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

Based on interviews and record reviews during a survey the facility failed to ensure the Director of Nursing served as a charge nurse only when the facility had an average daily occupancy of 60 or fewer residents. Specifically, both the Director of Nursing #1 and the Director of Nursing #2 worked as a charge nurse when the facility had a daily average census of greater than 60. The findings include: An undated document titled Director of Nursing Job Summary provided by the facility documented duties to include but were not limited to organize documented plans, organizes and directs the overall operations of the Nursing Service Department in accordance with all state, federal and local guideline/regulations to ensure that the highest degree of quality care was always maintained. The Director of Nursing shall maintain and adhere to a master staffing plan, provide adequate and professional nursing and paraprofessional personnel sufficient and commensurate with the type and amount of nursing needs of individual residents. The facility policy and procedure tilted Daily Staffing revised on 08/2025, documented minimum critical staffing levels will be addressed in the facility assessment. The Nursing supervisor was instructed to contact the Director of Nursing and/or Administrator any time staffing levels fall below minimum/critical to initiate an emergency plan. The State Operations Manual dated 07/23/2025, documented a Charge Nurse as a licensed nurse with specific responsibilities designated by the facility that may include staff supervision, emergency coordinator, physician liaison, as well as direct resident care. The facility assessment with a review date of 04/06/2026 documented the staffing plan to meet the needs of the residents for day shift consisted of one (1) full time Director of Nursing, one (1) full time Assistant Director of Nursing, two (2) full time Unit Coordinators (one (1) Licensed Practical Nurse and one (1) Registered Nurse), four (4) Licensed Practical Nurses and ten (10) Certified Nursing Aides. The evening shift required two (2) part time Nursing Supervisors, three (3) Licensed Practical Nurses and eight (8) Certified Nursing Aides. The overnight shift required one (1) full time nursing supervisor, two (2) Licensed Practical Nurses and four (4) Certified Nursing Aides. Review of the facility daily staffing sheets dated 04/19/2026- 05/27/2026 revealed Director of Nursing #1 and #2 were counted in the facility's numbers to meet their minimum staffing for direct care to the residents. Review of the daily schedule report for May 10th and May 20th documented Director of Nursing #1 worked as a charge nurse on 05/10/2026 from 7:00 PM to 7:00 AM, and on 05/20/2026 from 3:00 PM to 1:00 PM to meet the facility's minimum staffing requirements. On 05/26/2026 Director of Nursing #2 was scheduled from 7:00 AM to 1:40 PM as the Director of Nursing and scheduled as a charge nurse from 11:00 PM to 7:00 AM to meet the facilities minimum staffing numbers. Review of the Facility Daily Staffing dated 05/10/2026 documented the resident census was 76. Review of the Facility Daily Staffing dated 05/20/2026 documented the resident census was 77. Review of the Facility Daily Staffing dated 05/26/2026, documented the resident census was 80. During an interview on 5/26/2026 at 10:41 AM, the Staffing Coordinator stated if the Director of Nursing was on call and a nurse had called off, they would rely on the Director of Nursing to meet the minimum staffing requirements. They stated they would first try to get per diem staff, agency staff and/or would go around the entire building to ask staff if anyone would stay to fill the vacant shift. They stated they would also send out a mass text to all staff before they would utilize the Director of Nursing. During an interview on 05/27/2026 at 9:14 AM, (former) Director of Nursing #1 stated they worked from 7:00 AM to 3:00 PM Monday through Friday and would also work as a supervisor when the facilities minimum staffing number could not be met. They stated on 05/10/2026 they worked as the Director of Nursing during the day (7:00 AM to 3:00 PM), and from 7:00 PM to 7:00 AM as a charge nurse. They stated on 05/20/2026 worked from 7:00 AM to 3:00 PM as the Director of Nursing and as charge nurse from 3:00 PM to 11:00 PM to meet the facilities minimum requirements for staffing. They stated they were not aware of the regulation that the Director of Nursing was unable to work as a charge nurse unless the census was 60 or below. During further interview 05/27/2026 at 9:52 AM, the Staffing Coordinator stated Director of Nursing #2 worked from 7:00 AM until 1:30 PM on 05/26/2026. They stated Director of Nursing #2 left early because they were scheduled to return to work for the overnight shift. They had come in again on 05/26/2026 at 10:39 PM and left on 05/27/2026 at 7:51 AM. They stated they had to rely on the Director of Nursing on occasions to meet their minimum staffing requirement. They stated they were not aware of the regulation that the Director of Nursing was unable to work as a charge nurse only when the census was 60 residents or below. They stated they relied on the Director of Nursing as minimal as possible and were usually able to get a per diem nurse or an agency nurse but not always. During an interview on 05/27/2026 at 10:25 AM, the Administrator stated when it came to meeting the minimum staffing requirement, they would require all departments to chip in. They stated all department managers would be expected to come in if required. They stated if the Staffing Coordinator tried to contact sister facilities, per diem nurses and agency nurses with no luck the Director of Nursing would have to come in. They stated they were aware of the regulation the Director of Nursing was not to work as a charge nurse when the facility had a daily average census of 60 or above. They stated they were also aware the Director of Nursing #2 came in to work the overnight shift as a charge nurse on 05/26/2026. They stated the Director of Nursing #2 was a Registered Nurse and they did not have a lot of Registered Nurses, so they had no choice. On 05/27/2026 at 11:15 AM an attempted telephone interview with Director of Nursing #2 was mad, a voice mail was left with no repsonse. During an interview on 05/27/2026 at 11:40 AM, (former) Administrator #2 stated it was a directive of the organization per their union contract not to pull a cart nurse (charge nurse) to also act as a supervisor unless they were fully staffed. They stated it fell onto the facility management to cover shifts that required management to meet the needs of staffing. They stated they recalled when multiple ill staff were out, they relied on Director of Nursing #1 to pick up shifts to ensure the minimum staffing requirements were met, if no one else was available. During an interview on 05/27/2026 at 12:39 PM, the Corporate Clinical Director stated the Director of Nursing cannot work any additional role simultaneously in their 40-hour work week. They stated that above and beyond their 40 hours a week they could pick up additional shifts to meet the minimum staffing requirement or for extra money. They stated they felt this was a common practice utilized among many facilities. 10 New York Codes Rules Regulations 415.13(b)(1)

Based on observations, interviews and record review conducted during a survey, the facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for three (3) (Heritage unit (C/D), Main Dining Room, and Woodland Heights unit (A/B)) of three (3) test trays. Specifically, food and beverages during meals were served at suboptimal temperatures, were not palatable, and were not attractive looking. Residents #1, #2, #3, #7, #11, #21, #42, #56, #61, and #85 were involved. The findings include:The policy titled Food Preparation, Service and Distribution dated 10/2022 documented the facility would assure safe and sanitary food preparation, holding, transport and distribution to prevent food borne illness. Tray line and/or alternate meal preparation and service areas may include steam tables, where hot prepared foods are held and served, and chilled areas where cold foods are held and served. The facility will avoid the following potential risks to reduce food borne illness: not holding food in the danger zone (temperatures above 41 degrees Fahrenheit and less than 135 degrees Fahrenheit). The policy documented dining locations includes any area where one or more residents eat their meal. These include dining rooms or mobile food carts that maintain food at a proper temperature and out of danger zone. The facility staff will serve hot foods hot and cold foods cold in accordance with resident preference. Serving temperatures are not to be confused with proper cooking and holding temperatures.During an interview on 05/19/2026 at 9:55 AM, Resident # 21 stated the food in the facility was not good, some things were overcooked, the vegetables were always mushy, and the grilled cheese sandwich was usually burnt and greasy.During an interview on 05/19/2026 at 10:25 AM, Resident #7 stated the meals were always cold, bland and late. During an interview on 05/19/2026 at 1:46 PM, Resident #85 stated the food was nasty and the temperature of the food was usually cold.During an interview on 05/20/2026 at 8:27 AM Resident #1 stated the food was just not good. The meat was too tough to chew and sometimes dry. They stated they preferred to eat in their room, and the food was sometimes cold by the time staff brought their tray.During the Resident Council meeting on 5/20/26 at 8:50 AM, Residents #2, #42, and #61 all stated the vegetables were always mushy, there was not enough variety and occasionally the food was cold.During an interview on 05/20/2026 at 10:41 AM, Resident #56 stated the temperatures of the food are always cold and the lids covering the food do not help. They stated they wait for an hour to get their tray in their room.During an interview on 05/20/2026 at 11:02 AM, Resident #3 stated all meals are served cold.During an interview on 05/20/2026 at 11:04 AM, Resident #11 stated that food is always served cold and sometimes it would taste good but sometimes it did not.During an observation in the Main Kitchen on 05/21/2026 at 11:30 AM, temperatures were taken of the foods in the steam table by [NAME] #1 using a facility stem-type thermometer. The temperatures were as follows:-Ham with pineapple-150 degrees Fahrenheit-Ground ham-140 degrees Fahrenheit-Rice-180 degrees Fahrenheit-Chicken breast-135 degrees Fahrenheit-Chili-160 degrees Fahrenheit-Cooked spinach-150 degrees FahrenheitDuring an interview on 05/21/2026 at 11:32 AM, [NAME] #1 stated ideal hot holding temperatures of the foods in the steam table were between 145- and 150-degrees Fahrenheit, and a plate warmer was used.Additional temperatures were taken of foods in the steam table on 05/21/2026 at 12:00 PM as follows:-Mixed vegetables in water-140 degrees Fahrenheit-Ground ham-second temperature taken-150 degrees Fahrenheit1. During an observation on 05/21/2026 at 12:29 PM, the test tray for the Heritage unit (also known as Unit C/D) left the Main Kitchen in an enclosed cart. The meal cart arrived to the unit at 12:29 PM and the last tray was delivered at 12:44 PM. At 12:46 PM the test tray observation was started, and the meal contained the alternate meal choice, a plate with a covered bowl of chili and a serving of steamed spinach, milk and juice. The meal did not look attractive. The following temperatures were obtained with the Evening Dietary Supervisor, using the facility's manual thermometer:-Steamed Spinach-115 degrees Fahrenheit, looked watery, tasted slightly warm and was flavorless. -Chili with beef -140 degrees Fahrenheit, it had no beans and looked thin.During an interview on 05/21/2026 at 12:49 PM, the Evening Dietary Supervisor stated hot foods should be served between 145 degrees Fahrenheit to 165 degrees Fahrenheit, and cold foods should be served between 35 degrees Fahrenheit to 45 degrees Fahrenheit.During an interview on 05/21/2026 at 12:54 PM, Resident #21 stated they did not like the look of the meal, so they were not going to eat it. They requested a sandwich.During an interview on 05/21/2026 at 12:55 PM, Resident #1 stated they did not want to try the meal, they ordered a bowl of soup and a peanut butter and jelly sandwich.2. During an observation on 05/21/2026 at 12:59 PM, the test tray for the Main Dining Room left the Main Kitchen in a small open cart. At 1:00 PM a test tray observation started, and the meal contained mechanical soft (easily chewed and swallowed) foods. The following temperatures were obtained with the Director of Dietary using the facility's thermometer:-Ham-115 degrees Fahrenheit, tasted lukewarm.-Rice-90 degrees Fahrenheit, tasted bland and cold.-Vegetable Mix, zucchini and cauliflower -110 degrees Fahrenheit tasted bland and lukewarm.During an observation and interview on 05/21/2026 at 1:00 PM, the Director of Dietary tasted the test tray items and stated the ham was not too cold for them but would prefer the temperature to be at least 140 degrees Fahrenheit for the residents. They stated the rice was bland and could be warmer, the vegetables were bland but not undercooked, not overcooked and would like them to be a little warmer. They stated when the food came out of the kitchen, they allowed the residents to season the food to their liking so that was why the food tasted bland. They stated condiments are left on the tables and residents can season to taste. 3. During an observation on 05/21/2026 at 1:13 PM, the test tray for the Woodland Heights unit (also known as Unit A/B) left the Main Kitchen in a small open cart. The first meal cart arrived at 1:08 PM and the second small open cart arrived at 1:13 PM. The last tray was delivered at 1:23 PM and a test tray observation started at 1:25 PM. The following temperatures were obtained with the Evening Dietary Supervisor using the facility's thermometer:-Ham-112 degrees Fahrenheit, tasted lukewarm.-Vegetable Mix, zucchini and cauliflower-114 degrees Fahrenheit. It tasted watery, with no flavor and was lukewarm.-Coffee: 124 degrees Fahrenheit, tasted warm, not hot.During an interview on 05/21/2026 at 1:34 PM, the Evening Dietary Supervisor stated the food temperatures should have been higher. They stated the temperatures were not warm enough for eating and palatability. They stated the vegetables were not seasoned and were cooked in water. They stated Woodland Heights Hall trays were the last to be served and that during serving the lids covering the food are removed. They stated if the food was kept covered more it could help with maintaining warmer temperatures of the food. During an observation and interview on 05/21/2026 at 1:40 PM, Resident #11 received rice, ham and zucchini for lunch. Resident #11 stated the food was not warm enough and the coffee was never hot; it was just warm.During an interview on 05/21/2026 at 1:54 PM, Resident #3 stated the vegetables had no flavor and were not hot.During an interview on 05/27/2026 at 12:13 PM, the Corporate Clinical Director stated they were unsure what the safe temperature ranges were that food should be served at but cold food needed to be served cold and hot foods needed to be served hot and the food items could not sit around too long. They stated the facility should be following the safe food temperatures to prevent any food borne illness.During an interview on 05/27/2026 at 12:54 PM, the Director of Dietary stated they would expect the hot foods to be served to the residents between 145 -155 degrees Fahrenheit and cold foods be served at least 38 degrees Fahrenheit or lower. They stated that temperature ranges were for safe health, properly cooked foods and palatability. The Director of Dietary stated that they speak to residents at random and participate in the resident council meeting and the resident's biggest food complaints were cold coffee and occasionally cold foods. They added that the facility changed their food distributor at the beginning of the month, and they feel the food quality has improved along with the residents' complaints.10 New York Codes Rules Regulations 415.14 (d) (1) (2)

Based on record review and interviews conducted during the survey, the facility failed to ensure a Pre-admission Screening and Resident Review (PASSAR), Level I identification screen, was completed prior to admission for two (2) (Residents #5 and #32) of two (2) residents reviewed. Specifically, there was no evidence that the screen was completed prior to admission for Residents #5 and #32. The findings are:The policy titled Pre-admission Screening and Resident Review, revised 11/2023, documented a screen is required for every resident prior to admission regardless of length of stay. A copy of the resident's most recent screen accompanies the resident upon transfer to a hospital or another Residential Health Care Facility.The policy titled Pre-admission Process, revised 12/16/2021, documented that all residents will have a completed screen which shows the minimum qualifications for admission to a Residential Health Care Facility are met.1. Resident #5 had diagnoses including bipolar disorder (a mental health condition that causes extreme, unusual shifts in mood, energy, activity levels, and concentration), anxiety and depression. The Minimum Data Set (a resident assessment tool), dated 03/27/2026, documented they were cognitively intact, always understood and always understands others.Review of Resident #5's medical record, including the electronic and paper record, revealed they were admitted to the facility on [DATE]. There was no Level I Pre-admission Screening present in the medical record prior to the date of admission. Consequently, the resident was admitted without verification of whether a Level II assessment was required.During an interview on 05/21/2026 at 12:18 PM, the Social Worker stated they were unable to locate the Pre-admission Screening and Resident Review (PASSAR) for Resident #5. They stated the resident transferred from a facility that was no longer operating, and they were unable to contact them. The Social Worker stated resident #5 did have bipolar disorder diagnosis, but they were well controlled on their medication and had been followed by psychiatry. During an interview on 05/22/2026 at 8:45 AM, the Social Worker stated, at the time of Resident #5's admission, Former Administrator #2 reviewed the admission documents, and they should have noticed the screen was missing. They stated the screen was important because it alerted them if the resident required a higher level of care, mentally or cognitively. If they did require a level II referral, they would need to know what recommendations were made.2. Resident #32 had diagnoses including dementia with agitation, major depressive disorder and polyosteoarthritis (degenerative joint disease). The Minimum Data Set, dated [DATE], documented Resident #32 had moderate cognitive impairment. They were understood and understand others and had behavioral symptoms.Review of Resident #32's electronic medical record revealed that the resident was admitted to the facility on [DATE]. There was no evidence of a Level I Preadmission Screening form in the medical record prior to the date of admission.During an interview on 05/22/2026 at 9:09 AM, the Social Worker stated they did not have a Pre-admission Screening and Resident Review (PASRR) for Resident #32. They stated Resident #32 was transferred from another facility in 2021 and they were not part of the admissions process then. They stated Resident #32 should have a Preadmission Screening and Resident Review, so the facility had guidelines that were appropriate for the resident. During an interview on 05/26/2026 at 1:39 PM, the Administrator stated they would have expected the person that accepted admission paperwork to review it and make sure the screens were there. They stated the screen was important to know if residents required more services. 10 New York Codes, Rules and Regulations 415.11(e)

