 stated they provided morning care for Resident #37 that morning and had the nurse apply the Calmoseptine Ointment to their buttocks, the resident heard this and stated, it was not true. Certified Nurse Aide #1 stated they would have the nurse apply the treatment again. During an interview on 07/16/2026 at 11:59 AM, Resident Care Coordinator Licensed Practical Nurse #2 stated upon the observation and measurements, Resident #37's pressure ulcer had definitely declined. They stated that no one had informed them that Resident #37's skin condition had declined, and they should have so that additional interventions could have been put in place. Resident Care Coordinator Licensed Practical Nurse #2 stated they would notify the nutritional department for additional support; would educate Resident #37 on the importance of getting out of bed; contact therapy for a pressure-reducing mattress, and place Resident #37 back on enhanced barrier precautions. Additionally, they would confirm with the provider the treatment recommendations from the wound evaluation for a treatment change. During a follow up interview on 07/17/2026 10:55 AM, Certified Nurse Aide #1 stated they completed morning care for Resident #37 on the 07/15/2026 and they had told Resident Care Coordinator Licensed Practical Nurse #2 that Resident #37's skin needed to be looked at, and the resident was having increased pain, but the pressure ulcer was not open. During a telephone interview on 07/17/2026 at 1:06 PM, Licensed Practical Nurse #4 stated the certified nurse aides provided morning care for Resident #37 and then the nurse will apply the cream to the resident's buttocks. Licensed Practical Nurse #4 stated if they signed that they had applied cream to Resident #37's buttocks, they did it. They stated they could not recall if the resident had any pressure ulcers. They stated if they saw an area of concern they would have reported it to the provider. During an interview on 07/17/2026 at 1:12 PM, Resident Care Coordinator Licensed Practical Nurse #2 they stated they completed a skin check on Resident #37 on 07/09/2026 and they had one pressure ulcer bilaterally on both sides of their buttocks and it was not open. They stated if it was open, they would notify the provider to update the treatment. They stated the certified nurse aides do not document in the resident's electronic medical record regarding skin conditions and the nurses relied on them to notify them if they observed a resident had a change in their skin condition. They stated the process was for the medication/treatment nurse to complete the pressure ulcer treatments, monitor for changes, complete and document the weekly skin checks in the treatment record, and notified them, the Director of Nursing and the provider of the skin change concerns. Resident Care Coordinator Licensed Practical Nurse #2 stated they were responsible for documenting on the weekly skin tracking sheets. During a telephone interview on 07/17/2026 at 2:06 PM, the Medical Director stated their expectations were for nurses to complete a resident's treatment as ordered. They stated if the staff have any questions or concerns, they can contact them at any time. They stated they had not seen Resident #37 pressure ulcer yet but stated that it was very unlikely that a stage 1 pressure ulcer could progress to stage 2 pressure ulcers and a stage 3 pressure ulcer overnight. They stated that they were at the facility on 07/15/2026, and if they would have been notified there were concerns with Resident #37's skin they would have evaluated the resident during their rounds. The Medical Director stated that no one had notified them of this, and they would have expected the staff to have notified them.During an interview on 07/17/2026 at 4:14 PM, Resident #37 they stated the staff were not consistently putting the cream on twice a day, they stated some did and some did not. They stated the pressure ulcers caused them pain. On a scale from one to 10, the pain ranged from six to eight and had gotten worse since admission. They stated at times, their pain was 10 if they had been in their wheelchair for too long, during transfers and when they were getting incontinent care. During an interview on 07/17/2026 at 4:18 PM, the Director of Nursing stated they did not feel that Resident #37's pressure ulcers to their buttocks could have progressed from a stage 1 to four stage 2 pressure ulcers and one stage 3 pressure ulcer overnight. They stated this would occur over several days because the stage 3 pressure ulcer had exudate (drainage from a wound bed) and that would take more than a day to progress to that point. They stated this should have been recognized sooner to ensure the resident was provided with the appropriate treatment and interventions. 2. Resident #9 had diagnoses including stage 4 pressure ulcer (full-thickness skin and tissue loss) of left buttock, dementia, and diabetes mellitus. The Minimum Data Set, dated [DATE] documented Resident #9 had moderate cognitive impairment, was usually understood, and usually understands. The assessment tool documented the resident had one (1) stage 4 pressure ulcer that was presented upon admission. The undated Comprehensive Care Plan documented Resident #9 had impaired skin integrity related to stage 4 pressure ulcer to the left buttock. Interventions included administering treatment per medical doctor order; monitoring left buttock for signs/symptoms of infection; evaluating and measuring wound site at least weekly. Document outcome and treatment progress/changes; medical provider evaluation of skin/wound as needed; soak 4 by 4 gauze in Dakins (antiseptic solution) pack wound wet to dry, cover with bordered gauze; follow recommended infection control precautions; and educate on making frequent shifts in body weight, and importance of offloading, repositioning. The care plan documented Resident #9 was at risk for impaired skin integrity. Interventions included use of an air mattress.The Visual/Bedside Kardex Report dated 07/16/2026 documented Resident #9 required air an mattress on the bed, weekly skin checks, report changes in skin integrity, encourage back to bed between/after meals, and out of bed for meals, turn and position every two to three hours and as needed as resident allows, enhanced barrier precautions, and change every two to three hours and as needed.Review of the Medication Review Report dated 07/16/2026, documented an active order dated 06/09/2025 to flush stage 4 pressure ulcer with Dakin's solution. Soak 4 by 4 gauze in Dakins (antiseptic used to clean and disinfect wounds, prevent infection, and promote healing), pack wound wet to dry, cover with bordered gauze every day and evening shift, and as needed. Active order dated 10/02/2025 documented Dakins (1/4 strength) solution, apply to pressure ulcer topically every day and evening shift.Review of the Treatment Administration Record from 06/01/2026 - 06/30/2026 documented an order to flush stage 4 pressure ulcer. Dakins (1/4 strength). Soak 4 by 4 gauze in Dakins. pack wound wet to dry, cover with bordered gauze every day and evening shift. There was no documented evidence of the treatments being completed for eight of 30-day shifts (7:00 AM3:00 PM); and three of 30 evening shifts (3:00 PM-11:00 PM) as ordered.Review of the Treatment Administration Record from 07/01/26 - 07/15/2026 documented an order for Dakins (1/4 strength) external solution, apply to pressure ulcer topically every day and evening shift. Flush stage 4 pressure wound with Dakin's solution. Soak 4 by 4 gauze in Dakins pack wound wet to dry, cover with bordered gauze every day and evening shift. There was no documented evidence of the treatments being completed on six of 15 day shifts; and three 15 evening shifts as ordered.During an interview on 07/17/2026 at 2:34 PM, Licensed Practical Nurse #1 stated that Resident Care Coordinator Licensed Practical Nurse #2 typically completes resident treatments on the day shift during the week. They stated it had been a few weeks since they last completed Resident #9's pressure ulcer treatment, but the pressure ulcer looked the same and had not declined. Upon review of Resident #9's Treatment Administration Record, Licensed Practical Nurse #1 stated there were blanks on the Treatment Administration Record which could mean the treatments were not done.During an interview on 07/17/2026 at 2:36 PM, Resident Care Coordinator Licensed Practical Nurse #2 stated the nurses were responsible for completing resident treatments. They stated it was important for treatments to be completed as ordered so the pressure ulcer does not decline or become infected. Upon review of Resident #9's Treatment Administration Record, Resident Care Coordinator Licensed Practical Nurse #2 stated the blanks indicated the treatments were not signed for or that they were not completed.During an interview on 07/17/2026 at 2:45 PM, the Director of Nursing stated the licensed nurses were responsible for completing ordered treatments and documenting they were completed. They stated it was important for treatments to be completed to promote healing. During a telephone interview on 07/17/2026 at 2:03 PM, the Medical Director stated they expected orders to be followed, and treatments to be completed. They stated if Resident #9's treatments were not being completed their pressure ulcer could get worse.10 New York Codes, Rules, and Regulations (NYCRR) 415.12(c)(2)

Based on observations, interviews, and record reviews conducted during the survey, the facility failed to maintain an effective infection prevention and control program to provide a safe and sanitary environment to help prevent the transmission of infections for one (Resident #1) of three residents reviewed for enhanced barrier precautions (interventions designed to reduce transmission of multi-drug-resistant organisms including gown and glove use during high contact resident care activities). Specifically, staff did not wear proper personal protective equipment while providing incontinent care for Resident #1. Additionally, there were multiple observations of Resident #1's suprapubic catheter (a tube inserted into the bladder, through the abdomen, to drain urine) drainage bag and tubing lying on the floor, including staff placing them on the floor during care. The findings are:The facility policy and procedure titled Infection Prevention and Control General, dated 05/2023, documented the primary purpose of this facility's infection prevention and control program is to establish guidelines to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Standard and transmission-based precautions are to be followed to prevent the spread of infections. The hand hygiene procedures to be followed by staff involved in direct resident contact. Establish guidelines to follow in the implementation of infection control precautions. Establish guidelines to follow in implementing Standard and Transmission precautions for the handling of blood, body fluids, secretions, excretions, mucous membranes, and non-intact skin.The facility policy and procedure titled Catheter - Urinary, Condom Application, dated 01/01/2000, documented when a resident is admitted with an indwelling catheter, the facility must ensure that the resident receives appropriate treatment and services to prevent urinary tract infections to the extent possible. Catheter use would require the placement of enhanced barrier precautions.Resident #1 had diagnoses of obstructive and reflux uropathy (kidney damage or scarring caused by urine flowing backward from the bladder into the kidney), hematuria (the presence of blood cells in the urine), and a history of urinary infections. The Minimum Data Set (a resident assessment tool) dated 05/05/2026 documented the resident could be understood by others, could understand others, had a suprapubic indwelling catheter, and utilized a manual wheelchair. Resident #1 was dependent on staff for toileting and toileting hygiene.A comprehensive care plan dated 06/05/2026 documented Resident #1 had an alteration in skin integrity due to a colostomy (a surgical procedure that creates a new path for wastes to leave the body due to a diseased colon) and a suprapubic catheter. Interventions included but were not limited to enhanced barrier precautions. Resident #1 had bladder incontinence related to obstructive and reflux uropathy with interventions that included, but were not limited to, appliance of a suprapubic 22 French (measurement scale used to describe the dimension of medical device tubing) 30 cubic centimeter catheter, change urinary drainage bag as needed, urinary catheter care was to be provided every shift, and catheter bag was to be placed in a privacy bag.Review of the Kardex (a guide used by staff to direct care) dated 07/17/2026 documented Resident#1 was placed on enhanced barrier precautions and had a suprapubic catheter.During an observation on 07/13/2026 at 6:15 PM, Resident #1 had part of their urine drainage bag and approximately three to four inches of their catheter tubing lying on the floor while they were in the dining area. Additionally, the catheter bag was not placed in a privacy bag.During an observation on 07/13/2026 at 7:10 PM, a sign was observed on the outside of Resident #1's door. The sign alerted visitors and staff:- Contact precautions were in place, everyone must clean their hands, including before entering and when leaving the room.-Providers and staff must also put on gloves before room entry, discard gloves before room exit, put on gown before room entry, and discard gown before room exit.During an observation on 07/13/2026 at 7:54 PM, Resident #1 was lying in their bed and one half of their catheter drainage bag and three to four inches of their catheter tubing was lying on the floor.During an observation on 07/15/2026 at 1:02 PM, Resident #1 was in the dining area and three to four inches of their catheter tubing was lying on the floor under their wheelchair.During an observation on 07/15/2026 at 1:12 PM, Resident #1 was brought to their room by Certified Nursing Aide #4, and the catheter tubing was dragging on the floor under the resident's wheelchair while they transported the resident to their room. The resident was placed in their room and Certified Nursing Aide #4 left the room with catheter tubing on the floor.During an observation and interview on 07/15/2026 at 1:16 PM with Licensed Practical Nurse #1 observed Resident #1's catheter and stated that the tubing was lying on the floor and should not ever be on the floor. They stated Resident #1 was at a high risk for urinary infections. Licensed Practical Nurse #1 entered the resident's room to remove the catheter tubing from the floor without washing their hands or applying gloves. Licensed Practical Nurse #1 placed the catheter tubing in Resident #1's catheter privacy bag but did not wipe down the tubing that had been on the floor.During an observation on 07/15/2026 at 2:58 PM with Certified Nursing Aide #2, they entered Resident #1's room and washed their hands and put on clean gloves but did not apply a gown before they provided care for Resident #1 after their colostomy (artificial connection of the bowel to the skin surface) had leaked. Certified Nursing Aide #2 took the catheter bag and tubing off of the resident's wheelchair and placed it on the floor as they transferred Resident #1 into their bed and performed care. After incontinent care was completed, Certified Nursing Aide #2 picked up the catheter bag and tubing from the floor, fed it through Resident #1's clean brief and pants, and then took the catheter bag and tubing and hooked it to the side of Resident #1's bed using the same gloves that they provided incontinent care with.During an interview on 07/15/2026 at 1:08 PM with Certified Nursing Aide #4, they stated Resident #1 was at risk for urinary tract infections and they had noticed the catheter tubing dragged on the floor and should have picked it up while they transported Resident #1 to their room. They stated they had witnessed Resident #1's urinary catheter tubing lying on the floor before and thought it was too long and should be shorter but never notified the nurse. They stated they were new to the facility and thought the nurses were aware and would address it.During an interview on 07/16/2026 at 4:16 PM with Certified Nursing Aide #2, they stated they entered Resident #1's room, washed their hands, and put on clean gloves, but they were never told the resident was on enhanced barrier precautions. They stated that this resident was not their normal resident and felt someone should have told them. They stated they should have looked outside of the resident's door or checked the Kardex to see if they required additional personal protective equipment. They stated they normally do that but felt they were just thrown some wash rags and told to clean up Resident #1, so they were caught off guard. They stated they should not have placed the resident's catheter and tubing on the floor while they provided incontinent care because the floor could be dirty and this could transmit germs that can cause an infection.During an interview on 07/16/2026 at 4:21 PM with the Resident Care Coordinator, Licensed Practical Nurse #2, they stated Certified Nursing Aide #2 should have put a gown on before they provided incontinent care to Resident #1. They stated this was important to ensure their germs do not enter the catheter insertion site and the resident's germs do not contaminate staff. They stated that the staff should be aware of the precaution signs on residents' doors before entering the room and should also be more cautious and ensure residents' catheter tubing was never on the floor. They stated Licensed Practical Nurse #1 should have washed their hands, put on clean gloves, and cleansed the tubing with an alcohol wipe when they removed Resident #1's catheter from the floor. They stated that Certified Nursing Aide #4 should not have transported Resident #1 with the tubing dragging on the floor and they should have notified nursing staff if they had noticed the tubing on the floor multiple times.During an interview on 07/16/2026 at 5:18 PM with the Director of Nursing, they stated that Certified Nursing Aide #4 should not have transported Resident #1 with their catheter tubing dragging on the floor. They stated staff needed to pay more attention and if it happened once, it would likely happen again. They stated that Certified Nursing Aide #2 should have been wearing a gown while they provided incontinent care for Resident #1 and should not have placed the catheter and tubing on the floor while they put Resident #1 in bed. The Director of Nursing stated Licensed Practical Nurse #1 should have cleaned their hands, applied gloves, and wiped the resident's catheter tubing with an alcohol wipe after they took it off of the floor. They stated they will put a new process into place to ensure this does not occur again. 10 New York Codes, Rules, Regulations 415.19(a)(2)