Based on observation, interview, and record review conducted during survey the facility failed to ensure residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing for one (Resident #3) of two residents reviewed. Specifically, Resident #3's air/foam mattress pressure pump was disconnected from pump, and the pump was unplugged preventing air flow use with mattress.The findings include: The facility policy and procedure titled Documentation of Pressure Ulcer and Chronic Wounds) revised 6/23, documented that pressure ulcers and chronic wounds were monitored closely to monitor effectiveness of treatment and change in risk factors. Risk factors were identified and suggested interventions may be implemented or modified on an as needed basis. Review of undated Self-Adjusting Air/Foam Mattress with Optional Alternating Pressure Pump operation manual, documented the mattress was indicated for the prevention and treatment of any and all stage pressure ulcers when used in conjunction with a comprehensive pressure ulcer management plan. To use as an alternating system with pump, connect pump hoses extending from the mattress. Plug pump into a properly grounded wall outlet. Switch to the ON position, and air will begin to flow into mattress. Resident #3 had diagnoses that included osteomyelitis (infection and inflammation of the bone), pressure ulcer of sacral region-stage four (4) (damage to the skin and underlying soft tissue, involving full-thickness skin and tissue loss at the base of the spine), and spinal stenosis (narrowing of the spinal canal). The Minimum Data Set (a resident assessment tool) dated 12/12/2025 documented that Resident #3 was understood, understands, and was cognitively intact. Resident #3 required substantial assistance to dependent assistance with bed mobility. Resident #3 was at risk of developing pressure ulcers and had two (2) Stage 3 (full thickness tissue loss) pressure ulcers present on admission; and one (1) stage 4 (full thickness tissue loss) pressure ulcer present on admission. The undated Comprehensive Care Plan documented that the resident was at risk for impaired skin integrity related to impaired mobility, moisture and pressure injuries. Interventions included administer treatments as ordered, educate regarding making frequent small shifts in body weight, pressure reduction device for bed: air mattress to be set for 238 pounds. The Kardex (guide used by staff to provide care) dated as of 5/11/2026 documented the resident utilized a pressure reduction device for bed an air mattress to be set for 238 pounds. The Order Summary Report dated 05/27/2026 documented an order for every two (2) hour offloading while in bed for skin integrity and to document all refusals dated 03/27/2026. The Treatment Administration Records dated 01/01/2026 through 05/27/2026 revealed there was no documented evidence regarding the use or monitoring of the air/foam mattress's function and settings. Review of Wound Care Assessment/Consultation dated 05/12/2026 completed by Wound Consultant documented Sacrum/Coccyx Stage 4 (four) pressure ulcer measured 8.0 centimeters in length, 9.0 centimeters in width and 2.5 centimeters in depth. Left Buttocks Stage 3 (three) pressure ulcer measured 7.5 centimeters in length, 4.5 centimeters in width and 0.1 centimeters in depth. Right Buttock Stage 3 (three) pressure ulcer measured 3.0 centimeters in length, 1.5 centimeters in width and 0.1 centimeters in depth. The healing status of all the pressure ulcers was documented as plateau/stalled. Recommendations/Interventions documented the use of pressure redistribution device. Review of Nursing Weekly Skin Status Documentation completed by the Director of Nursing #1 on 05/20/2026 documented Sacrum/Coccyx Stage 4 (four) pressure ulcer measured 9.5 centimeters in length, 8.5 centimeters in width and 2.5 centimeters in depth. Left Buttocks Stage 3 (three) pressure ulcer measured 8.5 centimeters in length, 8 centimeters in width and 0.1 centimeters in depth. Right Buttock Stage 3 (three) pressure ulcer measured 3.0 centimeters in length, 2 centimeters in width and 0.1 centimeters in depth. During intermittent observations on 05/20/2026 at 11:09 AM, 05/21/2026 at 9:56 AM and 12:33 PM, 05/22/2026 at 8:27 AM, and 05/26/2026 at 7:00 AM, 7:33 AM, and 1:46 PM, Resident #3 was in bed the air mattress hose was disconnected from pump, and the pump was unplugged hanging from foot board of bed. During an observation on 05/26/2026 at 8:37 AM, Licensed Practical Nurse #2 and Licensed Practical Nurse #3 Resident Care Coordinator, provided pressure ulcer care to Resident #3's pressure ulcers located on the resident's coccyx/sacrum, right buttock and the left buttock. Licensed Practical Nurse #2 completed treatments to all of the pressure ulcers as ordered. The air mattress pump was not connected or functioning during the observation. During an observation and interview on 05/26/2026 at 1:46 PM, Certified Nurse Aide #1 stated Resident #3 had pressure ulcers on their tailbone, and both buttocks. Certified Nurse Aide #1 reviewed the Kardex from the resident's closet, dated as of 05/11/2026 and stated Resident #3 should have an air mattress on their bed and that it did not look like they did. They stated the air mattress would be blowing air and that it was not. During an interview on 05/26/2026 at 1:57 PM, Licensed Practical Nurse #2 stated they did not know why Resident #3's air mattress was not functioning. They stated Resident #3 was planned to have an air mattress to assist with offloading, to help prevent further deterioration of their pressure ulcers. During an interview on 05/26/2026 at 2:05 PM and 2:19 PM, Licensed Practical Nurse #3 Resident Care Coordinator stated they were not aware that Resident #3's air mattress was not functioning properly or that the pump was disconnected. They stated it was important for Resident #3 to have an air mattress to prevent continuous pressure on their pressure ulcers, to help prevent worsening of pressure ulcers. They stated the nursing aides and nurses were responsible to ensure the air mattress was on and to notify maintenance of any function issues. Licensed Practical Nurse #3 Resident Care Coordinator stated Resident #3 had a room change on 05/03/2026. During an observation and interview on 05/26/2026 at 2:11 PM, the Director of Maintenance stated Resident #3 mattress was a Dual Mattress that will not collapse if the air pump if off. They identified that the air hose for the air mattress portion of the mattress was not connected to the pump and that the pump was not plugged in. They located the air hose from the mattress and connected it to the air mattress pump at the foot end of the bed, plugged the air pump in and then turned on the air pump. The Director of Maintenance stated they were not part of the room swap (change) on 05/03/2026. During a telephone interview on 05/27/2026 at 8:57 AM, Director of Nursing #1 stated they were not aware that Resident #3's air mattress was not functioning. They stated they would expect nursing staff to check air mattresses to ensure they were functioning properly and to notify them or the maintenance department if they were not. They stated air mattresses were important in relieving direct pressure and promoting healing. During an interview on 05/27/2026 at 11:18 AM, the Director of Maintenance stated Resident #3's mattress needed to be plugged in and connected to ensure proper inflation of the air mattress component. They stated they would expect the mattress to be inflated for proper use. They stated maintenance was not notified of any issues pertaining to Resident #3's air mattress through their electronic record system. During a telephone interview on 05/27/2026 at 11:42 AM, the Wound Consultant stated the expectation was that Resident #3 was being encouraged to offload by turning and positioning in bed and that their air mattress was operational for offloading to prevent wound deterioration and promote wound healing. They stated because Resident #3's mattress was not completely deflated; they did not feel the lack of the air pump was detrimental to their pressure ulcers. During a telephone interview on 05/27/2026 at 12:17 PM, Registered Nurse Supervisor #1 stated Resident #3's mattress was moved during a room change on 05/03/2026. They stated nursing and housekeeping staff moved Resident #3's air mattress only and not the bed frame. Registered Nurse Supervisor #1 stated they did not see Resident #3's air mattress set up after it was moved, and could not say if the mattress was plugged in. They stated it would be important for the air mattress to be set up correctly to promote pressure reduction and that the care plan was followed. During an interview on 05/27/2026 at 12:34 PM and 1:49 PM, the Corporate Clinical Director stated they would expect nursing staff to check that the air mattresses were operating every shift. 10 New York Code Rules Regulations 415.12 (c) (1)

Based on observation, interview and record review conducted during the survey, the facility failed to ensure they established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) (Resident #2 ) of four (4) 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) and one (1) of one (1) facility legionella program. Specifically, staff did not wear appropriate personal protective equipment during wound care for Resident #2 and the facility's Legionella Water Management Plan was not reviewed or revised annually. The findings include:The policy titled Policy on Disease-Specific Isolation/Precautions last revised 12/19/24 documented enhanced barrier precautions referred to an infection control intervention designed to reduce the transmission of multidrug resistant organisms that employs targeted gown and glove use during high contact resident care activities. Enhanced barrier precautions are used in conjunction with standard precautions and expand the use of personal protective equipment to donning (putting on) gowns and gloves during high contact resident care activities that provide opportunities for transfer on the multidrug resistant organisms to staff hands and clothing. Enhanced barrier precautions may be recommended for residents with wounds, generally chronic wounds.Review of the Enhanced Barrier Precaution signage (a sign used by the facility to indicate a resident required enhanced barrier precautions) documented that everyone must wear gloves and a gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing briefs or assisting with toileting, device care or use; and wound care (any skin opening requiring a dressing).1.Resident #2 had diagnoses including diabetes, ulceration of the left leg, and peripheral vascular disease (narrowing of arteries that reduce blood flood to limbs). The Minimum Data Set (a resident assessment tool) dated 04/03/2026 documented Resident #2 was cognitively intact, understood and understands. Resident #2 had one (1) Stage III (3) pressure ulcer (an open area on the skin caused by prolonged pressure characterized by full thickness tissue loss, visible subcutaneous fat, but no visible muscle, tendon, or bone)The comprehensive care plan dated 05/22/2026 documented Resident #2 was at risk for infection related to wounds with interventions including enhanced barrier precautions and to observe/report signs of infection.The Kardex Report (a guide used by staff to provide care) dated 04/30/2026 documented Resident #2 was on enhanced barrier precautions.Review of the Order Recap Report dated 05/01/2026 - 05/31/2026 document Resident #2 had the following active medical provider orders:-cleanse open area on buttocks with normal saline, pat dry and apply honey hydrogel (a medical-grade honey with an acrylic gel) and cover with dry clean dressing daily for wound care. The start date was 04/22/2026.-gentamicin (antibiotic) to left pinky toe topically and cover with alginate dressing (a high absorbency dressing) daily for vascular ulcer (an opening in the skin from impaired blood circulation). The start date was 05/22/2026.Review of the Wound Care Assessment/Consultation note dated 05/12/2026, the Wound Consultant documented Resident #2 had a stage III (3) pressure ulcer to the left buttocks measuring 0.8 centimeters (length) x (by) 0.4 centimeters (width) x 0.1 centimeters (depth). The wound had a pink/red/healthy wound bed with excoriated (red or bleeding partial-thickness skin loss)/denuded (moist) wound edges. The Wound Consultant documented Resident #2 had a left great toe vascular wound measuring 1.0 centimeters (length) x1.0 centimeters (width) x 0.1 centimeters (depth) with minimal bleeding and there was slough (yellow/white dead tissue) along with pink/red/healthy tissue to the wound bed.During a wound care observation and interview on 05/26/2026 at 1:18 PM, Resident #2 was observed to have an enhanced barrier precaution signage on the wall/door frame prior to entering their room. Written in black ink on the sign was the room number, D (door) and W (window). Licensed Practical Nurse #1 donned gloves and completed the treatments to Resident #2's left buttock pressure ulcer and left pinky toe vascular ulcer per medical provider orders. Licensed Practical Nurse #1 did not wear a gown during the wound care treatments. During an interview after the treatments were completed, Licensed Practical Nurse #1 stated they did not have to wear a gown for Resident #2's treatments because the enhanced barrier precaution signage on the door was for Resident #2's roommate not Resident #2. After reviewing the signage on the door, Licensed Practical Nurse #1 stated the sign did say to utilize enhanced barrier precautions while providing care for both residents in that room. They stated they did not wear a gown but should have. Licensed Practical Nurse #1 stated the purpose of utilizing enhance barrier precautions during wound care treatments were, so they did not pass infection to each other or themselves.During an interview on 05/27/2026 at 11:34 AM, Registered Nurse #1 Resident Care Coordinator stated the last time they assessed Resident #2's wounds were on 05/22/2026 and the resident had a pressure ulcer to their left buttock and a macerated (breakdown of skin due to moisture) pinky toe and both areas were chronic. Registered Nurse #1 Resident Care Coordinator stated there was scant (small) amount of drainage at that observation from Resident #2's left buttock wound. They stated that every resident that had a wound was to be on enhanced barrier precautions and staff were to wear gowns when preforming wound care so that staff did not cause an infection or transmit anything to each other. Registered Nurse #1 Resident Care Coordinator stated they were not aware that Licensed Practical Nurse #1 did not wear a gown during Resident #2's wound care observation on 05/26/2026 but Licensed Practical Nurse #1 should have.During a telephone interview on 05/27/2026 at 11:57 AM, the Wound Consultant stated they were familiar with the enhanced barrier precautions regulations but did not have any expectations for grown use during wound treatment care but would expect staff to follow the facilities policy. They stated they were providing wound consult visits for Resident #2 due to the resident having a pressure ulcer to their buttock and vascular wounds to their left foot. The Wound Consultant stated Resident #2's buttock wound was usually moist when they assessed their wound, and they would wear gowns during their rounds because it was just safer to do so. The Wound Consultant stated the purpose of enhanced barrier precautions was to prevent infection not only from person to person but also from wound to wound.During an interview on 05/27/2026 at 12:13 PM, the Corporate Clinical Director stated that if staff were providing care to any residents that had any additional open areas such as foley catheters or wounds, staff were expected to wear gloves, gowns and masks. They stated they were not familiar with Resident #2 but if the resident did have any wounds, then the resident would be on enhanced barrier precautions to protect the resident from staff bring germs to the resident. 2. Review of the facility's collection of Legionella documents revealed it contained Form DOH (Department of Health)-5222, Environmental Assessment of Water Systems in Healthcare Settings, dated 07/07/2025, completed by the Director of Maintenance and the Sampling and Management Plan for Healthcare Facilities: Guidance and Template, effective 10/31/2023, completed by Former Administrator #1.Review of the Sampling and Management Plan for Healthcare Facilities: Guidance and Template, effective 10/31/2023, revealed the Point of Contact was listed as Former Administrator #1, along with their contact information. Former Director of Nursing/ Infection Preventionist #1 was listed as the team member responsible for infection control.During an interview on 05/21/2026 at 9:45 AM, the Director of Maintenance stated Former Administrator #1 reviewed and updated the facility's Legionella Water Management Plan in 2023 due to a potential Legionella concern at that time. They stated they did not know if the plan had been reviewed or revised since then. Additionally, on 05/26/2026 at 3:13 PM, the Director of Maintenance stated the Environmental Assessment of Water Systems and the Legionella Water Management Plan should be reviewed annually. They stated they personally reviewed the Environmental Assessment of Water Systems every year, and in the past, the Administrator had reviewed the Legionella Water Management Plan.During an interview on 05/21/2026 at 9:55 AM, Director of Nursing #1 stated they were not sure if the Legionella Water Management Plan had been reviewed or revised since 2023 and they needed to look into it further. On 05/21/2026 at 11:00 AM, Director of Nursing #1 submitted a written note that stated the 2023 document was the most recent version.During an interview on 05/26/2026 at 2:30 PM, the Administrator stated they had become the facility's Administrator in May 2026, they had not yet personally reviewed the facility's Legionella Water Management Plan, and it should be reviewed annually. Additionally, on 05/26/2026 at 3:35 PM, the Administrator stated they had also checked with Former Administrator #2 but were unable to locate any documentation that showed the Legionella Water Management Plan had been reviewed or revised since October 2023.10 New York Codes Rules Regulations 415.19(a)(2)New York Codes Rules Regulations Title 10 4-24-2.4(c)

Based on record review and interviews during a survey, the facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents for one (1) (Resident #1) of three (3) residents reviewed for accidents. Specifically, Resident #1 who had severe cognitive impairment, a history of elopement, exit seeking and wandering behaviors, exited the facility through the delayed egress (security device that's restricts exit by sounding an alarm and delays a door from opening for 15-30 seconds) equipped front door on 06/19/2025 at 9:41 PM without staff's knowledge. This resulted in no actual harm that was Immediate Jeopardy and Substandard Quality of Care with the likelihood of serious harm, serious impairment, serious injury or death to Resident #1's health and safety. The findings are:The policy titled Risk for Elopement, dated 01/26/2022 documented a safe environment is provided for residents who are at risk to wander.The policy titled Missing Resident, Elopement, Dr. Walker dated 09/2023 documented a situation in which a resident leaves the premises or a safe area without a facility's knowledge and supervision would be considered an elopement. This situation represents a risk to the resident's health and safety and places the resident at risk of heat or cold exposure, dehydration and/or other medical complications, drowning or being struck by a motor vehicle. All staff will be able to follow an organized plan to enable the facility to locate a missing resident as quickly as possible. The code alert system is utilized to deter resident elopement, for residents with a history of elopement. Maintenance staff, nursing supervisors or staff in close proximity will respond to door alarms and ensure that residents do not elope.The policy titled Elopement Security System Alarms/Devices dated 09/2024 documented security alert devices are used to alert staff to resident movement outside a designated area. All staff will be trained in the proper working of alarm devices and how to respond to an activated alarm.Resident #1 had diagnoses that included dementia, chronic kidney disease (gradual loss of kidney function), and seizures. The Minimum Data Set (a resident assessment tool) dated 04/25/2025 documented the resident had severe cognitive impairment, physical behavioral symptoms directed towards others, rejection of care, and wandering behaviors.The Comprehensive Care Plan dated 07/26/2023 documented Resident #1 was at risk for elopement related to confusion and dementia. Documented interventions included the resident would utilize a wander detection/monitoring system (wearable alert device) to their right ankle. On 04/15/2025, the documented goal was that the resident would remain on the premises through next review. (07/2025 next review due).The Kardex (guide used by staff to provide care) dated 06/19/2025 documented Resident #1 was independent with the use of a rolling walker for ambulation (walking) and was at risk for elopement.The Nursing Elopement Risk Data Collection Tool dated 05/07/2025 documented that Resident #1 had a history of unsafe wandering, opening doors to outside and/or elopement, made statements they were leaving or seeking to find someone/something and were at risk for elopement.The Progress Note completed by Licensed Practical Nurse #2 dated 06/18/2025 at 1:46 PM documented Resident #1 wanders throughout the shift. Resident with repetitive statements help me and/or I'm scared. 1:1 (one to one) support, food, drink, and toileting provided with zero effect. Repetitive statements, wandering and an increase in anxiety noted.Review of video surveillance footage revealed that Resident #1 exited the facility through the delayed egress front door on 06/19/2025 at 9:41 PM. At 9:43 PM, Certified Nurse Aide #1 goes to the front door, reactivating the door's alarm system but neglected to open and verify if any residents had exited the building.The Accident/Incident - Elopement report completed by Registered Nurse #2 dated 06/19/2025 at 9:45 PM documented Resident #1 pushed on the front door; due to the delayed egress Resident #1 was able exit the facility. Resident #1 was found walking down the road by a bystander who called emergency services. The nursing supervisor was notified by local emergency personnel and Resident #1 was brought back to facility. Resident #1 was unable to give an account of the events. The report documented predisposing factors that included the resident had impaired memory, wandered, and exhibited active exit seeking behaviors.A handwritten statement included in the facility's investigation signed by Certified Nurse Aide #2 dated 06/20/2025 documented that Resident #1 was asking for help at approximately 9:00 PM on 06/19/2025, and they assisted the resident to bed.A typed statement provided by Certified Nurse Aide #1 included in the facility's investigation dated 6/20/2025 documented that they heard the alarm go off. They went to the door, looked out and did not see anybody, so they returned to the floor.A local police department report dated 06/19/2025 at 10:05 PM documented that a caller reported an elderly person appearing confused at a local restaurant (0.2 miles from the facility). Emergency Medical Services responded and found the person had left a nearby nursing home; staff of the nursing home contacted and were responding.During a telephone interview on 02/05/2026 at 9:20 AM, Certified Nurse Aide #1 stated they responded to an activated alarm at the front door entrance on 06/19/2025 at approximately 9:45 PM. They looked out the door into the entryway, did not see anyone, turned the alarm off and reactivated the system. Certified Nurse Aide #1 stated they did not open the door or look outside the secondary exterior doors because they didn't think a resident could get out of the building. Certified Nurse Aide #1 stated they did not notify the nursing supervisor of the sounding alarm.During a telephone interview on 02/05/2026 at 9:27 AM, Licensed Practical Nurse Supervisor #1 stated Resident #1 had been following them around the during the shift on 06/19/2025 and was anxious. Licensed Practical Nurse Supervisor #1 stated they last saw Resident #1 between 9:15 PM and 9:30 PM on 06/19/2025, and assumed staff had assisted the resident to bed. They were unaware Resident #1 had exited the building until local emergency services personnel came to the facility at approximately 10:10 PM and reported Resident #1 was across the street in a parking lot. The emergency services personnel requested them (Licensed Practical Nurse Supervisor #1) to follow them to the parking lot to see if they could identify the individual. Licensed Practical Nurse Supervisor #1 stated when they got to the parking lot of the local restaurant, a good Samaritan was there and they had stated that they were driving on Route 31 (a state highway with a speed limit range of 25 - 55 miles per hour), when they saw a person ambulating with a walker on the side of the highway. They pulled over, assisted them into their car, drove to the restaurant parking lot, and contacted emergency medical services. Licensed Practical Nurse Supervisor #1 stated that no staff members had reported to them that a door alarm had been activated and reset.During a telephone interview on 02/05/2026 at 11:33 AM, the Medical Director stated when the alarm was activated on 06/19/2025, staff should have checked the outdoor area to ensure no residents had exited the facility, notified the nursing supervisor, and ensured all residents were accounted for.During an interview on 02/05/2026 at 11:57 AM, the Acting Director of Nursing stated on 06/19/2025 staff should have determined what activated the alarm, checked the outdoor area for any residents; notified the nursing supervisor of alarm activation, and ensured that all residents were accounted for.During an interview on 02/05/2026 at 12:11 PM, the Administrator stated when the alarm on the front door was activated on 06/19/2025, the staff should have walked outside the building, checked the surroundings for any residents; notified the supervisor of the alarm activation; ensured all residents were accounted for and activated the elopement protocol if all of the residents were not accounted for. The Administrator stated that facility staff were not aware Resident #1 had exited the building until emergency services personnel arrived at the facility at approximately 10:10 PM to report Resident #1 was at a nearby restaurant parking lot.Based on observations, interviews and record review the survey team determined the facility removed immediacy as of 06/24/2025 and corrected the non-compliance.Resident #1 was assessed by nursing staff for injuries, and none were noted.Resident #1's care plan was updated to include 1:1 staff supervision.The delayed egress locking system on the front door was changed out for a wander guard locking system (an electronic system designed to protect seniors with dementia from wandering away from care facilities). The removal of the delayed egress allows the door to remain secure unless a code is entered.Other exit doors were evaluated and changed to a Mag Lock System (access control device that uses an electrical current and a magnet to secure a door).Resident #1 already had a wander alert device in place, that works in conjunction with the wander guard locking system put in place at the front door.85 % (percent) of all staff were educated on Elopement/Resident Safety and expectations when an alarm was activated. This training is also presented in general orientation for new staff and agency staff.Facility conducts ongoing missing person drills.Facility conducts ongoing audits to monitor compliance with response to alarms and alerts. 10 New York Code Rules and Regulations 415.12(h)(1)(2)

Based on observation, record review, and interview conducted during a Standard survey completed on 7/19/24, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases/infections or implement a system of surveillance designed to identify possible communicable diseases/infection before they can spread to other persons in the facility for three (Residents #3,22, and 37) of six residents reviewed. Specifically, the issues involved; staff did not wear a gown during peripherally inserted central catheter (a catheter that is inserted through a vein and advanced until the tip enters the central venous system) care; staff did not wear a gown and gloves during medication administration for a resident on contact and enhanced barrier precautions (infection control interventions including gown and glove use for high contact resident care activities designed to reduce transmission of multidrug-resistant organisms) (Resident #22). Residents who had an indwelling urinary catheter did not have signs posted that indicated enhanced barrier precautions (Resident #3, 37) and staff did not wear a gown while emptying the urine collection bag (Resident #37). In addition, the Infection Preventionist/program did not track close contacts of residents who were diagnosed with scabies (parasitic infestation of the skin caused by tiny mites). The findings are: The policy and procedure titled Infection Prevention and Control-General Statement dated 5/2023 documented the facility would perform surveillance investigation and monitoring to prevent the spread of infection. This includes a system for preventing and controlling infections and communicable disease for all residents and staff. The Centers for Medicare and Medicaid Services Quality Safety and Oversight memoranda QSO-24-08-NH dated 3/20/24, documented enhanced barrier precautions were indicated for residents with indwelling medical devices even if the resident was not known to be infected or colonized with a multidrug-resistant organism. Examples of indwelling medical devices include central lines and urinary catheters. Enhanced barrier precautions were to be used when staff performed wound care for any skin opening that required a dressing. The memo also documented enhanced barrier precautions are employed for high contact resident care activities including the care or use of a urinary catheter. The document titled Policy on Outbreak Investigation and Infection Control Measures revised 6/24 documented an outbreak is one case of infection that is highly communicable, including scabies. Steps to be taken to facilitate the investigate include but are not limited to clarification of nature and extent of problem, planning investigative process, institution of control measures. The document titled Policy on Disease Specific Isolation/Precautions dated 6/11/24 documented Enhanced Barrier Precautions may be recommended for residents with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a multidrug-resistant organism. Examples of indwelling medical devices include central lines and urinary catheters. Contact precautions are intended to prevent infections that are spread by direct contact or indirect contact with the resident or their environment and require use of personal protective equipment, including gown and gloves upon entering the room. 1. Resident #22 diagnosis include necrotizing fasciitis (bacterial infection), methicillin resistant staphylococcus aureus (antibiotic resistant bacteria) infection and Alzheimer's disease. The Minimum Data Set (resident assessment tool) dated 6/10/24 documented the resident understood, usually understands, and had severe cognitive impairment. Resident #22 was dependent on staff for transfers, required partial/moderate assist with hygiene, and received intravenous (through the vein) medications. During an observation on 7/15/24 at 10:40 AM, Resident #22's private room had sign (laminated orange) posted outside room indicating enhanced barrier precautions. At 10:44 AM Resident #22 exited the shower room in a shower chair covered with a bath blanket. Nursing staff transporting Resident #22 to their room were wearing a gown and gloves. The comprehensive care plan revised on 7/16/24 documented Resident #22 had an active infection related to infected sacral (area above the tailbone) decubitus (bedsore) and rash positive for scabies 7/16/24. Interventions included enhanced barrier precautions, labs and diagnostic testing per medical doctor order, transmission-based precautions as per policy, and administer antibiotic/medication as ordered. Review of Lab Results Report dated 7/16/24 documented a skin scraping to rule out scabies was collected on 7/16/24 at 9:00 AM and reported on 7/16/24 at 2:45 PM. The results showed sarcoptes scabiei (scabies). Review of Kardex Report (guide used by staff to provide care) dated 7/17/24 documented enhanced barrier precautions and transmission-based precautions as per policy. During an observation on 7/17/24 at 8:43 AM, Resident #22's private room had additional signage posted outside the room that included a white laminated sign with stop signs present instructing all staff and visitors to check with the nurse prior to entering the room. Different precaution levels were listed that included contact, droplet, enhanced droplet, and airborne. The sign indicated what personal protective equipment was needed for each precaution level. Contact precautions were marked and indicated use of gloves and gown. The enhanced barrier precaution sign remained. During an observation from the hallway on 7/17/24 at 1:55 PM, Registered Nurse Resident Care Coordinator #1, was in Resident #22's room wearing only gloves and was observed to disconnect infusion tubing connected to Resident #22's right arm, peripherally inserted central catheter (PICC) and flushed the catheter with a syringe. Registered Nurse Resident Care Coordinator #1 adjusted Resident #22 bed sheets over their arms while they leaned into the side of the bed with their scrubs (clothing) touching the sheets on the bed. During an interview on 7/17/24 at 1:59 PM, Registered Nurse Resident Care Coordinator #1 stated the facility identified residents on precautions by the signs that were posted outside the resident's room and that they received a list from the Director of Nursing or Assistant Director of Nursing of all residents on precautions. They stated the type of personal protective equipment that was required depended on what type of precautions a resident was on and what the staff were doing with the resident on precautions. Registered Nurse Resident Care Coordinator #1 stated they did not know why Resident #22 was on enhanced barrier precautions, but believed it was for wound care. They stated that enhanced barrier precautions were implemented on residents with an active infection. They stated they did not apply a gown prior to entering Resident #22's room as they were not performing wound care. During an observation and interview on 7/17/24 at 2:05 PM, Registered Nurse Resident Care Coordinator #1 observed the signage outside Resident #22's room and stated that Resident #22 was on contact precautions. Then stated I guess I should have been wearing a gown as it states it right there on the sign. They stated it was important to follow precautions to prevent spreading whatever it was the resident had. Additionally, they stated they did not know Resident #22 had scabies and should have been informed. During an observation of medication administration on 7/18/24 at 8:25 AM, Licensed Practical Nurse #3 entered Resident #22's room. There were signs on the outside of the room that indicated the resident was on contact precautions and enhanced barrier precautions. The Licensed Practical Nurse #3 did not put on personal protective equipment including gloves and gown before they entered the room. The Licensed Practical Nurse #3 handed the plastic medication cup to the resident, the resident took the medications and handed the cup back to the Licensed Practical Nurse #3. The Licensed Practical Nurse #3 then touched the overbed table and brought it closer in front of the resident and exited the room without washing their hands. The Licensed Practical Nurse #3 went to their medication cart and performed hand hygiene with hand sanitizer. The Licensed Practical Nurse #3 stated they thought Resident #22 was on precautions because of their wound and was on intravenous antibiotics. Licensed Practical Nurse #3 stated they weren't sure about the two signs outside the resident's doorway and that anyone with a foley catheter or wound were on enhanced barrier precautions. If a resident was on contact precautions you had to wear gloves and a gown when they were dealing with that specific area during hands on care, not when they passed a meal tray or gave medications. During an interview on 7/19/24 at 12:39 PM, Infection Preventionist/Director of Nursing stated they expected nursing staff to wear proper personal protective equipment prior to entering a resident's room as posted on the precaution signs posted outside a resident's room. They stated Registered Nurse #1 should have been wearing a gown and gloves prior to entering Resident #22's room because that was what was required. They stated wearing a gown protects personal clothing from coming in contact acquiring what the resident has. 2. Review of Precaution Status Weekly Report updated 7/15/24, Resident #3 and Resident #37 were not listed as being on precautions, specifically enhanced barrier precautions and had foley catheters. Resident #3 had diagnoses included obstructive and reflux uropathy (obstruction in the urinary tract), benign prostatic hyperplasia with lower urinary tract symptoms and retention of urine. The Minimum Data Set, dated dated dated [DATE] documented Resident #3 usually understood/usually understands, had moderate cognitive impairment and an indwelling catheter. The comprehensive care plan initiated 11/1/2022 documented Resident #3 had a urinary catheter. Interventions included urinary catheter care every shift, change urinary drainage bag as needed, and follow orders for catheter/irrigation. There was no documented evidence the resident was on enhanced barrier precautions. During an observation on 7/15/24 at 11:53 AM, 7/18/24 at 9:38 AM and 7/19/24 at 12:50 PM, Resident #3 was in their room and had a foley catheter bag in a privacy cover. There was no signage posted indicating Resident #3 was on enhanced barrier precautions, and there was no personal protective equipment set up outside the resident's room. During an interview on 7/17/24 at 1:43 PM, Certified Nurse Aide #7 stated they were aware of which residents were on precautions by the signage posted outside the resident's room, bins with personal protective equipment were also located outside the room, and they also received a report from the nurse. They stated they knew what personal protective equipment to wear by what was posted on the sign. Certified Nurse Aide #7 stated personal protective equipment was required for residents on enhanced barrier precautions, which would include any resident with a wound, infection, or tubes going into their bodies. During an interview on 7/18/24 at 10:01 AM, Licensed Practical Nurse #5, Unit Manager, stated Resident #3 was not on enhanced barrier precautions because their urine was contained within the foley. They stated that nursing staff used standard precautions and if staff felt they would be splashed while draining urine from the urinary collection bag they could wear a gown. Licensed Practical Nurse #5 stated enhanced barrier precautions weren't needed for residents with a foley. Resident #37 had diagnoses including hemiplegia (paralysis on one side of the body), type 2 diabetes, and major depressive disorder. The Minimum Data Set, dated dated dated [DATE] documented the resident had moderately impaired cognition and an indwelling urinary catheter. The comprehensive care plan dated 6/26/24 documented the resident had a urinary catheter related to neurogenic bladder (bladder with diminished sensation). Interventions included catheter care every shift and to follow provider orders for catheter/irrigation. There was no evidence the resident was on enhanced barrier precautions. During observation on 7/16/24 at 2:49 PM and 7/17/24 at 8:24 AM Resident #37 was in their room with a foley catheter bag in a privacy cover. There were no signs for enhanced barrier precautions on the doorway or wall near the door. There was no bin for personal protective equipment near the resident's door. During an observation on 7/18/24 at 1:52 PM, Certified Nurse Aide #5 wore gloves while they emptied Resident #37's urine collection bag. The Certified Nurse Aide #5 did not wear a gown during the observation. During an interview on 7/18/24 at 2:00 PM, Certified Nurse Aide #5 stated they never wore a gown when they emptied a foley catheter because they tried to be careful and not splash the urine anywhere. The Certified Nurse Aide #5 stated they would wear a gown if the resident had something in the urine, like an infection. During an interview on 7/18/24 at 3:43 PM, the Registered Nurse Resident Care Coordinator #1 stated after a resident had completed their antibiotics for a multidrug-resistant organism, then they were placed on enhanced barrier precautions. It was for people who have had infections that never went away but weren't active anymore. They stated they've had education about it and the guidance was confusing. They didn't know residents with foley catheters were supposed to be on enhanced barrier precautions. During an interview on 7/19/24 at 9:11 AM, the Infection Preventionist/Director of Nursing stated residents who had a multidrug-resistant organism that completed antibiotic treatment but had a wound with secretions would be placed on enhanced barrier precautions when staff performed care. The Infection Preventionist/Director of Nursing stated a resident with a foley catheter would not have to be on enhanced barrier precautions and if staff felt there was a risk for splash when emptying a foley catheter bag they would wear a gown and the gown was optional with any resident who had a catheter or indwelling device. The Infection Preventionist/Director of Nursing stated that there was a risk for splashing of urine while staff emptied a foley collection bag. During an interview on 7/19/24 at 1:10 PM, Corporate Quality Assurance Nurse, stated everybody was on Enhanced Barrier Precautions, then changed to basically anyone not contained, to make it more homelike. Standard precautions are used for residents with foley catheters. They stated they can't say with 100% certainly that staff aren't going to get splashed. 3. The undated facility document titled Scabies Line List documented two residents were confirmed positive for scabies since 7/9/24. Review of the facility document titled Permethrin Cream List (topical treatment for scabies) starting 7/10/24 revealed a list of seven staff members including the Infection Preventionist/Director of Nursing and six Certified Nurse Aides. During a telephone interview on 7/18/24 at 11:15 AM, the Regional Epidemiologist stated during a facility outbreak, the Infection Preventionist/Director of Nursing should have a line list of every staff with potential exposures to the positive scabies cases and which staff accepted the treatment. The lists of contacts should be as inclusive as possible initially in order to treat them all at the same time ideally, that is what helps to not provide an escape system for scabies. During an interview on 7/19/24 at 9:11 AM, the Infection Preventionist/Director of Nursing stated the list they provided was the staff members who opted for scabies treatment, and it did not include all close contacts of the resident who tested positive for scabies on 7/9/24. They stated they had their scheduler working on that contact list. The Infection Preventionist/Director of Nursing stated that guidance from Epi (Epidemiologist) did mention contact tracing, but it had been confusing, and they were just trying to get everything done. They've had help with room cleaning but not much help with the contact tracing aspect. During an interview on 7/19/24 at 2:49 PM, the Infection Preventionist/Director of Nursing stated it was important to do the tracking so if anyone got a rash, they would know where it came from, and they could track back to know where it started and if it was spreading. During a telephone interview on 7/19/24 at 11:24 AM, the Medical Director stated that they had been informed of the outbreak and that the facility should have a list of staff who had contact with the scabies positive residents for tracking purposes. 10 NYCRR 415.19(a)(1)