Based on observation, interview, and record review conducted during the survey, the facility failed to ensure that each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychological well-being, in accordance with the comprehensive assessment and plan of care for one (Resident #6) of five residents reviewed for unnecessary medications. Specifically, Resident #6 did not have a psychiatry follow up visit as planned per the psychiatry consult recommendations. The findings included:The facility policy and procedure titled Consultants revised 2/2023 documented the facility arranges for qualified professional personnel to furnish specific services to residents and the facility, as recommended by the interdisciplinary team or provider. Consultant services were utilized for Psychiatry and consultants provide the facility with written, dated, and signed reports of each consultation visit. Such reports contain the consultants' recommendations, plans for implementation of their recommendations, findings and plans for continued service as appropriate.1. Resident #6 had diagnoses that included psychotic disorder with delusions (mental health condition), neurocognitive disorder with Lewy bodies (progressive brain disease), and anxiety disorder. The Minimum Data Set (a resident assessment tool) dated 05/21/2026 documented Resident #6 was cognitively intact, was understood, and understands. In addition, Resident #6 received antipsychotic medications on a routine basis.The undated Comprehensive Care Plan documented Resident #6 had mood problems and depression related to unspecified psychosis, and a psychotic disorder; and used psychotropic medications. Interventions included to administer medications as ordered and behavioral health/psychiatry consults as needed.The psychiatry consultation dated 04/07/2026 documented Resident #6 had a psychotic disorder. The plan included a follow-up in four (4) to six (6) weeks. The Licensed Practical Nurse #2 Resident Care Coordinator and the Director of Social Services initialed the consultation report.A Progress note dated 05/21/2026 at 4:05 PM the Director of Social Services documented Resident #6 notes occasional nightmares and follows psychiatry as needed.During an interview on 07/15/2026 at 8:52 AM, Resident #6 stated they have mental health issues, and the Director of Social Services takes care of arranging their telehealth appointments. They stated they usually have a telehealth appointment once a month and could not recall exactly when they had one last.During an interview and record review on 07/17/2026 at 11:00 AM, the Director of Social Services stated they were responsible for scheduling and arranging psychiatry consultations for residents. The Director of Social Services reviewed Resident #6's psychiatry consultation dated 04/07/2026 and stated the resident should have been scheduled for a psychiatry consultation by the end of May. They stated they track psychiatry visits on a spreadsheet, and they overlooked scheduling Resident #6's follow-up psychiatry consultation as recommended. They stated it was important to adhere to recommended follow up care to maintain stable mental health, a positive well-being and for quality of life.During an interview on 07/17/2026 at 11:22 AM, Licensed Practical Nurse #2 Resident Care Coordinator stated psychiatry consultation recommendations were reviewed by them and the Director of Social Services. They stated the Director of Social Services was responsible for setting up follow-up visits with the psychiatry provider.During an interview on 07/17/2026 at 11:39 AM, the Director of Nursing stated the expectation was that consultation recommendations were reviewed and that follow-up visits were set up accordingly to ensure continuation of care.During a telephone interview on 07/17/2026 at 2:03 PM, the Medical Director stated they expected recommendations for psychiatry visits to be followed. It was important that Resident #6 was routinely followed by psychiatry because they were receiving antipsychotic and antidepressant medications.10 New York Code Rules and Regulations 415.12(f)(1)

Based on observation, interview and record review completed during the survey, the facility failed to provide pharmaceutical services to meet the needs of each resident and the facility did not ensure that drug records were in order and that an account of all controlled drugs was maintained for one of one medication storage rooms. Specifically, on 07/13/2026, a controlled substance medication, Lyrica (pregabalin) (controlled substance used to treat pain and/or seizures) dose was unaccounted for, and additional controlled substance medications were not signed out or reconciled at the time of administration. Residents #7, #11, #14, #18, #27, and #37 were involved. The findings include:The facility policy and procedure titled Medication Administration Methods effective 3/2020, documented licensed nurses were responsible for directing and assisting with medications according to techniques approved for use at facility in compliance with State Department of Health code, rules and regulations and other applicable state and federal laws. Administration of controlled substances documented the amount to be offered is recorded on the Controlled Substances Inventory form prior to leaving the medication room and the medication administration is recorded on the electronic medication administration record. The facility policy titled Medication Handling Rules revised 7/2025, documented each dose administered is properly recorded in the patient/resident's medication administration record. Medication Error Report is completed for medication errors.The facility policy and procedure titled Receipt of Controlled Substances revised 11/2025, documented the controlled substance descending inventory sheet is retained on the nursing unit with the medication. It remains on the nursing unit in the Controlled Substance Binder containing all the controlled substance descending inventory sheets. Any discrepancy which has been found or suspected is immediately reported to the Director of Nursing.During an observation of the medication storage room on 07/13/2026 at 10:07 PM, Registered Nurse #2 reviewed Resident #14's controlled substance, Lyrica 75 milligrams, to reconcile against the Controlled Drug Received/Record/Disposition Form (the controlled substance descending inventory sheet) present in the Controlled Substance Binder. In the presence of the surveyor, they signed out a dose of Resident #14's Lyrica 75 milligrams indicating the date of 7/13/26, time 8:20 PM, amount given one (1), amount left two (2) and signed their signature on the Controlled Drug Received/Record/Disposition Form. Upon Registered Nurse #2 comparing the medication card containing Resident #14's Lyrica 75 milligrams to the Controlled Drug Received/Record/Disposition Form, they observed only one (1) capsule remaining in the blister pack, not two (2) as indicated as the amount left on the Controlled Drug Received/Record/Disposition Form. Additionally, Registered Nurse #2 was observed signing out additional controlled substances that they stated they administered earlier in the Controlled Substance Binder while reconciling their controlled substances.The following controlled substances were observed to be signed out and reconciled at the time of the observation on 07/13/2026 at 10:07 PM:-Tramadol (pain medication) tablet 50 milligrams, date 7/13/26, time 8:00 PM for Resident #11-Tramadol tablet 50 milligrams, date 7/13/26, time 9:00 PM for Resident #18-Lorazepam (antianxiety medication) tablet 0.5 milligrams, half tab (0.25 milligrams), date 7/13/26, time 9:00 PM for Resident #7-Tramadol tablet 50 milligrams, date 7/13/26, time 9:40 PM for Resident #37-Alprazolam (antianxiety medication) tablet 0.25 milligrams, two tablets (0.50 milligrams), date 7/13/26, time 8:00 PM for Resident #27.During an interview on 07/13/2026 at 10:32-10:38 PM, Registered Nurse #2 stated the count of Resident #14's Lyrica was correct when they completed the control substance count between shifts with Licensed Practical Nurse #1 at 3:00 PM on 07/13/2026. They stated there were three (3) Lyrica 50 milligrams remaining in the medication card at 3:00 PM. They stated they only administered one (1) Lyrica dose to Resident #14 during their shift, there should be two (2) doses remaining and there was only one (1). Registered Nurse #2 stated during controlled substance count between shift change with another nurse they physically go through every medication card; one nurse looks at the medication card and the other nurse looks at the amount left on the controlled drug record form. They stated they look at the medication card, say the number present and the nurse leaving verifies that number with what is written as remaining on the controlled drug record form. Registered Nurse #2 stated they sign out the controlled substance medications on the controlled drug record form when they have a down moment. They stated they do not sign out, reconcile the controlled substance medications at the time they remove a controlled substance from the medication card, or at the time of administration. They stated they should be signing out the controlled substances on the controlled drug record form when they pop it from the medication card, so they can verify the count is correct at that time. Registered Nurse #2 stated that more than likely they would have noticed the error in Resident #14's Lyrica count at the time of administration had they signed it out at the time they gave it. Registered Nurse #2 stated they could not account for the missing dose. Registered Nurse #2 stated they needed to notify the Resident Care Coordinator of the missing Lyrica dose, because there was an error in the count.During an interview on 07/13/2026 at 10:56 PM, Licensed Practical Nurse #2/Resident Care Coordinator stated a medication error would need to be completed. They stated the Director of Nursing and Administrator were made aware of the missing Lyrica for Resident #14. They stated an investigation would be started to determine the reason for the missing narcotic/medication error. They stated this was important to prevent diversion of controlled substances.During an interview on 07/17/2026 at 9:08 AM, Licensed Practical Nurse #2/Resident Care Coordinator stated the controlled substance medications should be signed out on the controlled drug record form as soon as the medication is given. They stated it was important to sign out and track when administering controlled substances for accurate documentation. They stated during the shift change between nurses, both nurses should be comparing the controlled drug record form with the medication card; comparing the prescription number, resident name, medication, dose and amount remaining to ensure the information is correct. During an interview on 07/17/2026 at 9:27 AM, Licensed Practical Nurse #1 stated if they noticed a discrepancy with the controlled substance count, they would notify the Resident Care Coordinator or the Director of Nursing so it could be investigated. They stated they would not want to be held accountable for a missing controlled substance. They stated prior to administering a controlled substance they verified the medication card count with the controlled drug record form to make sure they match before removing a dose from the medication card. They stated they signed the controlled substance medication out immediately after removing it from the medication card to make sure the count is accurate. They stated they would not wait on signing out a controlled substance because a million things could happen, they could forget about it then the count would not be correct.During an interview on 07/17/2026 at 9:38 AM, the Director of Nursing stated they expected licensed nurses when counting between shifts to be eyeballing both the controlled drug record form and the medication card to make sure nothing is missing, and the count is accurate. They stated the licensed nurses are to always have the Controlled Substance Binder with them and should sign controlled substances out on the controlled drug record form immediately after removing the medication from the medication card, and verifying the count is correct.During a telephone interview on 07/17/2026 at 10:24 AM, the Pharmacy Consultant stated controlled substances should be documented, signed for when given and reconciled against the controlled drug record form to prevent diversion, and to ensure residents are receiving their medications as ordered.10 New York Code Rules and Regulations 415.18(a)(b)(3)