Based on interview and record review conducted during a Complaint investigation (#NY00319528) during the Standard survey completed on 7/19/24, the facility did not ensure that all alleged violations of abuse and neglect were thoroughly investigated for one (Resident #36) of five residents reviewed. Specifically, there was a lack of employee interviews and statements to rule out abuse regarding an injury of bruising below the resident's right eye. The finding is: The facility policy and procedure titled, Facility Incident/Abuse Investigation and Reporting, with a revision date of 6/7/23, documented the facility will conduct an immediate and thorough investigation, upon discovery of an incident including injury of unknown source. An injury should be classified as an injury of unknown source when all of the following criteria are met: The source of the injury was not observed by any person; and the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. The investigation should rule out or confirm abuse, mistreatment, or neglect by review of supporting evidence, including interviews and statements that offer valid information, observations, and record review. The outcome is determined by fact, based on the evidence and not on opinion. The Director of Nursing services interview shall consist of but not limited to the following: an interview with the person(s) reporting the incident, pertinent staff interviews preceding the incident minimally 2 shifts for any unexplained injuries of unknown etiology. Resident #36 had diagnoses that included unspecified dementia without behavioral disturbance, mood and anxiety disorder, peripheral vascular disease (decreased blood flow of extremities), spinal stenosis (a condition where spinal column narrows and compresses the spinal cord). The Minimum Data Set (a resident assessment tool) dated 6/17/23 documented Resident #36 had severe cognitive impairment. The assessment tool documented that Resident #36 had no impairment on the upper or lower extremities and was totally dependent on staff for locomotion on unit and off unit, including extensive assistance for personal hygiene and bathing. The comprehensive care plan dated 6/24/23 documented Resident #36 had a self-performance deficit related to dementia and spinal stenosis while transferring. Resident #36 was care planned for a maximal assist of two, handheld assist stand pivot method. Resident #36 was non-ambulatory and was wheelchair dependent and was to have two care givers for personal hygiene due to behavioral problems. Review of a Progress Note dated 7/26/23 at 7:32 AM by Licensed Practical Nurse Supervisor # 1 documented they were notified Resident #36 had a small, dark purple bruise to the outer aspect of right eye. Resident #36 was combative with care and often swings randomly at times striking themselves or others. Resident #36 showed no signs or symptoms of pain. Review of an incident report dated 7/26/23 at 4:00 AM completed by Licensed Practical Nurse Supervisor #1, documented they were notified that Resident #36 had a small, dark purple bruise to the outer aspect of their right eye. Resident was noted to be combative with care, and often swings randomly at times striking themselves or others. Resident #36 showed no signs or symptoms of pain. Resident #36 was unable to give description of the incident. Resident #36 was oriented to person. Predisposing Physiological factors included agitation, severe cognitive decline, impaired memory, confused, and incontinent. Resident #36 was a two-assist transfer and call bell was within reach, plan of care was followed. A note on the incident report dated 7/28/23 written by the Director of Nursing, documented the investigation was completed. The resident was unable to make a statement as to what happened due to their current mental status. A Certified Nursing Assistant found a deep purple bruise measuring 1 x 1 to the resident's outer right eye. No other delayed injuries were observed, no care plan changes were made. The resident was a 2-person caregiver due to how combative the resident was during care and the bruise was attributed to this combativeness. There were no interviews or statements from staff who worked the previous two shifts included for this investigation. During an interview on 7/19/24 at 1:47 PM with Certified Nursing Assistant #1, they stated during their shift on 7/26/23 they noticed the bruising on Resident #36 right eye when they entered the resident's room to perform care and they informed their supervisor immediately. They stated they were trained to have two assists with this resident due to combative behavior. They stated they would give the resident a towel or sheet to keep their hands busy while the other aide provided care. During an interview on 7/19/24 at 1:59 PM with Licensed Practical Nurse #5, they stated that Resident #36 was to always have two aides while providing care due the resident's behaviors. The aides were trained if Resident #36 became combative to reapproach the resident later. They stated that Resident #36 did try and kick them the other day and tried to swat them a few times. They stated they were trained to reapproach at another time when Resident #36 was combative. During an interview on 7/19/24 at 1:53 PM with the Director of Nursing, they stated that they were able to rule out abuse for the incident that occurred on 7/26/23 because they knew Resident #36 was combative and would grab their own arms, flail their arms in the air, and often hit themselves. They stated this Resident always had two care givers when providing care, one to provide care and one to distract the Resident. They stated that the bruising of the right eye was not an unknown injury and did not go back 48 hours to get witness statements because they believed the injury was of a known source. They stated that based on their investigation they concluded the Resident's regular demeanor and combativeness was the cause. If they believed the injury to be abuse, they would have reported it as abuse. During an interview on 7/19/24 at 2:36 PM with the Administrator, when asked if they felt that the Director of Nursing did a complete investigation on the incident that occurred on 7/26/23 with Resident #36 right eye injury of unknown source, they stated due to the resident's combativeness it was a reasonable conclusion the injury occurred due to Resident #36 behaviors. The Administrator stated getting witness statements from staff who worked previous shifts could have been done and would be a good step to take in the future, however, it did not change their position about this incident's conclusion. They stated that they felt a reasonable conclusion was founded and that the injury of Resident #36's right eye was due to combativeness and probably self-inflicted. 10NYCRR 415.4(b)(3)

Based on interview, observation, and record review conducted during a Complaint investigation (#NY00322578) conducted during a Standard survey, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #38) of two residents reviewed for accidents. Specifically, Resident #38 who was a risk for elopement, eloped from the facility without staff knowledge and was outside of the facility for 20 minutes. The finding is: The policy and procedure titled Risk of Elopement dated 1/26/22 documented that a safe environment is provided for patients/residents who are at risk to wander. The policy and procedure titled Loss of Resident/Missing Resident dated 11/09 documented that all staff will be able to follow an organized plan to enable us to locate a missing resident as quickly as possible. The policy and procedure titled Elopement Security System Alarms/Devices dated 5/08 documented that security alert devices are used to alert staff to resident movement outside a designated area. The policy and procedure documented that alarm devices will be assessed at regular intervals to ensure proper functioning and wander guard devices will be monitored every shift by placing it on the treatment administration record. The policy and procedure titled Exits dated 10/22 documented that all unsupervised exits will be magnetically locked or equipped with an alarm and will be kept free of obstructions for the safety of security of the residents. The policy and procedure documented that at no time will the magnetic locks be disengaged or alarmed door alarms are in the off position and unsupervised at the same time. Resident #38 was admitted to the facility with diagnoses of dementia and depression. Review of the Minimum Data Set (a resident assessment tool) dated 6/8/24 documented that the resident was severely cognitively impaired, usually understood by others, sometimes understands others. The Minimum Data Set documented Resident #38 had wandering behaviors one to three days in the last seven days. Review of an Elopement Risk assessment dated [DATE] documented that Resident #38 was ambulatory (can walk independently); was a new admission and questioned the need to be in the facility; cognitively impaired with poor decision making skills; has a diagnosis of dementia; has a history of wandering; making statements of leaving or looking for someone; displays behaviors that indicated that an elopement may be forthcoming; educate staff to and add to care guide; utilize wander guard system; apply wander detection bracelet; and post resident's photo at the front desk. Review of the comprehensive care plan dated 7/26/23 it documented that Resident #38 was a risk for elopement with interventions to include a wander guard alarm and the resident's photograph at the front desk to identify them. Review of the physician order dated 7/26/23 documented that Resident #38's wander guard placement was to be checked every shift. Review of an undated document titled Nursing Supervisor Door Check Log documented that all doors should be checked every shift to ensure they were locked by trying to push the door open and, if there were any issues with the door, the door must be manned until maintenance fixed the problem. Review of a Nursing Supervisor Door Check dated 8/14/23 to 8/22/23 documented that doors were checked on the 11 PM to 7 AM shift. Review of the August 2023 Mag Lock and Wander Guard System Daily Audit documented that the magnetic lock doors were in working order and that the delayed egress (exit) signage was posted. Review of the August 2023 treatment administration record documented that Resident #38's wander guard was checked on each shift. Review of a security video dated 8/21/23 revealed that at 3:54 PM, Certified Nurse Assistant #9 left through the Unit C emergency exit door. The ambulance door was noted to have an emergency exit only sign. At 3:58 PM, Resident #38 left through the same door. The Investigation Summary Form dated 8/21/23 documented that Resident #38 was last seen at 3:53 PM by the Unit C emergency exit door and the resident was redirected away from the door. Certified Nurse Assistant #9 exited the Unit C emergency exit door at 3:55 PM. Certified Nurse Assistant #9 did not let the door closer close the door as designed and manually closed the door which caused the door not to latch correctly. Resident #38 pushed open the Unit C emergency exit door at 3:58 PM. At 4:12 PM, a family member reported that a resident may be outside the facility. Resident #38 was found on a neighbor's front lawn at 4:19 PM. It was noted that the Unit C emergency exit door does not have a wander guard alarm. Multiple observations of Unit C emergency door exit from 7/15/24 to 7/19/24 during day shift hours revealed that the door was locked. Additional observations during this time of the Unit C emergency exit door revealed no staff exited the emergency exit door. Multiple observations from 7/15/24 to 7/19/24 of Resident #38 wandering through the facility. Resident #38 did not attempt to leave the facility during these observations. Resident #38 was noted to have a wander guard bracelet on their ankle. During a telephone interview on 7/18/24 at 10:13 AM, Certified Nurse Assistant #9 stated they entered a code on the Unit C emergency exit door and exited the facility to go to their car to retrieve their phone. They stated that they obtained the code from another employee to open the emergency exit door. Certified Nurse Assistant #9 stated they saw other employees use that exit before. They stated that held the door open because they saw a nurse and they thought the nurse might want to use the door as well. They stated that they did not know that Resident #38 was behind them or in the hall. Certified Nurse Assistant #9 did not see the resident exit the building. They stated they thought they closed the emergency exit door correctly. They stated that they were in-serviced on elopement after the incident. Certified Nurse Assistant #9 stated that they no longer work for the facility. During an interview on 7/18/24 at 10:52 AM, the Director of Nursing stated that Certified Nursing Assistant #9 saw them down the end of the hall and held the door open. They stated that made a no motion with their hands to indicate that they weren't leaving the building. The Director of Nursing stated that they were going to talk to Certified Nurse Assistant #9 after they came back into the facility. The Director of Nursing stated that they thought that Certified Nurse Assistant #9 had closed the door all the way, so the lock engaged. The Director of Nursing did not realize that the door was not closed. The Director of Nursing stated that they did not realize that Resident #38 had left the building through the emergency exit door. They stated the resident was brought back, and a full body assessment was done to check for any injuries. The Director of Nursing stated that they expect employees to use the correct entrances and exits when entering or leaving the building. During an interview on 7/19/24 at 10:31 AM with the Administrator stated that they expect staff to use the correct employee entrances and exits. The Administrator stated that Certified Nurse Assistant #9 was an agency employee and no longer worked at the facility. The following corrective actions were implemented by the facility to correct the non-compliance as of 8/28/23 at 11:00 PM: -Resident #38 was assessed for injuries at the time of the elopement and none noted. -Starting on 8/21/23, facility staff and Certified Nursing Assistant #9 were educated on resident elopement; proper use of emergency exit doors; proper exit and entry doors for employees and to ensure doors latch correctly; and not to give door codes to outside vendors including agency staff. -During the Standard survey period from 7/15/24 to 7/19/24, Resident #38 was not observed attempting to elope. -During the Standard survey period from 7/15/24 to 7/19/24, employees were not observed using the Unit C emergency exit door as an exit or entrance. -During the Standard survey period from 7/15/24 to 7/19/24, emergency exit doors were observed to have emergency exit signs with instructions of how to open door in case of emergency. -During the Standard survey period from 7/15/24 to 7/19/24 verified through record review and staff interview, it was determined that the facility re-educated 100% of their employees on emergency exit doors, exits and entrances for employees, not to give door codes to outside vendors and elopement. 10NYCRR 415.12(h)(1)

Based on observation, interview, and record review conducted during a Standard survey completed on 7/19/24, the facility did not ensure that residents who had an indwelling (foley) catheter (tube inserted into the bladder to drain urine) received the appropriate care and services to manage catheters for one (Resident #37) of one resident reviewed. Specifically, there was lack of voiding trial (removal of a urinary catheter to see if someone can pass urine normally) when the resident was readmitted to the facility from the hospital with a foley catheter and the lack of a urology (part of health care that focuses on diseases of the urinary system) consult. The finding is: The policy and procedure titled Catheter (urinary) Insertion and Removal dated 9/2/20, documented prior to insertion or upon continued use upon admission, the unit coordinator or designee will discuss and document the involvement of the resident/representative of the risk and benefits of the use of a catheter, removal of the catheter when criteria or indication for use is no longer present, and the right to decline the use of a catheter. Resident #37 had diagnoses including hemiplegia (paralysis on one side of the body), type 2 diabetes, and major depressive disorder. The Minimum Data Set, dated dated dated [DATE] documented the resident had moderately impaired cognition and an indwelling urinary catheter. The comprehensive care plan dated 6/26/24 documented the resident had a urinary catheter related to neurogenic bladder (bladder with diminished sensation). Interventions included catheter care every shift and to follow provider orders for catheter/irrigation. Review of the hospital discharge summary dated 4/26/24 documented the resident was admitted with severe sepsis thought to be secondary to urinary tract infection with chronic foley catheter secondary to neurogenic bladder chronic foley catheter and to follow up with urology. Review of nurse Progress Notes dated 4/29/24 at 9:36 AM revealed the resident was seen by the Medical Director who wanted a voiding trial done to discontinue the foley catheter. On 4/30/24 at 2:21 PM, the resident's foley was removed. On 5/2/24 at 7:55 PM, the resident voided large amount of urine and had no complaints. Review of nurse and physician Progress Notes from 4/30/24-6/9/24 revealed the urinary catheter was not re-inserted and the resident was not seen by a urologist. The Order Summary Report (medical provider orders) documented an active order dated 6/12/24 for a foley catheter 16 French (measurement scale used to describe dimension of medical device tubing) with 10 cubic centimeter bulb, change as needed. Review of nurse and physician Progress Notes dated 6/12/24-7/17/24 revealed there was no documentation that a voiding trial was completed upon readmission from the hospital. During an interview and observation on 7/15/24 at 10:47 AM, Resident #37 stated they had a catheter that was put in during their last hospital stay and had asked staff to remove it. The resident stated it had been in for over two weeks and they had a urinary tract infection recently but wasn't sure if they still did. The resident had a urinary collection bag in a privacy bag hooked onto the bed frame that had clear yellow urine in the catheter tubing. During an interview on 7/18/24 at 1:49 PM, Licensed Practical Nurse #7 stated when the resident went to the hospital, they decided they had retention, so they put in the foley catheter, and the Licensed Practical Nurse #7 wasn't sure if they did a voiding trial when the resident returned to the facility in June. During an interview on 7/18/24 at 3:43 PM, the Registered Nurse Resident Care Coordinator #1 stated Resident #37 had a foley catheter for a neurogenic bladder diagnosis that was documented in a hospital discharge summary in April. The Registered Nurse Resident Care Coordinator #1 reviewed the resident's electronic medical record and stated they didn't see any urology consults and that the resident was re-hospitalized in June with stroke like symptoms caused by a urinary tract infection. They stated a voiding trial wasn't done since the readmission in June because of the same issue the resident was hospitalized with. During an interview on 7/19/24 at 10:00 AM, the Infection Preventionist/Director of Nursing stated they didn't know the reason Resident #37's foley catheter wasn't removed since most recent readmission, the Minimum Data Set (MDS) nurse would know because they make sure residents had the correct diagnosis and if the foley wasn't appropriate, they would do a voiding trial. During an interview on 7/19/24 at 10:39 AM, the Minimum Data Set (MDS) Coordinator reviewed Resident #37's electronic medical record and stated the resident got the neuromuscular dysfunction of the bladder diagnosis in April 2024 hospitalization and had a voiding trial when they were readmitted in April. They stated the resident didn't have the catheter when they went back to the hospital in June, and they didn't catch that because the discharge summary said chronic foley and it didn't click to them that the resident didn't have the foley when they were sent to the hospital in June. Because of the diagnosis of neurogenic bladder, they didn't question the foley catheter. The Minimum Data Set Coordinator stated it didn't look like the resident saw a urologist. During a telephone interview on 7/19/24 at 11:20 AM, the Medical Director stated Resident #37 should have had a voiding trial when they were readmitted from the hospital. When asked about the neurogenic bladder diagnosis from April and the subsequent voiding trial in April the Medical Director stated they always did a voiding trial when someone returned with a foley catheter. The Medical Doctor stated if they were not able to discontinue the foley, then they would follow up with a urologist. The Medical Director stated they didn't know why a voiding trial wasn't done when the resident was readmitted in June and that the resident was more at risk for sepsis, that was why they tried to remove the foley catheter as fast as they could. 10 NYCRR 415.12(d)(1)(2)

Based on interview and record review conducted during the Standard survey completed on 7/19/24, the facility did not ensure an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for one (Resident #65) of one resident reviewed. Specifically, Resident #65 received Augmentin (antibiotic, Amoxicillin-Potassium Clavulanate 875-125 milligram) for osteomyelitis (bone infection) since 7/25/23 and there was no ongoing monitoring by the Antibiotic Stewardship Program including communication, tracking of its use, appropriate indications for continued use, or follow up appointment with the Infectious Disease Physician as recommended. The finding is: Review of the policy and procedure titled Antibiotic Stewardship Program effective 5/2017, documented the primary goal is to optimize the treatment of infections and clinical outcomes while minimizing unintended consequences of antibiotic use. The antibiotic stewardship program includes a system of monitoring antibiotic use. Actions to improve antibiotic prescribing/use include institute an antibiotic time-out which is an antibiotic review process to reassess the ongoing need for and choice of antibiotic while waiting for more information. Tracking: the facility will track adherence to clinical assessment documentation of signs and symptoms, vital signs, and physical examination findings of infection; the facility will track adherence to prescribing documentation (dose, duration, indication.) Resident #65 had diagnoses which included osteomyelitis (bone infection) of vertebra, sacral (sacrum) and sacrococcygeal (sacrum/coccyx (tailbone)) region; pressure ulcer of sacral region (stage 4, full thickness tissue loss with expose bone, tendon, or muscle), and methicillin resistant staphylococcus aureus (bacteria that is resistant to certain antibiotics) infection. The Minimum Data Set (resident assessment tool) dated 7/8/24 documented Resident #65 was cognitively intact and was receiving an antibiotic. The comprehensive care plan initiated 1/2/2023, revised 4/18/2024 revealed there was no documented evidence of antibiotic use for osteomyelitis. Review of hospital consult by infectious disease dated 12/2/2022 documented sacral osteomyelitis. Recommendations included: 12/17/2022 start Augmentin 875 twice a day for months until wound is better; check labs (complete blood count, comprehensive metabolic panel, erythrocyte sedimentation rate, and c-reactive protein) monthly and fax to infectious disease. Additionally, recommended return to clinic in 3 months with future appointment scheduled for 3/2/23 with infectious disease. Review of the Order Summary Report from 1/2/23 to 7/17/24 documented an active physician order for Augmentin 875-125 milligrams with instructions to give 1 tablet by mouth every morning and at bedtime for osteomyelitis with a start date of 7/28/2023. There was no stop date. Review of the monthly infections list, as identified by the Director of Nursing from July 2023 to June 2024 revealed there was no documented evidence the antibiotic/Augmentin use was monitored and tracked for Resident #65. Review of Medication Administration Record from July 2023 through July 2024 documented Resident #65 received Augmentin 875-125 milligrams twice a day for osteomyelitis. Review of Progress Notes transcribed by Medical Provider, Medical Doctor #1, dated 8/21/23 through 7/11/2024 documented no evidence of antibiotic use and no documented rationale for the continued use of the antibiotic. Review of nursing Progress Notes dated 1/2/2024 through 7/17/2024 did not document evidence that Resident #65's was being monitored for antibiotic use. During an observation and interview on 7/17/24 at 11:15 AM, Resident # 65 was lying in bed watching television. Resident #65 stated they saw an infectious disease doctor while at a local hospital for their pressure ulcer on their butt prior to being transferred from a sister facility in January of 2023. Resident #65 stated they don't recall seeing an infectious disease doctor since. During an interview on 7/19/24 at 8:45 AM, Licensed Practical Nurse #5 Unit Manager stated the Infection Preventionist/ Director of Nursing tracks antibiotic use in the facility. Licensed Practical Nurse #5 Unit Manager stated that Resident #65 was started on Augmentin prior to coming to facility for osteomyelitis. They stated Resident #65's sacral pressure ulcer was healing well, and there has been no recent signs/symptoms of infection noted or reported. They stated that to their knowledge there has been no follow up consults related to Resident #65's osteomyelitis in the last year. Additionally, they stated that long term use of antibiotics could cause problems like Clostridioides difficile (C. diff- infection of the colon) and antibiotic resistance. During an interview on 7/19/24 at 8:57 AM, Director of Nursing/Infection Preventionist stated they generate, run an antibiotic report every month and discuss at quality assurance and performance improvement (QAPI) meetings. They stated they track only acute antibiotic use and residents who are admitted to the facility on an antibiotic. They stated they do not track Resident #65 antibiotic use for osteomyelitis as they were receiving it long term. Additionally, they stated they have not reviewed Resident #65 antibiotic use since Medical Doctor #1 reinstated it last year (7/2023). During a telephone interview on 7/19/24 at 10:47 AM, Pharmacy Consultant stated they do not provide, nor have they been asked to provide the facility with a monthly antibiotic report. They stated all antibiotics should be tracked, to monitor for appropriate usage and resistance. Additionally, they stated antibiotics were reviewed at quality assurance and performance improvement (QAPI) meeting. During a telephone interview on 7/19/24 at 11:15 AM, Medical Doctor #1 stated they expected the facility to follow protocol for tracking antibiotic use. They stated they accessed Resident #65's medical record electronically and that Resident #65 was receiving Augmentin for chronic osteomyelitis. Medical Doctor #1 was unable to say whether Resident #65 has had any follow up consults with infectious disease concerning the osteomyelitis. They stated they follow the recommendations from the wound team at the facility. They stated they would only document on the antibiotic if there were ill effects from it. Additionally, they stated they attend quality assurance and performance improvement (QAPI) meetings and antibiotic use was discussed, however they could not recall if Resident #65's use of Augmentin has been discussed. 10NYCRR 415.12(l)(1)

Based on interview and record review during an Abbreviated survey (Complaint #NY00322015) completed on 8/22/23, the facility did not ensure that they immediately informed the resident's representative and the physician when there was a significant change in the resident's health, mental, or psychosocial status for two (Residents #1 and #2) of three residents reviewed. Specifically, Resident #1 was observed to have a left heel blister and the facility did not notify their Health Care Proxy (HCP). Additionally, Resident #2 had a recent history of a gastrointestinal (GI) bleed and the facility did not ensure they immediately consulted with the resident's physician when the resident developed emesis that had a coffee ground (vomit that is brown or black with a lumpy texture that looks like coffee grounds and was a sign of internal bleeding) appearance. The findings are: The policy and procedure (P&P) titled Change in a Resident's Condition or Status revised 3/2020, documented that the resident, his or her attending physician and representative are notified of changes in the resident's condition and/or status within 24 hours. The P&P documented that nursing services will notify the residents' attending physician when there is significant change in the resident's physical, mental or psychosocial status, a need to alter treatment significantly or a decision to transfer or discharge the resident from the facility. The P&P documented unless otherwise instructed by the resident, a nurse will notify the resident's next-of-kin or representative when there is a significant change in the resident physical, mental or psychosocial status. 1. Resident #1 had diagnoses including Parkinson's disease, diabetes mellitus type II and dementia. The Minimum Data Set (MDS- a resident assessment tool) dated 6/24/23 documented Resident #1 usually understood, usually understands, and had moderate cognitive impairment. Review of the Nursing: Weekly Skin Check LPN (Licensed Practical Nurse) (Shower Check) dated 7/27/23 at 6:55 PM, LPN #1 documented that Resident #1 had a skin abnormality identified and heel discolored and supervisor noted. Review of the RN (Registered Nurse) Admission Skin assessment dated [DATE] at 5:26 PM, RN #1 (RN Supervisor) documented that Resident #1 had a left heel blister measuring 3.5 centimeters (cm) x 3.5 cm x 0 cm. Review of the Order Recap Report dated 8/18/23 documented on 7/28/23 an order was initiated for skin prep to be applied to left heel fluid filled blister every shift. Review of the Progress Notes dated 7/28/23-8/6/23 revealed that there was no documentation that HCP #1 or HCP #2 were notified that Resident #1 had a left heel blister. During a telephone interview on 8/18/23 at 9:10 AM, Resident #1's HCP #2 stated that Resident #1 was noted to have pressure ulcer sores on their heels when they were sent from the facility and admitted to the hospital on 8/6/23. HCP #2 stated the facility had never notified them of Resident #1 having pressure ulcers to their heels prior to hospitalization . During a telephone interview on 8/18/23 at 12:02 PM, HCP #1 stated they were Resident #1's HCP and they made medical decisions for Resident #1 along with HCP #2. HCP #1 stated the facility had never notified them that Resident #1 had any skin concerns including a new blister to their left heel. During a telephone interview on 8/21/23 at 2:22 PM, RN #1 stated when Resident #1 returned from an emergency room visit on 7/28/23 they completed an admission skin assessment. RN #1 stated they observed a fluid filled blister on Resident's #1 left heel. RN #1 stated the left heel blister was a serous (pale yellow, transparent body fluid) fluid filled blister that measured 3.5 cm x 3.5 cm x 0 cm. RN #1 stated they would usually notify the Resident Care Coordinator (RCC) verbally in person or write them an email when they observed a new area of pressure on a resident. RN #1 stated they could not locate an email for who they notified about Resident #1's heel, and they did not know if they verbally reported the area to anyone. RN #1 stated that they did not notify Resident #1's HCP and that it was the RCC's responsibility to notify a resident's representative of any new skin issues. During a telephone interview on 8/22/23 at 10:45 AM, LPN #1 stated on 7/27/23 they had found Resident #1 had fallen onto the floor. LPN #1 stated that when they were looking for any injuries, they observed that Resident #1's left heel was discolored. LPN #1 stated other nursing management staff responded to the fall but could not recall who they were. LPN #1 stated that the other supervisors also assessed Resident #1 for injuries and were aware of Resident #1 discolored area on their heel. LPN #1 stated they left the room at that point and the supervisors took over the situation. LPN #1 stated they documented Resident #1 discolored heel on the LPN shower sheet and did not notify the family of the new skin area. 2. Resident #2 had diagnoses including fracture of the right femur, GI hemorrhage and acute posthemorrhagic anemia (anemia due to a quick large amount of blood loss). The MDS dated [DATE] documented that the resident was understood, understands and was cognitively intact. Review of the Progress Notes revealed: -LPN #2 documented on 6/14/23 at 12:14 AM, that Resident #2 voiced GI upset and shortly after had a moderate amount of brown coffee ground emesis. -LPN #2 documented on 6/14/23 at 3:04 AM, that Resident #2 had another moderate amount of coffee ground colored emesis and vital signs were stable. -LPN #3 documented on 6/14/23 at 7:49 AM, that Resident #2 was having a large amount of coffee ground emesis. LPN #3 documented that the spouse and medical provider were notified, and the resident was sent to the hospital. Review of the hospital Discharge Summary dated 6/15/23, documented that Resident #2 had a recent admission to the hospital on 6/8/23 for a GI bleed and returned again to the hospital from the rehabilitation center on 6/14/23 due to emesis with blood in it. The summary documented that Resident #2 was admitted to the hospital for an upper GI bleed with severe gastritis (inflammation of the lining of the stomach) due to Helicobacter Pylori (bacteria in the lining of the stomach that causes an infection). During a telephone interview on 8/22/23 at 9:00 AM, the Medical Doctor (MD) #1 stated that their expectation for a resident that had coffee ground emesis with history of GI bleeding was staff to notify the medical provider immediately. MD #1 stated that a medical provider should have been notified after Resident #2's first episode of emesis for further orders. MD #1 stated they did not recall if they were notified about Resident #2 having coffee ground emesis on 6/14/23 during the night. During a telephone interview on 8/22/23 at 11:02 AM, LPN #2 stated that they worked the night of 6/14/23 and Resident #2 was having projectile emesis that was brown in color, foul smelling and it had an appearance of being coffee ground emesis. LPN #2 stated that they told the nursing supervisor but could not recall who the nursing supervisor was. They stated that they should have charted that they notified the supervisor in their nursing progress notes. In a further interview on 8/22/23 at 1:17 PM, LPN #2 stated occasionally they had to supervise the building and they were the supervisor on 6/14/23. LPN #2 stated they did not notify a medical provider during their shift about Resident #2 having coffee ground emesis because Resident #2 was resting comfortably, and their vital signs were stable. They stated that they notified LPN #3 when they arrived at work in the morning. LPN #2 stated that they should have called the MD after the first incident of emesis because Resident #2 had just returned from the hospital with a diagnosis of GI bleed. During a telephone interview on 8/22/23 at 1:23 PM, LPN RCC #3 stated the nursing staff should notify them verbally if a resident had a new area of skin concern. LPN RCC #3 stated they were not notified that Resident #1 had a new left heel blister on 7/28/23 and they should have been. LPN RCC #3 stated they were responsible for notifying the resident representatives when there was a change in the resident's condition, a change in their medications or a new area of skin concern. LPN RCC #3 stated they did not notify Resident #1 representatives of a left heel blister because they were unaware Resident #1 had one. LPN RCC #3 stated on 6/14/23 around 7:00 AM they were notified by a Certified Nursing Assistant (CNA) that Resident #2 had emesis. LPN RCC #3 stated that when they visualized the emesis it had the appearance of coffee ground emesis. LPN RCC #3 stated they notified the on-call medical provider and Resident #2 was sent to the hospital for evaluation around 8:00 AM. LPN RCC #3 stated they notified the medical provider because it was a change in Resident #2 condition. During a telephone interview on 8/22/23 at 1:34 PM, the Director of Nursing (DON) stated when a new pressure ulcer was observed, the resident's representative was to be notified because it was a change in the resident's condition. The DON stated it was the responsibility of the nurse that observed the area to notify the resident representative. The DON stated that they were not aware if Resident #1's HCP was notified on 7/28/23 of the new pressure area to their left heel. The DON stated that on 7/28/23, RN #1 measured the pressure area on Resident #1 and began a treatment. They stated that their expectation was that RN #1 would notify Resident #1's HCP because Resident #1 did not have capacity for medical decisions. The DON stated they expected staff to contact them and/or the medical provider when a resident started having coffee ground emesis. The DON stated Resident #2 had a history of a recent GI bleed and the medical provider should have been contacted immediately on 6/14/23 when the resident started having coffee ground emesis. The DON stated the importance of notifying the medical provider was because emesis of coffee ground appearance could be evidence that there is internal bleeding. The DON stated Resident #2 recently had a GI bleed and the presence of coffee ground emesis could mean Resident #2 was still bleeding. 10 NYCRR 415.3(f)(2)(ii)(b)