Based on interviews and record review conducted during the Abbreviated survey (Complaint #NY00385514) the facility did not ensure that residents were free from abuse and mistreatment for one (1) (Resident #1) of three (3) residents reviewed. Specifically, Certified Nurse Aide #3 was witnessed to slap Resident #1's head during care.The finding is:The policy Abuse Prohibition revised 2/2023, documented residents have the right to be free from physical abuse and mistreatment. The facility will not condone any form of resident abuse.The policy and procedure Facility Incident/Abuse Investigation and Reporting revised 6/7/23, documented mistreatment means inappropriate treatment of a resident. Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. Corporal punishment, which is physical punishment, is used as a means to correct or control behavior. The New York State Department of Health document titled Your Rights as a Nursing Home Resident in New York State revised 10/2022, documented as a resident you have the right to be free from abuse including verbal, sexual, mental and physical abuse.1.Resident #1 had diagnoses including dementia with severe agitation, polyosteoarthritis (multiple joints are affected by osteoarthritis (degenerative joint disease) and history of falls. The Minimum Data Set (a resident assessment tool) dated 6/5/25 documented Resident #1 rarely/never understood, rarely/never understands. No behaviors were exhibited. The comprehensive care plan revised on 6/24/25, documented Resident #1 had an alteration in their psychosocial well-being and cognitive loss. They had a potential for alteration in mood and behavior pattern/communication, at times had physical behaviors during care. Interventions included to establish trust with resident, monitor mood/behavior for changes, respond to behaviors with the following diversions/approaches: reassurance, staff supervision outside of room, family support, utilize mechanical support animal, sensory boards. The resident was care planned for 2 staff assist as needed if the resident was not cooperating during dressing. The facility incident report Physical Aggression Received, prepared by the Director of Nursing, dated 7/1/25 at 10:20 PM, documented Resident #1 was in bed being rolled to change clothing when Resident #1 bit the aide's right arm, not letting go. The aide reactively slapped Resident #1 on the top of their head. Predisposing physiological factors included: agitation, confusion, incontinence, and impaired memory. Review of the Facility Reported Incident received 7/2/25 at 11:23 AM, documented there was reasonable cause to believe that abuse, neglect or mistreatment occurred on 7/1/25 at 10:20 PM. Investigation findings documented the incident was witnessed, with reason to believe an aide slapped Resident #1 in the head while the aide was being bit. An investigation statement dated 7/1/25 at 10:30 PM, signed by Certified Nurse Aide #3, documented when they (Certified Nurse Aide #3 and #4) rolled Resident #1 towards the wall Resident #1 lifted their head to bite Certified Nurse Aide #3 on their right arm, as they had rolled Resident #1 to the wall. Certified Nurse Aide #3 documented they tapped Resident #3 on the head without realizing it because Resident #1 was not letting go.An investigation statement dated 7/1/25 at 10:20 PM, signed by Certified Nurse Aide #4 documented that after they (Certified Nurse Aide #3 and #4) started to roll Resident #1, Resident #1 started to get a little bit agitated. Certified Nurse Aide #3 was standing at Resident #1's head when Resident #1 bit Certified Nurse Aide #3's arm. Certified Nurse Aide #4 documented Certified Nurse Aide #3 stated I'm sorry, I'm sorry I shouldn't have hit you. The investigation summary dated 7/2/25 and signed by the Director of Nursing on 7/3/25, documented it was determined that no abuse occurred and there was no intent in harming Resident #1. The Director of Nursing documented the staff member (Certified Nurse Aide #3) had physical contact with Resident #1; however, it was not willful and was reactionary to the situation with no intent to injure Resident #1. During an interview on 7/8/25 at 1:06 PM, Resident #1's family member stated they were told that Resident #1 was tapped on the head. They stated they did not know if it was a hard tap or a soft tap, but that stuff should not happen in a nursing home. They stated if Resident #1 did bite, that they could not help it. Resident #1's family member stated they were not happy about the situation and whether it was meant or not, Resident #1 should not have been tapped on the head. During a telephone interview on 7/8/25 at 1:19 PM, Certified Nurse Aide #4 stated they assisted Certified Nurse Aide #3 with getting Resident #1 ready for bed. They stated Certified Nurse Aide #3 was at the head of the bed removing Resident #1's shirt and they were at the foot of the bed removing Resident #1's pants. They stated they heard Certified Nurse Aide #3 yell and witnessed, and heard Certified Nurse Aide #3 slap the left corner part of Resident #1's forehead and top head with their hand. They stated Certified Nurse Aide #3 knew what they did was wrong and immediately stated they should not have hit Resident #1. Certified Nurse Aide #4 stated they saw Certified Nurse Aide #3's arm in Resident #1's mouth. Certified Nurse Aide #4 felt that what they witnessed during care of Resident #1 was wrong and was physical abuse.During a telephone interview on 7/8/25 at 1:41 PM, Licensed Practical Nurse #2 stated Certified Nurse Aide #4 notified them after care of Resident #1 on 7/1/25 around 10:00 PM that Certified Nurse Aide #3 slapped Resident #1 on the face. They stated they asked Certified Nurse Aide #3 if they hit Resident #1 and Certified Nurse Aide #3 replied, they did not mean to, it was a reaction. Licensed Practical Nurse #2 stated when caring for residents with dementia you never knew what kind a behavior you will experience and that Certified Nurse Aide #3's reaction was not appropriate and a form of physical abuse. During a telephone interview on 7/8/25 at 1:54 PM, Licensed Practical Nurse #3 Supervisor stated they were notified at the end of the evening shift on 7/1/25 that Certified Nurse Aide #3 hit Resident #1 during care and that Certified Nurse Aide #3 was bit by Resident #1. They stated they called and notified the Director of Nursing of the abuse allegation. Licensed Practical Nurse #3 Supervisor stated abuse, slapping a resident, should not occur and that residents cannot protect themselves. During an interview on 7/8/25 at 2:45 PM, Certified Nurse Aide #3 stated during bedtime care of Resident #1 in bed, they were removing Resident #1's clothing and rolled them to their left side when Resident #1 leaned up and bit their right arm. Certified Nurse Aide #3 stated they tapped Resident #1's head with their left hand to get them off their arm. They stated they did not tap Resident #1 hard, that it was strictly a reaction because they were being bit and it hurt. They stated as soon as they tapped Resident #1, they should not have done that because it was wrong to hit residents. They stated, I know better. During interviews on 7/8/25 at 3:58 PM and 7/9/25 at 10:40 AM, the Administrator stated there was not intentional physical abuse of Resident #1 by Certified Nurse Aide #3. They stated the incident was reported to the Department of Health because it was an allegation of abuse. They stated under normal circumstances it would not be appropriate to slap a resident. The Administrator stated they would expect staff to remove their arm from a resident's mouth by pulling their arm away.During an interview on 7/9/25 at 11:02 AM, the Director of Nursing stated on 7/1/25 at about 10:45 PM Licensed Practical Nurse #3 Supervisor, along with Licensed Practical Nurse #2 notified them that while Certified Nurse Aides #3 and #4 provided care to Resident #1, Certified Nurse Aide #3 hit Resident #1 on the head in reaction to being bit by Resident #1. An examination was done on Resident #1 and no marks or injuries were observed. Certified Nurse Aide #3 was suspended pending investigation. They stated the allegation of abuse was verified by reviewing staff statements and looking at what qualified as abuse; it was reported to the Department of Health. They stated there was no intent determined, Certified Nurse Aide #3 did not think about it, they just reacted. The Director of Nursing stated they would not expect their staff to react like that. They expected staff to speak to the resident, suggest to resident to stop biting, or pull arm away from the resident's mouth. 10NYCRR 415.4(b)(1)(i)

Based on observation, interview, and record review completed during a Standard survey conducted from 6/6/22 through 6/10/22, the facility did not ensure that each resident who was unable to carry out activities of daily living (ADL's) receives the necessary services to maintain grooming and personal hygiene. Specifically, two (Resident #2 and #27) of two residents reviewed for ADL's had lack of hand hygiene and glove changes during morning (AM) care (Resident #27), and long whiskers on upper lip and chin (Resident #2). The findings are: Review of the facility policy and procedure (P&P) titled Activities of Daily Living dated 3/2020 documented a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including: Hygiene - bathing, dressing, grooming, and oral care. 1. Resident #27 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 5/5/22 documented resident #27 had moderate cognitive impairment, was frequently incontinent of urine, and required extensive assistance of one staff member for personal hygiene, toileting, and dressing. During an observation on 6/8/22 at 8:47 AM Certified Nurse Aide (CNA) #1 performed hand hygiene and donned (put on) gloves. CNA #1 cleansed Resident #27's genitalia, anus, and face without performing hand hygiene or changing gloves. CNA #1 continued to remove Resident #27's wet shirt (with a strong ammonia odor), wash the residents back, dress the resident, and transfer the resident into a wheelchair without performing hand hygiene or changing gloves. Review of the Centers for Disease Control and Prevention (CDC) definition of hand hygiene includes cleaning your hands by using either handwashing (washing hands with soap and water), or antiseptic hand rub (i.e., alcohol-based hand sanitizer including foam or gel). Hand hygiene is recommended before moving from work on a soiled body site to a clean body site on the same patient. Additionally, the CDC recommends wear gloves, according to Standard Precautions, when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin, or contaminated equipment could occur. Change gloves and perform hand hygiene during patient care when moving from work on a soiled body site to a clean body site on the same patient. Review of the comprehensive care plan (CCP) with initiated date 1/20/22 documented Resident #27 required extensive assistance of one staff member for bathing, personal hygiene, and dressing. During an interview on 6/8/22 at 9:08 AM, CNA #1 stated they messed up and should have performed hand hygiene and changed their gloves when they completed bottom half and again when they completed top half to avoid cross contamination. During an interview on 6/9/22 at 12:20 PM, the Director of Nursing (DON) Infection Preventionist (IP) stated hand hygiene and glove changes are required when going from a dirty area (genitalia/anus) to a clean area (face), and prior to donning clothing to prevent cross contamination. During an interview on 6/9/22 at 12:28 PM, the Administrator stated hand hygiene and glove changes were expected when moving from cleansing lower body to cleansing upper body, and prior to donning clothing for cleanliness and prevention of cross contamination. 2. Resident #2 admitted to facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #2 had moderate cognitive impairment and required extensive assistance of one staff member for personal hygiene. Additionally, the MDS documented no rejection of care or behavioral symptoms. During intermittent observations on 6/7/22, 6/8/22, and 6/9/22 between 7:30 AM and 3:00 PM Resident #2 was observed with facial hair on the upper lip and chin approximately one quarter inch in length. Review of the facility Kardex (guide for providing care) with a print date of 6/10/22 documented Resident #2 required extensive assist of one staff member for personal hygiene. During an interview on 6/9/22 at 11:49 AM, CNA #1 stated they provided care to Resident #2 earlier in their shift. CNA #1 stated they did not notice any facial hair on Resident #2. Upon entering Resident #2's room at 11:55 AM, CNA #1 stated the resident has long whiskers around the lip and chin. During an interview on 6/9/22 at 12:10 PM, Licensed Practical Nurse (LPN) #2 stated CNAs are responsible to trim residents' facial hair, and it is the LPN's responsibility to ensure the CNAs are completing the residents care which includes trimming facial hair. During an interview on 6/9/22 at 2:34 PM, the DON stated anyone in the nursing department should identify facial hair and ensure the facial hair is removed if the resident agrees to have the facial hair removed. 415.12(a)(3)

Based on observation, interview and record review conducted during the Standard survey started 6/6/22 and complete 6/10/22, the facility did not promote care for residents in a manner that maintains or enhances his or her quality of life, recognizing each resident's individuality for one (Resident #7) of three residents reviewed for dignity with dining. Specifically, staff was observed standing while feeding, conversing with other staff, and leaving the resident unattended/unassisted to circulate the dining room. The findings are: Review of a facility policy and procedure (P&P) titled Feeding a Resident dated 3/1/2020 documented all nursing staff is to provide assistance to residents who are unable to feed themselves. The procedures documented to assist a resident with their meal at eye level (sitting). Review of facility P&P titled Privacy in Treatment and Care dated 3/1/2020 documented the resident is treated with consideration, respect, and full recognition of his/her dignity and individuality. Dignity means that in their interactions with residents, staff carries out activities that assist the resident to maintain and enhance his/her self-esteem and self-worth. 1. Resident #7 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 3/19/22 documented Resident #7 was rarely/never understood and rarely/never understands. The MDS documented the resident required extensive assistance of one person for eating. The Comprehensive Care Plan (CCP) initiated 2/17/22 and revised 6/9/22 documented Resident #7 required total assist of one for eating related to cognitive and physical impairments. During a continuous breakfast observation on 6/8/22 between 8:22 AM and 9:26 AM the following was observed: -8:22 AM- Resident #7 was seated in a Geri chair (specialized mobile reclining chair) next to a dining table, tilted backward and feet elevated. A staff member delivered Resident #7's meal tray to the table and left the resident unassisted and unattended. -8:29 AM- Registered Nurse (RN) #2 stood at the foot end of Resident #7's Geri-chair and offered them food and fluids. -8:35 AM- RN #2 stood at the foot end Resident #7 of the Geri-chair while feeding the resident and conversed with other staff members. RN #2 did not converse with Resident #7. -8:37 AM- RN #2 stopped feeding Resident #7, circulated the dining room and encouraged other residents to eat. -8:39 AM- RN #2 while standing offered one spoonful of food to Resident #7; stopped, circulated the dining room and encouraged other residents to eat. -8:42 AM- RN #2 stood at the foot end of the Geri-chair and fed Resident #7. -8:44 AM- RN #2 left the dining room, and Resident #7 unattended and unassisted with their meal. -8:46 AM- RN #2 returned to the dining room, stood at the foot end of Resident #7 offered them food/fluids, and conversed with Licensed Practical Nurse (LPN) #2. RN #2 did not converse with Resident #7. -8:48 AM- RN #2 left the dining room to assist another resident. -8:49 AM- RN #2 returned to the dining room, again stood at the foot end of Resident #7; offered them one spoonful of food and some fluids; circulated the dining room and encouraged other residents to eat. -8:50 AM- RN #2 stood at the foot end of Resident #7 and offered them food and fluids. -8:55 AM- RN #2 stopped feeding Resident #7, circulated the dining room and encouraged other residents to eat. -9:00 AM- RN #2 stood at the foot end of Resident #7 and offered them food and fluids. -9:05 AM- RN #2 stopped feeding Resident #7, again circulated the dining room and encouraged other residents to eat. -9:06 AM- RN #2 stood at the foot end of Resident #7 offered them one spoonful of food and fluids, stopped feeding Resident #7, and began to clean up the dining room tables. Resident #7 was transported out of dining room at 9:26 AM. During an interview on 6/8/22 at 9:26 AM, RN #2 stated they should have sat down while feeding Resident #7 because it was a dignity issue to stand over them. RN #2 stated they should have provided their attention and conversation to Resident #7 during the meal, so the resident knows they are important. RN #2 stated they were unable to sit down and interrupted Resident #7's meal to assist and encourage other residents that were in the dining room because there was not enough staff. During an interview on 6/9/22 at 2:40 PM, the Director of Nursing (DON) stated they would have expected staff to sit down next to Resident #7 and provide their attention to the resident during the entire meal to promote dignity to the resident. 415.5 (a)

Based on observation, interview and record review conducted during the Standard survey started 6/6/22 and completed 6/10/22, the facility did not maintain drugs and biologicals labeled in accordance with current accepted professional standards, and include the appropriate accessory and cautionary instruction, and the expiration date when applicable for one medication cart of one medication cart reviewed. Specifically, the medication cart had multi-dose eye drop bottles that were open and in use, that were not labeled with open/discard date. This involved Residents #20, 26 and 32. The finding is: The facility policy and procedure (P&P) titled Medication/Treatment Labeling and Storage dated 3/1/20 documented it shall be the policy of the facility to maintain proper labels for medications and proper storing instructions. The Vendor or facility Pharmacy will label medication/treatments with auxiliary labels such as refrigerate, shake well, and whatever added directions for storage or use apply. Review of a reference titled Remedi Senior Care Education - Medications with Shortened Expiration Dates dated July 2015 documented ophthalmic product [MEDICATION(S)] refrigerate until opened, may be used for 42 days after opening. 1. Resident #20 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - a resident assessment tool) dated 4/10/22 documented Resident #20 was severely cognitively impaired. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident #26 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #26 was severely cognitively impaired. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Resident #32 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #26 was rarely/never understood and sometimes understands. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation of the facility medication cart on 6/7/22 at 9:34 AM, in the presence of Licensed Practical Nurse (LPN) #1, revealed the following: - an open and in use bottle of [MEDICATION(S)] 0.005% Solution (eye drops) with a pharmacy dispense date of 4/7/22 for Resident #20. The bottle or box was not labeled with an open date or a discard date. -an open and in use bottle of [MEDICATION(S)] 0.005% Solution with a pharmacy dispense date of 11/4/21 for Resident #26. The bottle or box was not labeled with an open date or a discard date. - an open and in use bottle [MEDICATION(S)] 0.005% Solution with a pharmacy dispense date of 11/9/21 for Resident #32. The bottle or box was not labeled with an open date or a discard date. During an interview on 6/7/22 at 9:34 AM, LPN #1 stated all eye drop bottles should have an open date written on them and should be discarded 30 days after opening. During an interview on 6/9/22 at 3:22 PM, the dispensing Pharmacy's pharmacist stated the [MEDICATION(S)] Solution eye drops identified as opened and undated for Resident #20, 26 and 32 should have been dated and discarded 30 days after opening. During an interview on 6/9/22 at 4:00 PM, Registered Nurse (RN) #2 stated the [MEDICATION(S)] Solution (eye drops) identified as opened and undated for Residents #20, 26 and 32 should have had an open date written on it and be discarded after 30 days. RN #2 stated there were additional unopened bottles of [MEDICATION(S)] for Residents #20, 26 and 32 in the over-flow cabinet in the medication room. During an interview on 6/10/22 at 8:07 AM, the Director of Nursing (DON) stated the nurses were responsible to date the eye drop box or bottle when it was opened. They would have expected the nurses to identify the date during medication administration and discard it 30 days after opening. During an interview on 6/10/22 at 8:46 AM, the facility's Pharmacy Consultant stated they had not reviewed the medication cart or medication room for expired medications for the past few months and believed the last time they had reviewed medication storage was in January or February of 2022. The Pharmacy Consultant stated [MEDICATION(S)] should be dated when opened and discarded appropriately because it has a shortened expiration date. 415.18 (d)

Based on observation, interview, and record review conducted during the Standard survey started 6/6/22 and completed 6/10/22, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #27) of one resident's reviewed. Specifically, Resident (#27) with a history of falls, was observed to be transferred without the use of a gait belt (assistive device used to help safely transfer a resident) as planned. The finding is: The facility policy and procedure (P&P) titled Transfer & Ambulation, revised date 7/2014 documented all reasonable steps are taken to keep patients safe from accident and injury. Gait belts are provided to assist staff to safely transfer or ambulate patients. 1. Resident #27 was admitted to the facility with diagnoses including dementia, [CONDITION(S)] (tremors and rigidity of movement), and anxiety. The Minimum Data Set (MDS, a resident assessment tool) dated 5/5/22 documented Resident #27 had moderate cognitive impairment and required extensive assistance (staff provide weight bearing support) of one staff member for transfers and bed mobility. The comprehensive care plan (CCP) documented Resident #27 required extensive assistance of one staff member with the use of a gait belt for transfers (date initiated 1/20/22). The facility Fall Risk assessment dated [DATE] and signed by Registered Nurse (RN) #1 Resident Care Coordinator (RCC) documented Resident #27 was at high risk for falls, had multiple falls in the past six months, and exhibited loss of balance while standing. During an observation on 6/6/22 at 12:59 PM, certified occupational therapy assistant (COTA) #1 transferred Resident #27 from the wheelchair to the bed by placing their hands on each side of Resident #27's waist, pulling the resident to a standing position, and pivoting the resident into bed without the use of a gait belt. Resident #27 was observed to be unsteady, resistive, and almost fell to the floor during the transfer. During an interview on 6/6/22 at 1:04 PM, COTA #1 stated Resident #27 required extensive assistance of one staff member with the use of a gait belt for transfers. COTA #1 stated they forgot to apply the gait belt prior to transferring Resident #27. COTA #1 also stated Resident #27 was having difficulty transferring today (6/6/22), that they should have sat the resident back down, used the gait belt and gotten someone to assist with the transfer. During an interview on 6/9/22 at 10:58 AM, the Occupational Therapist (OT) #1 stated Resident #27 required extensive assistance of one staff member with the use of a gait belt for transfers. Additionally, the OT stated the gait belt was utilized for the safety of the resident during transfers to prevent falls. During an interview on 6/9/22 at 12:17 PM, the Director of Nursing (DON) stated staff should follow the CCP to ensure the safe transfers of residents. During an interview on 6/9/22 at 12:30 PM, the Administrator stated the CCP should be followed for the safety of the resident, staff member, and the prevention of falls. 415.12(h)(2)