Based on interview and record review during a Standard survey started 9/28/22 and completed 10/4/22, the facility did not ensure that all alleged violations including abuse are reported immediately, but not later than 2-hours after the allegation is made to the appropriate officials (including the State Survey Agency). Specifically, one (Resident #39) of one resident reviewed for allegation of physical abuse was not reported to the New York State (NYS) Department of Health (DOH) as required. The finding is: The policy titled Abuse Reporting and Facility Incident Reporting revised date 4/1/21 documented any alleged violations involving mistreatment or abuse will be reported to the appropriate involved parties and state agencies. The facility administrator, or designee, notifies the State Licensing and Certification Agency when there is an allegation that a resident has been abused. All alleged violations involving abuse against a resident are reported immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involve abuse, to the administrator of the facility and to other officials (including the State Survey Agency) in accordance with State law through established procedures. 1. Resident #39 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- a resident assessment tool) dated 8/17/22 documented Resident #39 was usually understood, usually understands, and severely cognitively impaired. The untitled comprehensive care plan with revised date of 7/29/21 documented alteration in psychosocial well-being; alteration in mood disorder. Interventions include two staff if available when providing care dated 11/25/21 and two staff and that the members in room with all and that the personal care dated 9/18/21. Respond to behaviors with the following diversions/ approaches: resident makes false accusations towards staff, calls staff and residents inappropriate names and yells at them, has boundary issues with other residents-direct resident back to room or help phone their sister, re-approached at a later time. Review of Director of Nursing (DON) summary dated 4/29/2022 documented on 4/29/2022 at approximately 4:30/4:45 AM Resident #39 stated to Licensed Practical Nurse (LPN) #1 that he was beat up by a big black (explicit word). LPN #1 immediately reported accusation to Registered Nurse (RN) #1 Supervisor. RN #1 immediately reported to Resident #39's room to interview and physically assessed the resident. During interview resident stated it happened last week and it was the certified nurse aide (CNA) #4. Through further questioning resident changed their story to state that the person who beat them was a young boy and it happens weeks ago. A full head to toe assessment revealed no injury. LPN #1 performed neuro checks, all within normal limits for resident baseline. Incident reported to DON. DON in and interviewed resident at approximately 6:30 AM. Resident stated they were not beat up but was lonely and bored and wanted some attention. Two alert and oriented residents were interviewed to determine care provided by CNA #4 and they had no issues. LPN #1 and RN #1 the stated that CNA #4 has always been noted to be patient and caring and have never received a complaint previously. Resident care planned for two assist care at all times due to history an accusatory statements. Resident has a history of discriminatory language targeting African Americans. Staff who had routinely worked with CNA #4 spoken with and stated all care performed with two assist and no care concerns during any interactions in April. Staff reminded to report any and all care concerns immediately. CNA #4 stated they always provide care with two assist due to resident accusations. Nothing unusual occurred with the resident during care in the last weeks. Review of the NYS DOH Automated Complaint Tracking System (ACTS) Facility Summary between 4/1/22 and 6/8/22 revealed that no report from the facility had been filed regarding the allegation of physical abuse for Resident #39 on 4/29/22. During an interview on 10/3/22 at 12:06 PM, LPN #1 stated Resident #39 came to them and reported that CNA #4 had come into their room and beat them up. The accusation was reported to RN #1 Supervisor. During a telephone interview on 10/3/22 at 12:58 PM, the DON stated, I did not feel this incident was reportable to the state because after we did our investigation for the allegation of abuse, it was felt there was no abuse. I am familiar with the reporting the regulations for reporting abuse as I use the New York State (NYS) reporting manual from August 2016. I am not aware of the abuse regulations from the CMS (Centers for Medicare and Medicaid Services) federal guidelines. During an interview on 10/3/22 at 2:05 PM, RN #1 Supervisor stated they remembered Resident #39, the incident and started an investigation. They reported it immediately to the DON. During an interview on 10/3/22 at 2:56 PM the Administrator stated, I would consider the allegation made by Resident #39 an allegation of abuse. The investigation was not reported to the NYS DOH because after the investigation the DON felt it was not abuse. I am familiar with the reporting process and use the NYS reporting manual. 415.4(b)(4)

Based on record review and interviews conducted during the Standard survey started on 9/28/22 and completed on 10/4/22, the facility did not develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care. Specifically, three (Residents #18, 25, and 49) of four residents reviewed for discharge planning lacked a referral to the local contact agency when a desire to return to the community was expressed. In addition, the facility did not develop a care plan that included the resident's discharge planning needs to address their desire to return to the community (Resident #25). The findings are: The facility policy and procedure (P&P) titled Discharge Plan dated 3/2020 documented an individualized interdisciplinary discharge care plan is developed with input from the patient and patient's representative to meet the patient's needs and goals. For patient's that request return to the community and express an interest in receiving information, the Social Worker (SW)/Discharge Planner will make referrals as appropriate and document such referrals. 1. Resident #18 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Sets (MDS-a resident assessment tool) dated 4/19/22 and 7/20/22 documented Resident #18 was cognitively intact and expressed an interest in speaking to someone about the possibility of leaving the facility and returning to live and receive services in the community. The MDS documented a referral to the local contact agency was not needed. The comprehensive care plan revised 4/22/22, documented Resident #18 expressed an interest in returning to the community. Interventions included to evaluate preferences and needs for possible transition to community and provide information about community services/support and assist as needed. Review of interdisciplinary Progress Notes from 4/1/22 to 9/30/22 revealed there was no documented evidence that a referral to the local contact agency was made or a reason why a referral was not made. During an interview on 9/29/22 at 8:40 AM, Resident #18 stated they would like to return to the community and had never been referred to the local contact agency. The resident stated they would be interested in more information about the agency. During an interview on 9/30/22 at 3:00 PM, the SW stated when a resident expressed an interest in being discharged , they would call the resident's family or health care proxy to see if it was possible, safe, in the resident's best interest and within their capabilities to go home. The SW stated they were aware of the independent living center; it was called the Good Neighbor Program (open-door program) but thought a referral to this agency was a last resort if the resident wasn't able get more independent on their own. The SW stated they had not made a referral for Resident #18 to the Good Neighbor Program because they were waiting for some medical consults the resident was having prior to making a referral. 2. Resident #25 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #25 was cognitively intact and expressed an interest in speaking to someone about the possibility of leaving the facility and returning to live and receive services in the community. The MDS documented a referral to the local contact agency was not needed. The comprehensive care plan revised 11/24/21, documented Resident #25 did not express an interest in returning to the community. Interventions included the resident required long term placement and to maintain their customary routine. Review of SW Progress Notes dated 6/28/22 at 8:54 AM, documented Resident #25 stated they wanted to be home by Christmas as they were still paying rent on their apartment and hoped to return. The SW documented the resident would need to be independent in all self-care activities of daily living (ADLs) in order to return home. A meeting was to be set up with the resident's health care proxy (HCP) to discuss the living environment. The resident was referred to therapy to work on goals needed to return to the community. There was no documented evidence that a referral to the local contact agency was made or a reason why a referral was not made. During an interview on 9/28/22 at 2:58 PM, Resident #25 stated their plan was to get home before Christmas. The resident stated they had tried a rehab program to help them walk again. The resident stated they did not know if any referrals were made, or any agencies were contacted to assist with their discharge plan. During an interview on 9/30/22 at 3:00 PM, the SW stated Resident #25 expressed an interest in going home, so they started a rehab program a couple months ago, but the resident didn't progress to be more independent with ADLs. The SW stated they did not think of the Good Neighbor Program for the resident and didn't make a referral. During an interview on 10/3/22 at 10:00 AM, the MDS Coordinator stated when a resident expressed, they wanted to return to the community, they would tell the SW and then the SW came up with a plan. The MDS Coordinator stated when the facility developed a discharge plan, the SW decided when a referral to an outside agency was needed. During further interview on 10/3/22 at 11:50 AM, the SW stated they would be responsible to update the discharge planning care plan. The SW stated the care plan was reviewed in June and at that time the resident expressed an interest in returning to the community and was reviewed again in August, but it wasn't updated because the resident had an acute illness. During an interview on 10/4/22 at 10:59 AM, the Administrator stated they were familiar with the local contact agency and had recently given the SW information on the program that they had obtained online. The Administrator stated they didn't know if their discharge planning policy specifically covered making a referral to the local contact agency and was not aware of the MDS questions regarding the resident's discharge interest and needing to make a referral. 3. Resident #49 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #49 was understood, understands and cognitively intact. Section Q: Resident responded yes to the question do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community and no-referral not needed was marked for has a referral been made to the local contact agency. The untitled care plan dated 5/13/21 documented Resident #49 expressed an interest in returning to the community. Interventions included to evaluate preferences and needs for possible transition to community and provide information regarding community services/ support and assist as needed. During an interview on 10/4/22 at 10:37 AM, Resident #49 stated they would like to go home as soon as they are able to and that this was their goal since admission. They stated they have not received or have been given any information or have spoken to anyone about services available in the community. During an interview on 10/4/22 at 10:44 AM, the SW stated they have not referred or given Resident #49 any information regarding community services or support and the open-door program information was not given. The Social Worker stated they thought they did not have to give that information to the resident until they were actually being discharged . 415.3(c)(3)