Based on interview and record review conducted during a Standard survey completed on 10/10/19, the facility did not ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment are thoroughly investigated for one (Residents #8) of one resident reviewed for verbal abuse. Specifically, the facility did not complete a thorough investigation to rule out verbal abuse after Resident #8 filed a complaint. The facility's investigation lacked staff and resident's statements. The finding is: The facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property dated 8/1/17 documented abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse includes verbal, sexual, physical and mental, including abuse facilitated or enabled through the use of technology. It is the policy of the facility that reports of abuse are promptly and thoroughly investigated. When an incident or suspected incident of abuse is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include: Who is involved; Residents' statements; description of resident's behavior and environment at the time of the incident; observation of resident and staff behaviors during the investigation. 1. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 8/7/19 revealed the resident was cognitively intact, understood and usually understands. During an interview on 10/7/19 at 10:30 AM Resident #8 stated, One evening I was in extreme pain because I had been sitting up for a long period of time and it stated to get late. At around 9:00 PM, I put my call bell on to ask when they would be putting me back to bed and the nurse named (name of employee) yelled at me saying, I am not the only resident here and that there are 40 other residents they have to take care of and that I would have to wait. Resident #3 stated after (name of employee) yelled at her the resident began to cry really bad alone in her room. The resident stated (name of employee) was very mean and felt that it was verbal abuse. Resident stated she told the DON (Director of Nursing) about the incident and since that incident (name of employee) has not been on her side. When she sees (name of employee) in the halls, she is a lot nicer to her. She does not feel afraid of (name of employee). Review of the Complaint/ Grievance Form dated 8/9/19 revealed nature of the complaint was regarding to speak with the resident of delay of evening cares. When answering needs staff short with responses. Did note overnight staff assisted with cares and resident's preferences/ comfort. Response to complainant: General in service to be initiated. DON made aware- noted RN (Registered nurse)/ all staff doing multiple roles previous evening. Action Taken: In service initiated about appropriate responses, timely call bell answering. Recommendations: Noted resident has a very specific routine for care in room. Overall most are aware and adhere to resident's preferences and patterns. Continue to monitor for any further concerns. Reviewed/ Resolved: No harm. On 8/13/19 complainant notified: met with resident, updated on general in service, no further concerns. Review of Inservice Record/ Summary Report of Meeting dated 8/9/19 subject covered: all residents are to be treated with respect at all times regardless of your position you are assigned to on that scheduled day. Answer call lights respond appropriately complete task if able. Anyone can answer a call bell, and everyone can be friendly when responding. During an interview on 10/9/19 at 1:36 PM, the Social Worker stated, I started the complaint that Resident #8 had regarding the staff. I was looking at this for abuse and trying to rule it out. I did not receive statements from the staff or other residents. Resident stated she was waiting to go to bed and got to bed later than she planned. Apparently, staff had another resident they were attending to. The resident complained that it was just the evening staff on. I was not sure which staff she was speaking of, it may have been two RNs (registered nurses) she was speaking of, (name of employee and name of employee). An in-service was generated the next day on how staff should be responding to the call bells. I did meet with the Administrator and Director of Nursing regarding this and it was decided that it was more an issue with customer service versus abuse. During an interview on 10/9/19 at 1:48 PM, the DON (Director of Nursing) stated When we do investigations and if staff is involved, I will have them give me statements. I did speak to the staff that were on. I have to look for the statements. I normally will give the statements to the Social Worker to keep in her files. We typically speak to other resident regarding issues to establish if it was a pattern, but I did not talk to any other residents. This complaint we were not looking at it for abuse. This resident is very particular with when and how things are done. We were looking at the complaint for customer satisfaction, not abuse. The resident never told me that anyone yelled at her and I felt it wasn't abuse because the resident never reported to me that staff was verbally abusing her. During an interview on 10/9/19 at 1:58 PM the Administrator stated, The resident said she did not like the response the nurse gave her. We felt that is the difference between the way the nurse responded and how the resident took. The nurse gave her a quick short answer. At first, we were looking at it as abuse, but felt that it wasn't, and it was just how the resident took the response. At the time we heard about the complaint I thought it was about customer service. We never considered it was neglect or abuse. The nurse the resident was speaking of was (name of employee). I am going to tell you that I do not think that there are any statements from staff or other residents because we were looking at it more for customer satisfaction. This was not reported to the Department of Health because we felt it was not abuse, we were looking at. During an additional interview on 10/9/19 at 3:06 PM, the DON stated, I could not find any statement for the nurses or residents. I do not have any. During an interview on 10/10/19 at 7:59 AM, the Social Worker stated, The DON and I submitted the allegation to the DOH NYS (New York State Department of Health) last night. We feel that this could have been possible verbal abuse after speaking to the surveyor. We also re-interviewed the resident and started interviewing staff. 415.4(b)(3)

Based on observation, interview, and record review conducted during the Standard survey completed on 10/10/19, the facility did not ensure each resident's drug regimen is free from unnecessary drugs, and residents who have not used [MEDICAL CONDITION] drugs are not given these drugs unless the medication is necessary to treat a specific condition as [DIAGNOSES REDACTED]. An unnecessary drug includes drugs used without adequate indications for its use and without adequate monitoring for one (Resident #9) of five residents reviewed for unnecessary medications. Specifically, there was a lack of revised non pharmacological interventions and behavioral documentation to support the increased dose of [MEDICATION NAME] (antipsychotic medication). The finding is: The facility policy and procedure titled Use of Psychoactive Medications with a revision date of 3/2015 documented [DIAGNOSES REDACTED]. Antipsychotic medications will generally only be considered if the following conditions are also met, the behavior symptoms present a danger to the resident or others, the symptoms are identified as being due [MEDICAL CONDITIONS] and behavior interventions have been attempted and included in the plan of care (P[NAME]). For enduring psychiatric conditions, antipsychotic medications will not be used unless behavioral symptoms are persistent or likely to occur without continued treatment and not sufficiently relieved by non-pharmacological interventions. 1. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS -a resident assessment tool) dated 8/8/19 documented the resident was is cognitively intact, understood and usually understands. The MDS documented the resident received antipsychotic medication. Review of the Order Summary Report dated 10/1/19 revealed an order for [REDACTED]. Review of the untitled comprehensive care plan with a revision date of 8/15/19 revealed the resident had a mood problem related to [MEDICAL CONDITION] depression and anxiety. [MEDICAL CONDITION] drug use on file. Per psychologist recent Gradual Dose Reduction (GDR) of antipsychotic medication along with resident's hearing difficulty increases risk of paranoia. Interventions to include 1:1 with social work as needed, [MEDICATION NAME] per order, phone family when anxious for reassurance and offer a snack/food as needed. Review of an untitled Nurse Practitioner (NP) progress note dated 8/13/19 revealed under Assessment and Plan documented [MEDICAL CONDITION] take a ½ (one half) tab of 5 mg [MEDICATION NAME], GDR. Progress Note dated 8/13/19 at 7:39 AM documented NP in to see the resident, new order to decrease [MEDICATION NAME] to 2.5 mgs. Psych recommended to decrease to 4 mg, despite their recommendations, NP wants to decrease [MEDICATION NAME] to 2.5 mg. Progress Note dated 8/15/19 at 1:32 PM documented no behaviors today. Pharmacy called to clarify insurance refusal for 4 mg as recommended by psych, stated will only cover 1 pill a day, despite [DIAGNOSES REDACTED]. Does not come in 4 mg tablets. Progress Note dated 8/15/19 at 3:06 PM documented resident took all his belongings from the dresser and closet and threw them all over the room; was very upset and became verbally aggressive with staff, easily redirected and did go back and cleaned it up. The Psychotherapy Progress note dated 8/15/19 documented the resident's current symptoms were mild depressed mood, mild anxiety and mild suspicious behavior. The resident displayed mildly suspicious thinking regarding lost personal items that have never been in the facility, strongly suggest the resident receives some additional staff attention to assist with letting go of things that can't be rectified. Progress Note dated 8/16/19 at 11:35 AM documented, resident with increased anxiety today regarding dentures and dental visit today. Spoke with pharmacy for paper work to authorize [MEDICATION NAME] 4 mg per psych recommendations. Review of the Progress Notes 8/17/19 through 8/23/19 revealed there was no documented evidence of behaviors. Review of a History and Physical dated 8/23/19 revealed the resident had been on [MEDICATION NAME] and moods have improved significantly. Recently decreased [MEDICATION NAME] and he was getting extremely agitated and obsessive, compulsive thoughts as well as paranoid. Patient was also having significant mood swings. Assessment and Plan; [MEDICATION NAME] was decreased, mood and behaviors increased, 5mg was a slightly higher dose as he became slightly drowsy, give him 4 mg. Progress note dated 8/23/19 at 10:27 PM revealed approval given to increase [MEDICATION NAME] to 4 mg. During an observation on 10/09/19 at 2:26 PM revealed the resident in w/c (wheelchair) at the nurse' station talking to a nurse regarding upcoming appointments, good spirits. There were no behaviors or anxiety noted. During an observation on 10/10/19 at 7:28 AM the resident was in his room sleeping in his wheel chair. There were no behaviors or anxiety noted. During an interview on 10/10/19 at 8:16 AM, the Social Worker (SW) stated the Behavior Modification Assessment Record Committee (BMARC) was held monthly. The resident's behaviors are that he gets very anxious. It's usually a team decision for GDR but she was unsure why it was increased to 4 mg in (MONTH) from 2.5 mg with stable behaviors. Non- pharmacological interventions included the resident goes to see the SW usually daily. Additionally, Staff should be documenting during times of anxiety and if non- pharmacological interventions are working or not. During an interview on 10/10/19 at 10:53 AM, the Pharmacy Consultant stated she believed it was an insurance issue the medication was increased because [MEDICATION NAME] only comes in 2 and 5mg and is not scored. It was discussed at last BMARC because she was confused of why the facility was making multiple changes with the medication, This was a mess, because the behavior documentation wasn't there, I told them (the interdisciplinary team) if their having a problem with the medication they should be documenting it in the medical record. The Pharmacy Consultant also stated there was a couple behavior episodes documented at that time, but was unsure if that was the reason the medication was increased to 4 mg. There should be non- pharmacological interventions documented with the episodes. During a telephone interview on 10/10/19 at 11:50 AM, the Director of Nursing (DON) stated BMARC was held monthly. The NP/MD usually are not in attendance. He (the resident) has anxious behaviors about his TV, oxygen, things like that. It's almost daily and usually managed with 1:1 with the SW, he sees her routinely. She was unsure of why the MD increased the [MEDICATION NAME] to 4 mg in the short time it was decreased by the NP. During a telephone interview on 10/10/19 at 12:09 PM, the NP stated if the resident was having behaviors it would have been reported to her. She GDR'd it to 2.5 mg because the recommend dose of 4 mg doesn't come that way and had something to do with the insurance. The resident was seen on 8/23/19 and the MD made changes to the [MEDICATION NAME]. She was unsure where the MD received the information on the resident's behaviors documented in his note; as the progress notes don't reflect those behaviors. During a telephone interview on 10/10/19 at 12:53 PM, the Medical Director stated he does not review the progress notes for resident behaviors, but he always rounds with the nurses and talks to the Social Worker. If the behaviors are documented in his note, then he got the behavior information from the nurses or Social Worker. 415.12(1)(2)(i)

Based on interview and record review conducted during the Standard survey completed on 10/10/19, the physician must sign and dated all orders, with the exception of influenza and pneumococcal vaccines during visits. Three (Residents #2, #23 and #24) of fifteen residents reviewed for physician had issues. Specifically, the facility did not ensure the physician or non-physician provider signed and dated all orders during visits. The finding is: The policy and procedure (P&P) titled Medication and Treatment Orders with a revision date of 4/2014 documented drug and biological orders shall be written, dated, and signed by the person lawfully authorized to give such an order. The signing of the orders shall be by signature or a personal computer key. Signature stamps may not be used. 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a resident assessment tool) dated 6/27/19 documented the resident was cognitively intact, was understood and understands. Review of the Nurse Practitioner (NP) visit note dated 10/1/19 revealed the resident was seen on this date by the provider. Review of the physician's orders [REDACTED]. 2. Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed the resident was moderately cognitively impaired, was understood and usually understands. Review of the Physician's visit dated 5/17/19 revealed the resident was seen on this date by the provider. Review of the physician's orders [REDACTED]. 3. Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was cognitively intact, was understood and understands. Review of the physician's orders [REDACTED]. During an interview on 10/10/19 at 9:39 AM, the Director of Nursing (DON) stated the Medical Director signs off all the physician orders [REDACTED]. The DON was unsure how offend or when the Medical Director signs off on the standing orders. The Medical Records Coordinator was responsible for monitoring the orders to ensure they were being signed electronically. During and interview on 10/10/19 at 9:49 AM, the Medical Records Coordinator stated he had work at the facility for approximately two months and was still learning. He was unsure how offend the physician orders [REDACTED]. During a telephone interview on 10/10/19 at 9:55 AM, the Medical Director stated he signs the orders everyday electronically. New orders should be signed with in 48 hours and standing orders should be signed every three months. 415.15(b)(2)(iii)