Based on observation, interview, and record review conducted during a Standard survey started on 9/28/22 and completed on 10/4/22, the facility did not ensure that residents who receive a [CONDITION(S)] medication have gradual dose reductions (GDR), unless clinically contraindicated, in an effort to discontinue these drugs for one (Resident #10) of three residents reviewed for antipsychotic medication use. Specifically, there was a lack of a GDR for a resident receiving antipsychotic medication and a lack of supporting documentation for the continued use of the antipsychotic. The finding is: The facility policy and procedure (P&P) titled [CONDITION(S)] Med Use Initiation and Gradual Dose Reduction dated 3/1/2020 documented that each resident is evaluated for the continued need of [CONDITION(S)] medications and the determination of whether they are being maintained on the lowest effective dose. The P&P documented a GDR is to occur with the first year after admission in two separate quarters, with at least one month between attempts unless clinically contraindicated. The P&P documented tapering may be indicated when the resident's clinical condition has improved or stabilized, the underlying causes of the original targeted symptoms have resolved, and/or non-pharmacological approaches have been effective in reducing the symptoms. The P&P documented the GDR is considered clinically contraindicated if the physician has documented the clinical rationale for why any additional attempted dose reductions at that time would be likely to impair the residents' function or increase distressed behavior. 1. Resident #10 had diagnoses of dementia without behavioral disturbance, [CONDITION(S)] (PVD-poor circulation of the lower extremities) and chronic obstructive pulmonary disease. The Minimum Data Set (MDS - a resident assessment tool) dated 7/10/22 documented Resident #10 was severely cognitively impaired, sometimes understands and usually understood. The MDS documented Resident #10 received antipsychotic medications on a routine basis, and there was no GDR attempted with the physician documenting a GDR attempt was clinically contraindicated on 1/6/22. The MDS documented that Resident #10 had no physical, verbal, or other behavioral symptoms that were directed nor non-directed toward others. During intermittent observations during the survey period of 9/28/22 to 10/3/22 from 10:00 AM to 3:00 PM Resident #10 had no violent outbursts or striking out at staff or residents. The Comprehensive Care plan with initiated/revision date of 12/15/21 (identified as current) documented Resident #10 had an alteration in mood and behavior pattern r/t (related to) dementia with behavioral disturbance. Interventions included to establish trust, identify interventions that where effective to minimize triggers; provide calm and reassuring environment; administer non-[CONDITION(S)] and [CONDITION(S)] medications per medical doctor (MD) order; and respond to behavior by walking away and reapproach. There were no targeted behaviors documented in the care plan. The Order Recap Report dated 10/4/22, documented a physician order on 12/16/21 for [MEDICATION(S)] 0.5 mg (milligrams) by mouth at bedtime for anxiety caused by tinnitus (ringing in the ears). -1/21/22 [MEDICATION(S)] was increased to 0.75 mg at bedtime for aggressive behaviors. -2/18/22 an additional dose of 0.25 mg was ordered daily for aggressive behaviors. -9/21/22 the indication for [MEDICATION(S)] 0.25 mg daily and 0.75 mg at bedtime for dementia with behavior disturbance. The Medication Administration Record (MAR) documented [MEDICATION(S)] 0.5 mg was to be administered at bedtime from 12/16/21-1/30/22. The MAR documented [MEDICATION(S)] 0.75 mg was to be administer at bedtime from 1/31/22-10/3/22. The MAR further documented [MEDICATION(S)] 0.25 mg was to be administer at 9:00 AM from 2/18/22-10/3/22. The MAR also documented Resident #10 refused medications at times. The Note to Attending Physician/Prescriber (documentation of recommendations from the Consultant Pharmacist) documented on 1/4/22 a recommendation to GDR the current dose of [MEDICATION(S)] to 0.25 mg daily. The physician response area was signed and checked agreed on 1/10/22. This GDR recommendation was not acted upon. On 7/18/22 a recommendation was made by the Consultant Pharmacist to GDR the current dose of [MEDICATION(S)] to just 0.75 mg at bedtime. The MD response was signed, checked disagree with benefits over risks handwritten on 7/21/22. Review of the interdisciplinary progress notes dated 5/1/22- 10/4/22 documented five episodes of verbal and/or physical aggression. Last being 8/25/22. Review of the Progress notes on 7/1/22, written by the Director of Social Work (SW) documented Resident #10's mood was stable. Review of the Progress notes written by the Medical Director for Resident #10 from 5/12/22-10/4/22 documented psych: displays comfort does not display anxiety or depression during encounter. The progress notes further documented documentation above supports appropriate use for each [CONDITION(S)] medication. There was no documented evidence of a clinical rational or the resident's behaviors were detrimental to resident or others. During an interview on 10/4/22 at 9:54 AM, CNA #2 stated they are familiar with Resident #10. Resident #10, at times, would push and yell at staff during care but the behavior would stop when the staff reapproached the resident, did not rush the resident, and wrote on a note pad the care they were to provide for the resident to read. CNA #2 stated that Resident #10 would yell out in the hallway, but not mean things. Resident #10 just wants someone to pay attention to them. During an interview on 10/4/22 at 10:11 AM, Register Nurse (RN) #3 stated they were familiar with Resident #10. RN #3 stated they have not witnessed Resident #10 to be aggressive with staff or residents. RN #3 stated that Resident #10 was hard of hearing and their behavior would consist of yelling out, repetitive speech and refusal of care. RN #3 stated Resident #10's behaviors would stop when the resident was reapproached, and staff wrote things down on the residents note pad for them to read. During a telephone interview on 10/4/22 at 10:50 AM, the Pharmacist Consultant stated that a GDR of an antipsychotic medication should be done quarterly but not in two consecutive quarters. They stated that Resident #10 did not have a GDR completed of their [MEDICATION(S)] and they recommended a GDR in January of 2022 and July 2022. During a telephone interview on 10/4/22 at 10:56 AM, the Medical Director stated that the regulation for a GDR of an antipsychotic medication was if a resident was stable then a GDR is to be attempted. They stated that Resident #10's targeted behavior was outbursts, agitation and Resident #10 had been aggressive in the past. During an interview on 10/4/22 at 11:56 AM, the Director of SW stated a resident receiving an antipsychotic medication should have a gradual dose reduction attempted yearly. The SW stated they attend and prepare the documentation for Behavior Modifying Agent and Review Committee (BMARC) meetings. Resident #10 was to be reviewed in August 2022, but the committee did not meet in August and Resident #10 was not placed on the September 2022 schedule. They stated they did not review Resident #10 in September because the MD disagreed with the GRD recommendation from the pharmacist consultant in July 2022. The Director of SW stated they did not receive any reports of Resident #10 being aggressive to staff or other residents and did not feel they were a harm to self or others. The Director of SW stated that targeted behavior for the use [MEDICATION(S)] was aggression and yelling. In a further interview on 10/4/22 at 12:26 PM, the Director of SW stated they were responsible for care planning of for the use of an antipsychotic medication. They stated Resident #10's care plan does not include the target behavior and that it should have. During an interview on 10/4/22 at 12:30 PM, the Director of Nursing (DON) stated they do not know how often a gradual dose reduction should be attempted for a resident receiving an antipsychotic medication. The DON stated that Resident #10's behaviors had improved and were minimal when compared to when they were first admitted . The DON stated they would expect Resident #10 care plan to be more detailed and have the targeted behaviors listed. 415.12 (I) (2) (ii)

Based on interview and record review conducted during the Standard survey completed on 10/21/20, the facility did not ensure that the attending physician documented in the medical record, their rationale for not acting upon a medication irregularity reported by the pharmacist for two (Resident #10 and #41) of five residents reviewed. Specifically, there is lack of a documented rationale for disagreeing with the consultant pharmacist's recommendations to discontinue a medication (Resident #10) and to change a medication from as needed (PRN) to routinely scheduled (Resident #41). The findings are: The policy and procedure (P&P) titled Medication Reconciliation and Admission Medication Review dated 9/15/20, documented the Consultant Pharmacist conducts a medical review in conjunction with a drug regimen review monthly and as needed. The pharmacy consultant reports irregularities to the attending physician, facility Medical Director, and Director of Nursing. On the next scheduled visit, the attending physician reviews and documents the irregularity and what/if any action has been taken to address it. Should there be no change, the physician documents their rationale. 1. Resident #10 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated 8/6/20 documented the resident was moderately cognitively impaired, was understood and understands. In addition, the MDS documented minimal depression, no behaviors, and antipsychotic medication was received on six of the past seven days. The Order Summary Report dated 10/20/20 included an active physician order [REDACTED]. Review of Note To Attending Physician/ Prescriber dated 8/14/20 documented the following recommendation: Resident #10 with an order for [REDACTED]. The Physician/ Prescriber Response section of the form documented the physician disagreed with the recommendation, signed and dated it on 8/19/20, but did not document the rationale. 2. Resident #41 was admitted to the facility with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident had severe cognitive impairment, was understood and understands. In addition, the MDS documented moderate depression, no behaviors, and antianxiety medication was received on six of the past seven days. The Order Listing Report with date range 1/23/20 through 10/31/20, included the order [MEDICATION NAME] (antianxiety medication) Solution 2 MG/ML (milligrams per milliliter) give 0.5 ml by mouth every 4 hours as needed for anxiety/restlessness/SOB (shortness of breath). Order date was 4/12/20 with revision date of 10/1/2020. Review of Note To Attending Physician/ Prescriber dated 7/6/20 included the following recommendation: Resident #41 currently receiving [MEDICATION NAME] 1 mg by mouth every 4 hours PRN for anxiety. It was noted the resident had received PRN [MEDICATION NAME] 16 times in the last 30 days. For resident's comfort and decreased anxiety, a recommendation is being made to discontinue PRN [MEDICATION NAME] and schedule [MEDICATION NAME] 1 mg by mouth twice a day for anxiety. The Physician/ Prescriber Response section of the form documented the physician disagreed with the recommendation, signed but did not date the form, and did not document the rationale. During a telephone interview on 10/21/20 at 11:03 AM, the current Consultant Pharmacist stated the expectation of the medical provider is to document a rationale in the medical record if they disagree with the Consultant Pharmacist recommendation. During a telephone interview on 10/21/20 at 12:20 PM, the current Medical Director, who is also Resident #41 and #10's attending physician, stated if a provider disagrees with a Consultant Pharmacist recommendation, they would expect ideally a rationale as to why the provider disagreed. During an interview on 10/21/20 at 1:21 PM, the Director of Nursing (DON) stated the attending physician is expected to document an explanation as to why they disagreed with a Consultant Pharmacist recommendation. 415.18(c)(2)

Based on observation, interview, and record review conducted during the Standard survey completed on 10/21/20, the facility did not ensure it is free of a medication error rate of five percent or greater. There were two errors for 30 observed medication opportunities resulting in a medication error rate of 6.67 % (percent). Specifically, medications were not administered in accordance with the physician's orders [REDACTED]. The finding is: The facility policy titled Medication Administration, dated 2/20 documented to locate the resident's EMAR (Electronic Medication Administration Record) to verify what medications are to be administered. Prior to administering medications follow the five rights of medication administration. a) verify it is the correct resident. b) check the medication cassette/ container with the EMAR to verify the correct drug. c) check the medication cassette/ container with the EMAR to verify the right dose. d) Check the medication cassette/ container with the EMAR to verify the right time. e) Check the medication cassette/ container with the EMAR to verify the right route. Administer the medications to the to the resident. Sign off administered medications via EMAR. 1. Resident #269 was admitted into the facility with [DIAGNOSES REDACTED]. The Comprehensive Care Plan (CCP) dated 10/9/20 documented Urge Bladder Incontinence related to overactive bladder and did not address the vitamin D deficiency. Review of an Order Summary Report dated 10/20/20 revealed orders for the following medications to be administered at 9:00 AM: [MEDICATION NAME] (ant-acid) OTC (over the counter) 20 mg (milligrams) give 2 tablets by mouth (po) one time a day (qd) [MEDICAL CONDITION](gastric [MEDICAL CONDITION] reflux disease), [MEDICATION NAME] tablet (Vitamin D)1,000 units give 1 tablet po qd for supplementation, Myrbetriq Tablet Extended Release (ER) 24 hours 50 mg (milligrams) give 1 tablet po qd for overactive bladder, [MEDICATION NAME] (statin- lowers cholesterol) tablet 20 mg give 1 tablet po qd for [MEDICAL CONDITION] (high cholesterol), [MEDICATION NAME] (anti-[MEDICAL CONDITION]) tablet 7.5 mg give 1 tablet po qd for pain, Trospium Chloride (anti-spasmodic) ER capsule 60 mg give 1 capsule po qd for bladder spasm, [MEDICATION NAME] (anti-convulsant) 300 mg give 1 tablet po three times a day (TID) for [MEDICAL CONDITION] (disease of nerves), [MEDICATION NAME] Chloride (anti-spasmodic) Tablet 5 mg give three tablets po TID for bladder spasms, [MEDICATION NAME] HCL (anti-emetic-nausea) tablet 10 mg give 1 tablet po qd for GI distress. During a medication administration observation on 10/20/20 at 9:11 AM Licensed Practical Nurse (LPN) #1 dispensed the following medications into a medication cup: [MEDICATION NAME] OTC 20 mg 2 tablets, Trospium CHL 60 mg ER 1 capsule, [MEDICATION NAME] 300 mg 1 capsule, [MEDICATION NAME] 20 mg 1 tablet, [MEDICATION NAME] 5 mg tablets give 3 tablets, [MEDICATION NAME] 10 mg 1 tablet, [MEDICATION NAME] 7.5 mg 1 tablet. LPN #1 verified each medication dispensed into the cup with the EMAR. The surveyor also verified each medication that LPN #1 dispensed into the medication cup and counted there were 10 pills in the medication cup. LPN #1 locked the medication cart and administered Resident #269 the medications. LPN #1 returned to the medication cart, unlocked the EMAR, clicked save and a green check mark appeared next to all scheduled 9:00 AM medications on the EMAR, indicating all 9:00 AM medications were given. LPN #1 did not dispense or administer Vitamin D or Myrbetriq as ordered by the physician however documented that he had. During an interview on 10/20/20 at 9:35 AM, LPN #1 stated he did not count the pills prior to administration, and he did not click on each medication (physician) order in the EMAR to verify each medication that was to be given prior to administration and he should have. During an interview on 10/20/20 at 11:34 AM, Registered Nurse (RN) #1 Resident Care Coordinator (RCC) stated medications are prioritized, compared one by one with the physician order [REDACTED]. Nurses are expected to click on each physician order [REDACTED]. The nurse should have clicked on each physician order [REDACTED]. During an interview on 10/21/20 at 1:07 PM, the Director of Nurses (DON) stated nurses are expected to follow the five rights of medication administration, and labels are checked against the EMAR. Each medication dispensed during administration should be checked yes on the EMAR and verified prior to administration. 415.12(m)(1)