Based on observation, interview, and record review conducted during a Standard survey completed on 4/28/17, the facility did not ensure that a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain grooming and personal hygiene. Three (Residents #18, 25 and #41) of five residents observed for personal care had issues that involved unwanted facial hair (#18), improper hand hygiene during care (#25) and long jagged finger nails (#41). The findings are: 1. Resident #18 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 1/5/17 revealed that the resident is cognitively intact, understood and understands. Additionally the resident required extensive assist of one person for personal grooming. Observation on 4/26/17 at approximately 9:05 AM revealed the resident pulling at whiskers on the side of her face that were approximately one inch long. Interview on 4/26/17 at approximately 1:44 PM with the resident revealed that the whiskers on the side of her face bother her and wishes they could do something for her. The resident then stated can they do something for me? Observation on 4/27/17 at approximately 8:18 AM revealed the resident still had whiskers on her cheek and chin after morning care. Certified Nurse Aide (CNA #1) was asked if morning care was completed, she stated yes. When asked if this included the removal of whiskers off the resident's face CNA #1 stated Oh, do you want me to shave her? Interview on 4/27/17 at approximately 10:56 AM revealed that the resident was bothered by her whiskers and she would like them removed stating especially the one on my cheek. Observation on 4/27/17 at approximately 12:30 PM revealed that the resident still had whiskers on her cheek and chin. Interview on 4/28/17 at approximately 7:28 AM with the Director of Nursing (DON) revealed that she expects her staff to remove whiskers as part of their morning care routine. The DON stated that they had CNA #1 remove the whiskers before she left for the day on 4/27/17. Review of the facility policy entitled A.M. Care' dated 5/2013 revealed that staff is to aid with shaving (male and female) as need. 2. Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is severely cognitively impaired and is always incontinent of bowel and bladder. The resident requires physical help in bathing, extensive assistance with toileting, and dressing. Review of the Kardex (guide used by staff to provide care) dated 4/28/17 revealed the resident is an extensive assist for incontinence care. During an observation of incontinence care on 4/27/17 at 1:34 PM, the Certified Nurse Aide (CNA #2) provided bowel incontinence care. The CNA dried the resident's buttocks with a towel and applied a barrier cream and then applied a clean incontinence brief. CNA #2 did not remove her gloves and wash her hands prior to applying the barrier cream and applying a clean brief. During an interview with CNA #2 on 4/27/17 at 2:11 PM, when asked if she usually provides incontinent care and uses the same gloves to apply barrier cream without changing her gloves or washing her hands CNA #2 responded, Yeah, I figured my gloves weren' t soiled, I could still use them. During an interview on 4/27/17 at 2:20 PM, the Director of Nursing (DON) stated she would have expected the CNA to change her gloves after incontinent care and wash her hands, apply clean gloves before applying barrier cream. Review of a facility policy entitled Hand Hygiene last revised 2010 revealed to wash hands with soap and water; before and after assisting a resident with toileting, and after performing personal hygiene. 3. Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact, understands and is understood. Further review of the MDS revealed no mood concerns, no [MEDICAL CONDITION] or behavioral symptoms. Observation on 4/26/17 at 10:55 AM revealed the resident's finger nails on all ten fingers were at least 1/8 of an inch over the tip of each finger and a couple of nails tips were jagged. During the observation, the resident stated that he did not want his fingernails to be that long but he did not have clippers to cut his nails. Review of the Comprehensive Care Plan with a revision date of 4/12/17, revealed approaches that include extensive assist of one person for bathing, dressing, transfer, toileting, bed mobility and oral care. Review of the Kardex dated 4/28/17 revealed the resident requires extensive assist of one person with bathing/ showering. Instructions on the Kardex include to monitor skin with daily care and weekly skin checks. Staff are to report any changes to the charge nurse. The resident prefers a shower two times a week. Instructions for personal hygiene include extensive assist of one person for oral care and that the resident prefers to have a long beard and to have the barber cut/trim his beard at the resident's request. Further review of the medical record revealed Weekly Skin Check LPN (licensed practical nurse) Shower Checks completed on 4/4, 4/11, 4/19 and 4/25/17. Each week either the Registered Nurse (RN) Resident Care Coordinator or the Director of Nursing (DON) documented, No new skin issues identified. No additional information was documented. Review of Progress Notes from 4/1/17 through 4/27/17 revealed no information regarding the condition of the resident's nails. During an additional observation of the resident on 4/27/17 at 8:37 AM the resident's finger nails were unchanged and remained long and jagged. During an interview with the DON on 4/28/17 at 7:39 AM, the DON stated that if a resident is a diabetic, the nurse will clip the resident's finger nails. The DON further stated that the resident's nails should be clipped by the nurse at weekly skin check. The DON stated she would check the Resident #41's nails once he is awake. During a later interview with the DON on 4/28/17 at approximately 9:00 AM, the DON stated that the resident's nails did need to be clipped. Review of the facility policy entitled Care of Fingernails/ Toenails, dated 2/05 revealed it was the responsibility of the Nursing Assistant or Licensed Nurse to clean the nail bed and keep the nails trimmed. The Nursing Assistants do not trim the nails of a diabetic resident. Nail care includes daily cleaning and regular trimming. 415.12(a)(3)

Based on interview and record review conducted during the Standard survey completed on 4/28/17, the facility did not ensure that residents are seen by a Physician at least every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. A Physician's visit is considered timely if it occurs no later than ten days after the date the visit was required. Two (Residents #24, 41) of 13 residents reviewed for frequency of Physician's visits had an issue involving Physician visits that were not completed as required. The findings are: 1. Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS, a resident assessment tool) dated 3/30/17 revealed the resident is severely cognitively impaired, is understood and usually understands. Review of the medical record revealed the most current Physician visit note was dated 1/18/17. Review of the Progress Notes revealed the Registered Nurse (RN) documented the Physician was in for a visit on 1/18/17 at 2:35 PM. On 4/5/17 at 10:19 PM, the Licensed Practical Nurse (LPN) documented that the Physician was in for a routine visit. The LPN documented new orders for an x-ray to lower sacral spine. During an interview with the Director of Nursing (DON) 4/8/17 at 7:59 AM, the DON stated she would expect a Physician's visit at least every 60 days for the resident. The DON stated that the nursing staff would write a Nursing Progress Note when the Physician saw the resident and if there were any new physician's orders [REDACTED]. 2. Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact, understands and is understood. Review of the medical record revealed the most current Physician's Visit Note was dated 1/18/17. Further review of the Medical Record revealed a Progress Note written by the LPN on 4/5/17 at 10:27 PM revealed that stated the Physician was in to see the resident for a routine visit and new orders were received for blood laboratory testing and the resident was referred to another Physician for bowel incontinence. During an interview with the Director of Nursing (DON) on 4/28/17 at 7:59 AM, the DON stated she would expect a Physician's Visit at least every 60 days for the resident. The DON stated that the nursing staff would write a Nursing Progress Note when the Physician saw the resident and if there were any new physician's orders [REDACTED]. Review of the Physician's Visit Reports from 12/28/16 through 4/26/17 revealed the following: - On 3/15/17 seven residents, who have been in the facility for more than 90 days, were seen by the Physician at an interval greater than 70 days. Two residents in the facility for less than 90 days, were seen by the Physician at an interval greater than 40 days. - On 4/5/17 five residents, who have been in the facility for more than 90 days, were seen by the Physician at an interval greater than 70 days. During an interview with the Medical Records Coordinator on 4/28/17 at 8:43 AM, the Medical Records Coordinator stated, I have been on the doctor to come and see these people. I give him a list of people that have to be seen and he picks and chooses which ones he sees. He (the Physician) will show up on second shift, stay for an hour and tells staff he will be here later. He leaves and then never comes back. During an interview with the Administrator on 4/28/17 at 8:50 AM, the Administrator stated, I thought this was resolved. We provide the Physician with a dictation service so we get his documentation. He (the Physician) will say he is coming back (to complete visits). I thought he was up to date. We had asked the Physician to come in during the dayshift for better coordination (of his services). During an interview with the Physician on 4/28/17 at approximately 9:00 AM, the Physician stated the facility tells him who needs to be seen at each visit and he will dictate his visit note. The Physician stated he thought he was up to date on his visits. Review of facility policy entitled Physician Services, revised (4/13) revealed that the Physician will perform pertinent, timely medical assessments. Further review of the policy revealed that Physician's Visits and the frequency of visits are provided in accordance with the current OBRA (Omnibus Budget Reconciliation Act- the minimum standards of care and right for nursing home residents) regulation and facility policy. 415.15(b)(2)(ii)

Based on interview and record review conducted during the Standard survey completed on 6/17/16, the facility did not provide the necessary care and services to attain and maintain the resident's highest practicable well-being. One (Resident #30) of nine residents reviewed for quality of care related to laboratory tests had issues involving the lack of timely follow up of urinalysis and urine culture and sensitivity (C&S - a laboratory test used to diagnose a urinary tract infection) results and a urinalysis and urine C&S that were not obtained per physician's orders [REDACTED].>The finding is: 1. Resident #30 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident is cognitively impaired, usually understands, and is usually understood. a.) Interview with the resident's responsible party on 6/15/16 at approximately 10:38 AM revealed that the resident had a urinalysis done and the responsibility party did not hear of the results until after they asked about them. Review of a Physician's Telephone Order dated 11/2/15 revealed an order to obtain a U/A (urinalysis) and a (urine) C&S. Review of a nursing Interdisciplinary Progress Note dated 11/3/15 revealed that the resident was refusing care and refusing to get out of bed. The Interdisciplinary Progress Note documented that the facility notified the responsible party that they were obtaining urine laboratory orders for the resident. Review of a 24 Hour Nursing Services Report dated 11/3/15 revealed there was a notation to obtain a urine sample for a urinalysis and a urine C&S. Review of a 24 Hour Nursing Services Report dated 11/4/15 revealed a notation under Labs to obtain blood work including a CBC (complete blood count), CMP (complete metabolic panel), and a TSH ([MEDICAL CONDITION] stimulating hormone). There was no documentation regarding pending urinalysis and C&S results. Review of the medical record revealed a Final Urine Culture Laboratory Report dated 11/11/15. The Laboratory (lab) Report documented that the urine specimen was collected on 11/3/15, the Preliminary result was dated 11/6/15, and the Final Report was dated 11/9/15. Review of nursing Interdisciplinary Progress Notes for 11/2015 revealed there were no notes written from 11/4/15 to 11/10/15. Review of a nursing Interdisciplinary Progress Note dated 11/11/15 revealed that the urinalysis and urine C&S results were received and the results were faxed to the physician. Interview with the Registered Nurse (RN #1) Resident Care Coordinator (RCC) on 6/16/16 at approximately 10:20 AM revealed that the nursing staff does not log urine tests in their lab requisition book. Further interview with the RN RCC on 6/16/16 at approximately 11:30 AM revealed that a urine C&S usually will have preliminary results in two to three days and if they didn't have the results, they would call the laboratory by the third day to verbally obtain the results. The RN RCC then stated that once they receive the results, they (nursing staff) should notify the resident's responsible party. Interview with the Director of Nursing (DON) on 6/17/16 at approximately 8:00 AM revealed that they (the facility) should have obtained the laboratory results within five days and they should notify the responsible party. Review of a facility policy and procedure entitled Scheduling and Tracking of Laboratory Tests dated 5/2013 revealed that all laboratory tests ordered by the Physician will be systematically scheduled and tracked, to ensure that all lab work ordered is obtained and results received. b.) Review of a physician's orders [REDACTED]. Review of the medical record, including nursing Interdisciplinary Progress Notes and Laboratory Reports from 12/30/15 to 1/30/16, revealed there was no documented evidence that a urinalysis and urine C&S was obtained . Interview with the RN RCC on 6/16/16 at approximately 11:30 AM revealed that she expects staff to carry out physician's orders [REDACTED]. The RN RCC then stated that they would call the hospital to see if there were any laboratory reports. Interview with the Receptionist on 6/16/16 at approximately 1:30 PM revealed that the only laboratory reports the hospital faxed to the facility for Resident #30 for the month of December were for a urinalysis on 12/14/15 and a CBC and CMP on 12/19/15. Interview with the Director of Nursing (DON) on 6/17/16 at approximately 8:00 AM revealed that she expects staff to carry out physician's orders [REDACTED]. 415.12

Based on record review and staff interview conducted during the Standard survey completed on 6/17/16, the facility did not maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized. Two (Residents #17, 30) of 22 residents' medical records reviewed for complete and accurate documentation had an issue involving physician progress notes [REDACTED]. The finding is: 1. Resident #17 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 5/5/16 revealed the resident is cognitively intact, understands, and is usually understood. Review of the medical record on 6/15/16, 6/16/16, and 6/17/16 revealed the most recent physician progress notes [REDACTED]. There were no current physician progress notes [REDACTED]. During an interview on 6/17/16 at 7:55 AM, the Medical Records Staff Member stated that they are waiting for some dictations from the Physician. The Medical Records Staff Member further stated she would find the dates that the resident was seen by the Physician. The physician visit dates provided by the Medical Records staff member are as follows: 8/19/15, 10/15/15, 12/17/15, 2/25/16, and 5/6/16. During an interview on 6/17/16 at 9:05 AM, the Administrator stated that Medical Records is responsible for ensuring that the physician progress notes [REDACTED]. The Administrator stated that the facility hired a transcriptionist about a year ago and the facility will be purchasing a dictation machine that does not leave the facility. The physician will dictate using the facility's dictation machine while at the facility and the tapes will be delivered directly to the transcriptionist by the facility. During a telephone interview on 6/17/16 at approximately 10:00 AM, the Physician stated that he dictates his progress notes on his computer and keeps a backup for his records. The Physician further stated that he is on his way to the facility and will allow the surveyor to listen to his dictations. During a follow up interview on 6/17/16 at approximately 10:07 AM, the Medical Records Staff Member stated that getting the Physician's Progress Notes has been an ongoing problem. During an interview on 6/17/16 at approximately 10:25 AM, the Physician stated that he has a backup of all his visits but is unable to provide them from his computer at this time. The Physician stated he will begin to hand write out some of his Progress Notes now. Review of a facility policy and procedure entitled Medical Records dated 5/13 revealed that the facility will keep resident records current, complete, legible, and available at all times to authorized personnel. 2. Resident #30 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident is cognitively impaired, usually understands, and is usually understood. Review of a Urinalysis and Urine Culture and Sensitivity Laboratory Report dated 12/14/15 revealed that a urine specimen was collected on 12/12/15 and sent to the laboratory. Review of the entire medical record, including physician's orders [REDACTED]. Review of the 24 Hour Nursing Services Report dated 12/12/15 revealed a written notation that a urine sample for Resident #30 was in the refrigerator and needed to be sent to the laboratory. Review of the 24 Hour Nursing Services Report dated 12/13/15 revealed a written notation that there was a urinalysis pending for Resident #30. During an interview on 6/16/16 at approximately 10:20 AM, the Registered Nurse (RN #1) Resident Care Coordinator (RCC) stated I don't see an order here for the urinalysis. The RN RCC stated that they should have a written paper order for the urinalysis. Interview with the Director of Nursing (DON) on 6/17/16 at approximately 8:00 AM revealed that she expects nursing staff to write any telephone orders from the physician in the resident's orders. Review of a policy and procedure entitled Transcribing physician dated 2/2009 revealed that upon receiving a physician order [REDACTED]. 415.22(a)(1,2,3)

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED 7/17/15. Based on observation, interview, and record review conducted during the Standard survey completed on 6/17/16, the facility did not ensure that residents who are unable to carry out activities of daily living (ADLs) receive the necessary services to maintain good grooming and personal hygiene. One (Resident #11) of three residents observed for personal care had issues involving incomplete incontinence care and barrier cream not applied after urinary incontinence care. The finding is: 1. Resident #11 has [DIAGNOSES REDACTED]. Review of the MDS (minimum data set-assessment tool) dated 4/4/16 revealed the resident has severe cognitive impairment, is always incontinent of bladder and bowel, and requires extensive assistance with ADLs (activities of daily living). Review of the Exceptional Care Plan dated 5/18/16 revealed the resident was identifies with the potential for skin breakdown due to incontinence, fragile skin, and decreased mobility. Care Plan approaches included the facility's Standard of Care for prevention of skin breakdown and urinary incontinence. Review of the undated Standard of Care entitled Urinary Incontinence revealed barrier creams are to be used on all incontinent residents and CNAs are to apply barrier cream following each episode of urinary incontinence. Review of the Care Guide, used by certified nurse aides (CNAs) to provide care, dated 6/15/16 revealed the resident is incontinent of bladder and bowel and receives incontinent care in bed with the assistance of two staff. Observation of morning care on 6/16/16 at 7:52 AM revealed the resident was wearing an incontinence brief while in bed. Twos CNAs (#1 and #2) were observed to remove the resident's brief, which was soiled with a small amount of urine, and provided urinary incontinence care. CNA #1 turned the resident on her left side, washed, and rinsed the resident's right buttocks and hip area. CNA #2 turned the resident onto her right side and washed the resident's left buttock and hip. CNA #2 stated she tinkled while we're cleaning her. CNA #2 finished cleaning the resident's buttocks and hips and the resident was turned onto her back. While being turned, the resident was incontinent of urine again. CNA #1 turned the resident onto her left side and placed a pad and an incontinence brief under the resident. The CNAs turned the resident onto her back, then onto her right side to pull the pad and brief flat under the resident. The CNAs fastened the brief without providing urinary incontinence care or applying barrier cream to the resident's buttocks. During an interview on 6/16/16 at 8:25 AM, CNA #1 stated we did think about it but we were out of linen, it was just a little urine, when asked if they thought about providing incontinence care after the resident was incontinent of urine. CNA #1 further stated normally we would have gone back and done it (incontinent care) and then put the barrier cream on, I'm very embarrassed. During further observation on 6/16/16 at 8:28 AM, CNA #1 lifted the pad on the resident's bed which revealed a wet spot measuring approximately four inches by four inches. During an interview on 6/17/16 at 7:57 AM, the DON stated I've been doing at least six incontinence audits per month. I don't know what to tell you about it. Our outcomes are good and UTIs (urinary tract infections) are not over 2 percent. They are very high functioning staff members and don't normally do it that way, it must have been nerves. 415.12(a)(3)

Based on observation, interview, and record review conducted during an Extended Survey completed 7/17/15, the facility failed to ensure that the resident environment remains as free of accident hazards as possible and that each resident receives adequate supervision to prevent accidents. Two (North, South) of two Dining Rooms observed for safe delivery of residents' meal trays revealed hot food, at temperatures of 195 degrees F (Fahrenheit) was served to residents. Meals were served without checking food temperatures at the point of service. Thirty-two residents resided in the facility on the day the high food temperatures were identified. Resident #48 was involved. This was widespread IMMEDIATE JEOPARDY AND SUBSTANDARD QUALITY OF CARE TO RESIDENT HEALTH AND SAFETY WITH NO ACTUAL HARM. In addition, one (Resident #48) of four residents reviewed for accidents had a history of [REDACTED]. This was no actual harm with potential for more than minimal harm that is not immediate jeopardy. The Immediate Jeopardy was removed on 7/17/15, prior to completion of the survey. The findings are: 1. Test trays were completed on 7/15/15 at the lunch meal due to resident complaints about the taste and palatability of the food. Review of the Week at a Glance Menu for the week of 7/12/15 revealed the Lunch meal included Cheesy Sausage/Spaghetti Bake, French Style Green Beans, Garlic Bread, and Cream Puff Cake. Review of the Dining Schedule dated 5/2015 revealed Breakfast was served at 8:00 AM, Lunch at 12:00 PM, and Dinner at 6:00 PM. Prior to the observation of lunch on 7/15/15, all three of the surveyors' digital thermometers were placed in an ice bath on 7/13/15 at approximately 3:30 PM. Thermometer #1 measured 31.1 degrees F, the Thermometer #2 measured 30.9 degrees F, and Thermometer #3 measured 30.8 degrees F. Review of the Food Temperature Log for Wednesday 7/15/15 at the noon meal revealed the temperature of the House Meat and Ground Meat (Cheesy Sausage/Spaghetti Bake) when it was removed from the oven was 198 degrees. The vegetable (French Style Green Beans) was 199 degrees F. The temperature of the Pureed Meat was190 degrees F and the pureed vegetable was 189 degrees F. The Food Temperature Log had a column for temperatures with an asterisk next to it (*), which identified that the temperature of the food items should be 180 degrees. Additional review of the Food Temperature Log revealed a notation at the bottom of the Log documented *these temperatures are not the recommended temperatures for point of service. Observation in the Kitchen on 7/15/15 at approximately 11:58 AM revealed the prepared hot foods were placed into a preheated portable steam table which was transported to the Unit Dining Rooms. The portable steam table was observed to arrive on the North Dining Room 7/15/15 at 12:01 PM. Test Tray temperatures were taken on 7/15/15 at 12:06 PM using Thermometer #2. The server placed two 4 ounce scoops of Cheesy Sausage/ Spaghetti Bake on regular plates with the French Style Green Beans in a monkey dish. The temperature of the Cheesy Sausage/Spaghetti Bake was 198.3 degrees F. The food item was stirred and temped again at 195 degrees and was hot. The temperature of the French Style Green Beans was 158 degrees F. A Test Tray was conducted in the South Dining Room on 7/15/15 at 12:37 PM after all of the residents in the dining room were served. Thermometer #3 was used to check the temperatures. The Cheesy Sausage/Spaghetti Bake was 195 degrees F and was very hot and the French Style Green Beans were 145 degrees and tasted okay. The Garlic Toast was 135 degrees and was warm and tasty. A third Test Tray was conducted on 7/15/15 on the North unit to represent a resident eating in their room. Temperatures were taken at 12:39 PM using Thermometer #1. The Cheesy Sausage/Spaghetti Bake was 152 degrees F and tasted good, flavorful, and it was at a palatable temperature to taste. The French style Green Beans were 134 and warm to taste. The garlic toast was 100 degrees and tasty. Interview with the Food Service Director (FSD) on 7/15/15 at approximately 2:30 PM revealed food temperatures are taken when the food comes out of the oven. The FSD stated they don't take temperatures at the point of service or at the end of meal service. During an interview at approximately 4:00 PM on 7/15/15, the FSD stated she did not know the food was that hot. Interview with the Corporate Registered Dietitian (RD) on 7/16/15 at approximately 11:00 AM revealed the facility was not taking temperatures at the point of service or at end of meal service. The RD stated that the facility was checking Test Trays on the weekends, which would provide temperatures at the end of service on those days, but not every day. 2. Resident #48 has [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed the resident was severely impaired for decision making. Review of the medical record Face Sheet revealed the resident was admitted to the facility on [DATE]. a.) Review of physician's orders [REDACTED]. Review of the Care Guide, used by certified nurse aides (CNAs) to provide care dated 7/16/15 revealed the resident requires total assistance with meals. Observation of breakfast on 7/15/15 from 8:30 AM to 9:00 AM revealed the resident was being fed by staff in the North Dining Room. The resident was observed to be resistive to the feeding assistance. Interview with a Registered Nurse (RN) on 7/15/15 at 3:52 PM revealed she fed the resident lunch on 7/15/15 and the resident hooted out a bit ugh, ugh, ugh when she took the first bite of food. The RN stated that she saw that there was steam rising from the food and so I immediately gave her a cold drink. I took the spoon and stirred the food about for a while as steam was coming from the food. In a bit, I resumed feeding the resident without any problem. I did not tell anyone that the resident reacted as though the food was very hot and I did not look at her mouth to make sure she did not burn her mouth. b.) Review of an Incident Documentation Tool dated 5/18/15 and Witness Statement Interviews dated 5/18/15 revealed a certified nurse aide (CNA) reported that the resident's arm protectors slid down while changing the resident into night clothes and she noticed a skin tear on the resident's left elbow. Additional review of the Incident Documentation Tool revealed that an RN documented that the skin tear measured 1.0 centimeters (cm) by 0.8 cm . Review of the resident's Care Guide dated 7/16/15 revealed the resident uses a Geri-chair, a Geri-chair cushion, and arm protectors on the right and left arms. Observations of the resident sitting in her Geri-chair on 7/14/15 at 9:08 AM and 7/17/15 at 10:00 AM revealed there was a 1 ½ inch tear on the vinyl upholstery of the right armrest and two 1 inch tears on the left armrest. The observation revealed that the torn armrests were jagged. Interview with the Maintenance Director on 7/17/15 at approximately 1:00 PM revealed he was not aware that the Geri-chair had tears on both armrests. The Director stated he is usually able to replace an armrest fairly quickly since he keeps a couple different sized armrests in the building. 3. Review of an untitled document, signed by the Administrator, dated 7/17/15 revealed a statement that the Immediate Jeopardy in the facility related to hot food temperatures was abated (removed) on 7/17/15. Review of an Abatement Plan dated 7/16/15 revealed the following corrective measures were implemented: - Food temperatures will be checked and documented in the dining room prior to meal service from the steam table to ensure that food is within acceptable parameters for consumption between 135 - 165 degrees. Food will be temped and documented at the end of meal service from the steam table to ensure that food temperatures remain acceptable for consumption between 135 - 165 degrees. - A formal QA (Quality Assurance) Review will be conducted daily for 14 days (start date 7/16/15), to address any necessary modifications, additions, or concerns identified through the process above. - Oral assessments were completed on all residents on 7/15/15 and no issues were found. - All full and part-time dietary staff were educated (with the exception of two employees) regarding proper food temperature to avoid food borne illness and proper food temperature at the point of service and end of service. In addition, dietary staff will be educated on the proper dial level that the steam table should be placed at for consistent heating levels. - The dietary staff will be educated on procedures to address food temps being too hot. If unable to obtain correct food temperatures at every meal, the employee must notify their supervisor immediately for further direction. The administrator will also be notified immediately. - A post-test will be conducted daily starting 7/16/15. - Temperatures will be taken at every meal indefinitely and the FSD will maintain the documented temperatures for six months. - The portable steam table was serviced on 7/16/15 to assure proper maintenance and functioning. - Nursing staff were educated on appropriate food temperatures for consumption on 7/17/15. - Facility policies for Thermometer Accuracy Check and Calibration/food Temperature Log were revised. Interviews with Dietary staff on 7/16/15 at 6:19 PM revealed the staff were inserviced and were aware of the need to check hot food temperatures at the point of service. The dietary staff stated that acceptable hot food temperatures ranged from 140 to 160, they would stir the food if it is too hot, and if food remained too hot, the supervisor is to be notified. Interviews with CNA, LPN, and RN staff on 7/17/15 between the hours of 9:00 AM and 11:00 AM revealed the staff were inserviced regarding meal service, acceptable hot food temperatures (135 to 165), and how to proceed if food is too hot. Observations of breakfast and lunch on 7/17/15 revealed that hot food temperatures were checked by the FSD on the steam table at the point of service and prior to being served to the residents. Observation of the breakfast meal on 7/17/15 revealed the following food temperatures were obtained: - Oatmeal - 136 degrees F - Egg omelet - 147.9 degrees F - Pureed omelet - 144 degrees F Observation of the lunch meal on 7/17/15 revealed the following food temperatures were obtained: - Macaroni and cheese - 152.3 degrees F - Baked fish - 142 degrees F - Pureed macaroni and cheese - 152 degrees F 415.12(h)(1)(2)

Based on observation, interview, and record review conducted during an Extended Survey completed 7/17/15, it was determined that the facility was not administered in an effective and efficient manner that would enable each resident to attain or maintain the highest practicable physical, mental and psychosocial well-being. Specifically, concerns rising to the level of immediate risk to resident health and safety included the facility's failure to monitor food temperatures at the point of service to residents to prevent food from being served at high temperatures that could endanger residents. This was a pattern of widespread IMMEDIATE JEOPARDY AND SUBSTANDARD QUALITY OF CARE TO RESIDENT HEALTH AND SAFETY WITH NO ACTUAL HARM. The Immediate Jeopardy was removed on 7/17/15, prior to the completion of survey. The findings are: 1. Refer to F323 - Accidents - scope and severity = L The facility failed to implement a system to ensure that residents' meals were served within acceptable food temperature parameters at the point of service to residents. Interview with the Administrator on 7/16/15 at approximately 3:00 PM revealed she was not aware that dietary staff were not checking food temperatures during meals at the point of service and she did not know that the food was so hot. The Administrator stated she should have known and became aware of the problem within the hour of the event occurring (7/15/15 - lunch meal). 415.26

Based on interview and record review conducted during the Extended survey completed on 7/17/15, the facility did not ensure that all alleged violations of mistreatment, neglect, or abuse are thoroughly investigated in a timely manner, and must prevent further potential abuse while the investigation is in progress. Two (Residents #13, 33) of two residents reviewed for abuse had issues involving the lack of a timely (#13) and/or thorough (Resident #33) investigation into residents' complaints of alleged abuse, neglect, or mistreatment by staff. In addition, the facility did not ensure that all alleged violations involving resident neglect or abuse were reported to other officials in accordance with State law through established procedures (including the State survey and certification agency). This was a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are: 1. Resident #13 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 4/16/15 revealed that the resident is cognitively intact, usually understands, and is understood. Further review of the MDS revealed the resident has experienced delusions, is totally dependent on two persons for bed mobility and transfer, and is totally dependent on one person for locomotion on and off the nursing unit. Review of a Progress Note, dated 7/8/15, revealed the Social Worker (SW) documented that a care planning meeting was conducted with the resident and his daughter. The SW documented that the resident was agitated and refused to sign the LOT (limitations of treatment) form and asked to have his daughter, who was present at the meeting to sign for him. The SW documented that the resident was angry with the team for not believing that four FBI (Federal Bureau Investigation) agents and State Troopers were in to see him. The SW documented that the resident mood was labile. Review of the Exceptional Care Plan, dated 7/08/15 revealed the problems of physical mobility/ activity of daily living (ADL) function related to an AKA (above the knee amputation) [MEDICAL CONDITION]([MEDICAL CONDITION] - stroke) with left sided weakness. The Care Plan documented that the resident refuses lower extremity passive range of motion due to sensitivity from the AKA. Review of the Care Guide (used by the certified nurse aide (CNAs)) to provide care), dated 7/14/15 revealed the resident has anxiety related to incontinence and the belief that others are out to harm him. Additional instructions stated SW to assist when anxiety is high. During an interview with the resident and his daughter on 7/13/15 at 10:53 AM, the resident stated that staff pushed his wheelchair along the wall, while transporting him back to his room, causing him leg pain. The resident stated that he informed the SW and the Registered Nurse (RN) Resident Care Coordinator (RCC) of this incident during a meeting the previous week. During an interview on 7/14/15 at approximately 10:00 AM, the SW stated that the resident reported during a care plan meeting on 7/8/15 that an aide had hit his leg into a wall. The SW stated that an investigation was in process but had not yet been completed. During an interview with the Administrator and SW on 7/15/15 at 9:31 AM, the Administrator stated that the CNA was coming in that day to provide a statement. The Administrator stated that an Occupational Therapy (OT) referral was made after the Administrator interviewed the resident and looked at his wheelchair. The Administrator stated that the facility will train staff in transferring, dignity, and customer service. Review of a Complaint/ Grievance Form dated 7/14/15 revealed the SW documented that the Resident had care issues during care conference. Resident states during transport from dining room, an aide was excited and bumped his leg on the wall. Further review of investigation documentation revealed a written statement by the RN RCC dated 7/14/14 that stated To the best of my recollection from (the) Team Care meeting (on) 7/8/15, (the resident) stated that on the previous evening, one of the CNA's was transporting the resident from dinner and hit his foot. Further review of the investigative documentation revealed that all statements regarding the allegation were obtained on 7/14/15 and 7/15/15. During an interview on 7/16/15 at 10:00 AM, the RN RCC stated that if anyone were to report abuse to her, she would bring the concern to the SW immediately. The RN RCC stated that the SW would interview anyone involved and inform the Director of Nursing (DON) and the Administrator immediately. The RN RCC stated during the interview that Resident #13 reported at a care meeting on 7/8/15 that someone had hit his foot. The RN RCC stated that she checked the resident's foot at that time and did not observe any injuries. The RN RCC stated that she spoke to the SW regarding the allegation and the SW was to talk with the resident and would investigate the allegation. The RN RCC stated that she would stay involved in an abuse investigation and she would follow up with the SW regarding the outcome of the investigation. The RN RCC stated she was going to follow up with the SW regarding Resident #13's allegation and would have expected an investigation to begin immediately after hearing the resident's complaint. During an interview on 7/16/15 at 10:08 AM, the SW stated that when she receives information about an allegation of abuse, she will meet with the resident or contact the family member to gather information; she will inform the Director of Nursing and Administrator; and begin to gather statements from staff immediately. The SW stated that she was informed of Resident #13's allegation, by the resident, at a Care Plan Conference attended by the resident and his two daughters during the late afternoon of 7/8/15. The SW stated that an investigation should have begun sooner. The SW continued to state that she should have spoken to the resident immediately after the Care Plan Conference. During an interview on 7/16/15 at 10:18 AM, the Administrator stated that any suspicions of abuse should be investigated immediately. A thorough investigation should be completed to rule out abuse and the investigation should be reported to the Department of Health as necessary. When asked if Resident #13's allegation was investigated in a timely manner, the Administrator stated it was not and that the investigation should have begun on the day of the Care Plan Conference. 2. Resident #33 has [DIAGNOSES REDACTED]. Review of the annual MDS dated [DATE] revealed the resident is cognitively intact, understands, and is understood. Interview with the resident on 7/13/15 at approximately 2:20 PM revealed the resident Someone pushed me into the wall as she was mad at me because it is hard for me to turn. I told them and she does not care for me anymore. During an interview on 7/13/15 at approximately 2:49 PM, the Administrator was able to recall that Resident #33 had concerns regarding an employee and that they removed that employee from caring for Resident #33. Review of a Complaint/ Grievance Form dated 4/16/15 revealed the SW documented a complaint from Resident #33 occurring on 4/16/15. Two CNA's (CNA #1 and 2) reported an incident to the SW that occurred overnight involving the resident and a CNA. The CNA (CNA #3) woke the resident for care and requested the resident to turn on her side. The resident asked for the CNA to wait a minute but she did not and pushed on her bad leg two times with the resident ending up against the wall. The resident stated that CNA #3 provided incontinence care while scrubbing very hard that left the resident feeling sore. Due to soreness, the resident remained in her room that morning. Interview with the Director of Nursing (DON), SW, and Administrator on 7/13/15 at approximately 4:56 PM revealed the SW initiated a Complaint Form and spoke to the resident. The interview identified the CNA involved. The SW confirmed that CNA #3 was working by looking at the schedule and they (SW, DON, and Administrator) decided to remove the CNA from caring for the resident. Continued interview with the DON revealed the nursing staff did not do a physical assessment of Resident #33; they did not interview other staff; and they did not discipline CNA #3 because the CNA had never had any formal complaints or discipline prior to this occurrence. The DON, SW, and Administrator all stated that looking back at this incident, they should have interviewed the staff on that shift as well as the shift after and documented those interviews. The DON and Administrator stated they would complete a full investigation that evening. Interview with the DON and Administrator on 7/14/15 at approximately 8:28 AM revealed the staff who worked the night shift of 4/15/15 through the day shift 4/16/15 were contacted and an investigation revealed the resident made a statement that CNA #3 pushed her against the wall and scrubbed hard while rendering incontinent care. The DON completed a full body exam and submitted a referral to PT (Physical Therapy) due to her decreased mobility. Interview with the DON on 7/15/15 at approximately 5:50 PM revealed the incident reported by the resident had a potential to be abuse and it should have had a full investigation at the time of allegation. At the time, the facility did not complete an incident report and did not report the incident to the New York State (NYS) Department of Health (DOH) according to State law. Review of a policy and procedure entitled Incident Documentation and Analyzing Facility Incidents dated 12/09 revealed all incidents involving resident care will be investigated and documented. A full assessment of the resident is to be completed, written statements from staff are to be collected, the resident is placed on the 24 Hour Report, and the incident is then forwarded to the DON for review. The DON will review all potential reportable incidents with the Administrator. Review of the 24 Hour Nursing Services Reports dated 4/15/15 to 4/18/15 revealed there was no documentation of the resident's reported concerns. 415.4(b)(2)(3)(4)