Based on observations, interviews and record reviews conducted during an abbreviated survey (Complaint # NY 082) completed on [DATE], the facility did not ensure the resident's right to refuse treatment for one (Resident #1) of five residents reviewed for advance directives. Specifically, Resident #1's wishes based on the advance directives were not honored. The resident had a MOLST (Medical Orders for Life Sustaining Treatment) form that indicated the resident wished to be a DNR/ DNI (Do Not Resuscitate/ Do Not Intubate). The resident was found unresponsive and Licensed Practical Nurse (LPN #1) began cardiopulmonary resuscitation (CPR) based on the resident's blue wrist band which designated the resident wanted CPR. Additionally, the facility did not have a written policy that coincided with the facilities expectation to verify resident's code status with the medical record. The finding is: 1. Resident #1 had [DIAGNOSES REDACTED]. The facility policy and procedure titled Cardio-pulmonary resuscitation dated [DATE], last revised on [DATE] documented residents suffering cardiac or respiratory arrest will receive the treatment of CPR unless there is a DNR order. Those residents who wish to be resuscitated shall wear a blue name band on their wrist. Code status will also be on the inside of the closet door of the resident room with the appropriate color paper with their name. For those residents who have obtained DNR orders, this shall be noted on the cover page of the EMR. All licensed nurses certified in CPR will know which residents requested full code status and will be aware of the facility policy and the location of the identifying blue band and to look in the EMR if name band is missing. Review of an undated Admission Checklist (not part of the medical record) revealed within first hour of admission: - Orders to be put into PCC (the electronic medical record which includes the physician orders [REDACTED]. Must include advance directives. - Place appropriate colored bracelet on resident and paper in the closet based on the MOLST. - Advance Directives must be addressed on the shift of admission or re-admission. Review of an Admission/ Readmission note dated [DATE] written by the Registered Nurse (RN) supervisor (RN #1) documented at 5:27 PM the resident was admitted from the hospital via stretcher at 4:40 PM. Resident #1 has a MOLST DNR/DNI signed and placed by spouse. A second note dated [DATE] written by RN #1 at 10:03 PM documented that all orders were reviewed with the physician. Review of the Clinical Physician order [REDACTED].#1 is a DNR/DNI. Review of the Weights and Vitals Summary report revealed that the resident's vital signs recorded at 1:06 PM on [DATE] were BP-,[DATE], Pulse-95, Respirations-20, oxygen saturation 94%. Review of the Resident Monitoring Log dated [DATE] revealed the resident's vital signs on the 2:00 PM to 10:00 PM shift were: Temperature- 96.8, BP- ,[DATE], Pulse-78, Respirations-20, oxygen saturation- 96%. Review of a change of condition note by the LPN supervisor (LPN #1) documented that at 3:50 PM staff walking by room found Resident #1 slumped in bed and non-responsive. LPN #1 assessed vital signs. Resident #1 had no pulse and was not breathing. Resident #1 had a full code wrist band on. A code was called, and CPR was immediately initiated by LPN #1, LPN #2, LPN #3 and LPN #4. The certified nurse aide (CNA) called 911. While other LPNs took over CPR LPN #1 went to the desk to get the resident's MOLST and prepare paperwork. Upon review of the MOLST it was noted that the resident was a DNR/DNI. Staff were informed and CPR efforts were ceased. Emergency Medical Technicians (EMTs) were on the scene and pronounced (death) resident at 4:15 PM. The physician and family were notified. Review of CPR Effort Log dated [DATE] revealed that compressions and ventilations started at 3:55 PM and ceased at 4:02 PM. AED (automated external defibrillator - medical device used to analyze the heart's rhythm and, if necessary, deliver an electrical shock, to help the heart re-establish an effective rhythm) was applied at 4:02 PM, advised not to shock. Review of facility investigation signed by the Director of Nursing (DON) on [DATE] revealed on [DATE] at 3:50 PM CNA #1 answered the call light and found the resident slumped over and called out for help. LPN responded. Resident had no blood pressure, no pulse and no respirations. Resident had a full code bracelet on the right wrist. LPN #1 initiated CPR and other LPNs continued compressions; 911 was called. LPN #1 found the MOLST, CPR was ceased, and emergency medical services arrived and pronounced resident expired. The investigation revealed RN #1 applied the wrist band. Per the DON's written statement in the investigation, the RN (RN #1) statement did not know color coded bands of the facility. The investigation conclusion supports that individuals did not follow policy and protocols for advance directives by not checking orders or the MOLST. Review of the social worker's written statement revealed that she was at the facility on [DATE] (Saturday) from 10:00 AM to 2:00 PM. She reviewed the resident's MOLST which stated resident was a DNR. She asked the RN supervisor if the resident had a band on and she said yes. Nothing was mentioned about the color of the band. The social worker checked to make sure the DNR order was in the electronic medical record and it was. The social worker stated that when a resident is admitted on a Friday, she verifies the advance directives on the following Monday. Since she was at the facility on Saturday, she only completed part of the process with the intent to complete it on Monday. Review of a summary of the investigation dated [DATE] signed by the DON revealed the resident was admitted to the facility on [DATE]. RN #1 (agency nurse) completed the admission orders [REDACTED]. RN # 1 documented this. The DNR/ DNI code status showed on the Medication Administration Record (MAR) and the treatment administration record (TAR) and the patient's home page in PCC. The 11:00 PM to 7:00 AM nurse (RN #2) checked off the second check for orders, evaluations, skin check as well as bracelet intact. On [DATE] the resident was found slumped over by the CNA #1. C NA #1 called for help. LPN #1 entered the room. C NA #1 told her the resident had a blue name band on. LPN #1 reacted. The code and 911 was called. Other nurses responded to the code. LPN #1 left the room, called the DON and indicated the resident was a full code. LPN #1 was instructed to continue compressions until EMTs arrived. DON called RN #2 and asked her to go to the facility to help and for moral support. RN #2 told DON that the resident was a DNR. LPN #1 called DON back and stated that CPR was initiated and performed for approximately 7 minutes. LPN #1 found the DNR and stopped the code. EMTs arrived and pronounced the resident. Per the DON statement, RN #1 started employment at the facility on [DATE] and was oriented by LPN #5 on admissions, advance directives and the color of the band for the code status. LPN #5 stated she stayed with RN #1 for 4 hours. The DON concluded that this was an isolated incident. During interview on [DATE] at 3:30 PM, RN #1 stated that she was oriented in [DATE] when she began employment by shadowing another nurse for about 4 hours. She said she did not receive orientation on the color name band to apply based on the resident's code status. On [DATE] she worked the 3:00 PM to 11:00 PM shift and completed the resident's admission. The resident came from the hospital with a MOLST that indicated the resident's code status was DNR/DNI. RN #1 applied a blue name band on the resident and wrote DNR/DNI on the underside of the band. RN #1 put the DNR order in the EMR/PCC. She placed the MOLST form in the advance directive binder kept on the unit. At the end of her shift she reported to the on-coming 11:00 PM - 7:00 AM nurse (RN #2) that the resident was a DNR/DNI. During an interview on [DATE] at 3:00 PM, RN #2 stated she worked [DATE] on the 11:00 PM to 7:00 AM shift. She received change of shift report from RN #1 and was told the resident was a DNR. RN #2 checked the resident's chart and noted the physician DNR order was present in the chart and in the MAR. During rounds on the 11:00 PM shift RN #2 glanced at the resident but did not note the color of the wrist band. On [DATE] at approximately 4:00 PM she received a call from the DON asking her to go to the facility (she lives close to facility) because a code was in process with the resident. RN #2 told the DON that the resident was a DNR. By the time RN #2 arrived at the facility the code had ended, and the resident expired. EMS had already pronounced Resident #1's death. RN #2 stated that to identify any resident's code status it's policy to check the physician orders, MOLST or the MAR because the code status is documented on the MAR. The resident wrist band is a secondary identifier of code status During interview on [DATE] at 3:45 PM, LPN #1 stated that she worked as the LPN supervisor on [DATE] on the 3:00 PM to 11:00 PM shift. CNA # 1 entered the resident's room and at approximately 3:55 PM and found the resident slumped over unresponsive. The aide immediately called for help and LPN #1 responded. She assessed the resident's vital signs. Resident had no pulse or blood pressure. The resident had a blue wristband on which indicates resident wishes for CPR. LPN #1 said she reacted and started chest compressions. She did not check the MOLST or physician orders [REDACTED]. The aide called code blue and called 911. Other nurses responded to the code and took over the resuscitation efforts. LPN #1 went to the desk to prepare paperwork in case resident was sent to the hospital. LPN #1 found the resident's MOLST and returned to the room to tell staff to stop resuscitation. The resuscitation efforts lasted approximately five minutes. The EMTs arrived and pronounced the resident. EMTs did not participate in the CPR. During an interview on [DATE] at 11:15 AM, LPN #2 stated she worked the 7:00 AM to 3:00 PM shift. On [DATE] at approximately 3:50 PM she was counting narcotics with the oncoming evening shift nurse. She heard a page that there was a code. LPN #2 went to assist, upon entering Resident #1's room CPR was in progress. Staff asked her to record the events, which she did. She took the resident's fingerstick blood sugar, it was 201. She recalled that chest compressions and breaths began at 3:55 PM and ceased at approximately 4:02 PM when LPN #1 came to the room and told staff to stop CPR because the resident was a DNR. Police were on the scene and outside Resident 1's room. EMS arrived after was CPR stopped. The resident showed no signs of life during CPR. She stated that the facility policy to identify a resident's code status is to check the MOLST or the electronic MAR. The last identifier would be the bracelet. She stated that usually the admitting nurse applies the resident's bracelet. During an interview on [DATE] at 11:30 AM, LPN #3 stated on [DATE] she worked 7:00 AM to 7:00 PM. At approximately 3:50 PM she was passing meds and CNA #1 signaled her that there was a code blue in the Resident 1's room. She got the crash cart and went to the room. CPR was in progress. Resident #1 had a blue name band on which means to do CPR. LPN #3 was told the resident was a full code by LPN #1. LPN# 3 asked if she was sure the resident was a full code. LPN #1 said yes. LPN #3 provided Ambu (handheld device used to provide ventilation to patients) breaths to the resident. LPN #1 then left the room to complete paperwork. LPN #1 returned a few minutes later and said she found the MOLST, Resident #1 was a DNR and to stop CPR. LPN #3 had just seen the resident one hour before and she was fine. LPN #1 stated that after this incident nursing staff were instructed to check the MOLST or physician orders [REDACTED]. During an interview on [DATE] at 12:45 PM, the Social Worker stated that Monday to Friday during regular hours she reviews the MOLST and advance directives with the resident and family. She applies the correct colored name band based on code status. During off-hours the supervisor checks the MOLST and advance directives upon admission and applies the name band. The social worker said she does formal audits every ,[DATE] months to check that the correct name band is on. If a resident's code status changes during the admission she reviews the changes to the MOLST with the family/resident and changes the wrist band. She stated that she is on the units daily and checks the wrist band whenever she is in a resident's room. On Saturday [DATE] she was at the facility as the administrator on duty. She reviewed the resident's MOLST and made sure the DNR order was in the computer. She did not check the resident's wrist band on [DATE] as she was performing administrator duties. She had planned to check it on Monday. During interview on [DATE] at 9:00 AM, LPN #5 stated that she oriented RN #1 in [DATE] by working with her for approximately two hours. She educated her on facility policies and procedures and gave her a tour of the building. LPN #5 said she did not orient RN #1 to the color of the wrist bands the first time. She oriented RN #1 at another time (she can't remember the timeframe) to the color of the name bands while they were doing a resident admission. During interview on [DATE] at 1:00 PM, the DON confirmed the contents of her written statement dated [DATE]. She stated that a blue bracelet indicates a resident wants CPR and a red bracelet indicates a resident is a DNR. The facility continues to use the colored piece of paper inside the closet of the resident. Blue piece of paper indicates the resident is a full code; red piece of paper indicates the resident is a DNR. The DON stated that all agency nurses are oriented to policies and procedures related to CPR and Advance Directives and it has been added to the agency nurse orientation checklist. She stated that Resident #1 was in the facility for approximately 24 hours and did not have a closet care plan or the colored piece of paper in the closet. During an interview on [DATE] at 2:00 PM with the Administrator and the DON, they stated the current policy and procedure cited above does not coincide with the facility expectation that nursing staff review the MOLST or the electronic medical record (EMR) to identify a resident's code status. 415.3(e)(l)(ii)

Based on observation, interview and record review conducted during the Standard survey completed on 2/12/19, the facility did not ensure that residents who have not used [MEDICAL CONDITION] drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record and residents who use [MEDICAL CONDITION] drugs receive gradual dose reductions (GDR) and behavioral interventions, unless clinically contraindicated, in an effort, to discontinue these drugs. One (Resident #3) of three residents reviewed for antipsychotic medications had an issue involving the administration of [MEDICATION NAME] ([MEDICATION NAME] - antipsychotic medication) since 3/22/18 with no GDR attempt. There was no specific condition to support the use of an antipsychotic medication; no care plan revisions to address the use of non-pharmacological interventions; and no documented evidence of ongoing behaviors to support the continued use of the medication. The finding is: 1. Resident #3 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set - a resident assessment tool) dated 11/1/18 revealed the resident had severe cognitive impairment. The MDS documented there were no indicators of [MEDICAL CONDITION] or behavioral symptoms; the resident received antipsychotic medications on a routine basis and a GDR was not attempted. The physician documented that a GDR was clinically contraindicated on 10/18/18. Review of the current comprehensive care plan (CCP) revealed the resident uses [MEDICAL CONDITION] medications (initiated 9/19/16, revised 1/29/19); [MEDICATION NAME] ([MEDICATION NAME] - antipsychotic medication) and [MEDICATION NAME] (antidepressant), for behaviors/aggressive agitated neuropsychiatric behaviors of dementia. Another focus area initiated 9/19/16 and revised on 6/29/18 documented that the resident was resistive to care and taking medications at times. She can be verbally and physically aggressive related to dementia. Diagnosis - aggressive agitated neuropsychiatric behaviors of dementia. Review of an Order Review History Report dated 1/11/19 through 2/11/19 revealed physician orders [REDACTED]. Review of Medication Administration Records (MARs) dated 3/22/18 through 2/2019 revealed the resident received [MEDICATION NAME] 0.5 mg twice daily, with occasional refusals. Additional review of the CCP revealed no documented evidence that non- pharmacological interventions were attempted prior to the initiation of [MEDICATION NAME] on 3/22/18 or revised during its use. Review of a Physician's Note dated 3/22/18 revealed the resident was relatively pleasant with the physician and slightly resistant to exam. No acute issues were identified that might precipitate behavioral issues. Impression: dementia with psychotic features with a plan to retry her on some low-dose [MEDICATION NAME]. Review of a pharmacy Note to Attending Physician/ Prescriber dated 7/3/18 revealed the resident was reviewed at the BMARC (behavior modifying agent review) meeting, the resident has been more accepting of care the past month and a recommendation was made for a GDR of [MEDICATION NAME] to 0.5 mg at HS (bedtime) for two weeks then to discontinue. The prescriber response dated 8/16/18 disagreed due to the patient being stable and has a history of verbally aggressive/ hostile behaviors per the NP (Nurse Practitioner). Review of Physician's Notes revealed the following: - 7/24/18 - Nursing staff report patient sometimes swears and screams out loud. Occasionally uncooperative with staff. Nursing staff reports patient is more comfortable in a recliner chair and has been more cooperative with staff. Assessment: patient does act out at times, remains on [MEDICATION NAME] for symptoms of agitation and neuropsychiatric behaviors associated with dementia, continue this as patient would likely have relapse of symptoms with GDR and more important for patient's comfort to have the symptoms controlled. - 10/18/18 - Patient is cooperative with AM care however she does have some vulgarities in her language. Continue to provide a safe and supportive environment, patient does occasionally have agitated behaviors but is easily redirected. Review of Progress Notes, written by a Nurse Practitioner (NP #1), revealed the following: - 6/28/18 - Patient is on comfort measures (conservative, supportive measures provided at the end of life); denies any pain when asked; and then after a few short questions becomes very vulgar with her language, swearing and tells writer to go away. GDR not indicated at this time due to patient having some aggression and psychotic features to her dementia. - 8/17/18 - Has increased lethargy and increased temperature, is on comfort measures only. Yells at staff to leave her alone. Plan was to start a Z-pack ([MEDICATION NAME]/antibiotic - 5-day treatment) and continue to monitor. For dementia, continue to provide a structured and supportive environment. For patient safety, recent GDR was recommended for her [MEDICATION NAME] by BMARC meeting. Declined GDR due to patient's behaviors. See previous note for further details. Review of Nursing Progress Notes revealed the following: - 3/8/18 - Resident was exposing herself in the TV lounge area by lifting up her shirt. CNA (certified nurse aide) went in, talked to the resident and to help the resident to pull her shirt down due to exposing herself. The resident punched the CNA in the mouth/ upper lip. The shirt was pulled down and resident left alone to be re-approached, no further behaviors. - 3/9/18 - Swearing and striking out at staff with care but no increase in this behavior - 3/12/18 - Physically and verbally aggressive with hands on care with range of motion CNA, non-pharmacological interventions included kindness and leaving alone. The resident was quiet when left alone - 3/20/18 - Derogatory remarks to another resident and nurse, left alone and re-approached. Remained quiet after, for 2.5 hours - 3/22/18 - Yelling at peers after noon meal, attempted to settle. Resident behavior continued, peers relocated, tolerated well - 6/5/18 - Combative with care, cursing at CNA. No other behaviors issues were documented during (MONTH) (YEAR) - 7/24/18 - When physician was auscultating lunge sounds she told the physician that is enough God [MEDICATION NAME]. No other behavior issues were documented during (MONTH) (YEAR) - 8/1/18 to 8/31/18 - No behavior issues were documented - 9/26/18 - Threw a cup at a nurse in dining room during meal. No other behavior issues documented - 10/1/18 to 1/31/19 - No behavior issues were documented - 2/1/19 to 2/11/19 - No behavior issues documented Review of the Behaviors point of care documentation (where CNAs document resident behaviors) dated 7/2018 to 2/11/19 revealed documented behaviors on 7/14/18 (kicking/ hitting), 8/3/18 (abusive language), 8/9/18 (rejection of care), and 1/10/19 (abusive language). During an observation of care on 2/8/19 at 11:43 AM, CNAs #1 and #3 transferred the resident into bed using a mechanical lift. The CNAs were talking to the resident and telling her what they were going to do. Resident did state leave me alone goddamn you and the CNAs explained to the resident what they were going to do. The CNAs completed incontinent care. The resident did verbalize once more get out goddamn you but was not physically aggressive. CNA asked the resident if she was ok. The resident stated no and asked the CNA to take her hand, the CNA held the resident's hand. The CNAs transferred the resident from her bed into her chair with the mechanical lift and the resident remained calm and cooperative. Further observation of a pressure ulcer treatment on 2/8/19 at 2:01 PM revealed the resident was calm throughout the treatment. During an interview on 2/11/19 at 10:28 AM, the Licensed Practical Nurse (LPN #1) Resident Care Coordinator (RCC) stated the resident was scratching, kicking, biting, and hitting at staff with hands on care and she wouldn't allow them to give care. The resident was also verbally aggressive. The LPN stated the [MEDICATION NAME] dose hasn't been decreased since it was started, and the resident still has behaviors, not as bad. The resident has improved and she's not as aggressive. The nurses are supposed to document the resident's behaviors, but she thinks they feel that's the resident's normal behavior, so they might not always document it. The LPN also stated they do BMARC meetings; the Social Worker and Pharmacy Consultant decide who get seen and the pharmacist will fill out a form when a GDR is suggested. During an interview on 2/11/19 at 10:35 AM, the Social Worker (SW) stated they have BMARC meetings monthly and review residents quarterly to discuss who should have a GDR. Resident #3 was reviewed last month, and they did not recommend a GDR. The team looks at her behavior or if her mood has decreased. Their decision depends on the resident, with some you don't want to mess with their medications. The SW stated this resident is pretty stable, can be redirected with short conversation, and didn't think her behaviors were a threat to the resident or others. During a telephone interview on 2/11/19 at 11:13 AM, the Consultant Pharmacist stated the reason for using the [MEDICATION NAME] for this resident was that she was increasingly agitated with hands on care during ADLs. The [MEDICATION NAME] was started in (MONTH) (2018) and there has been no GDR. The resident is reviewed quarterly in BMARC; they did recommend a GDR; and the NP documented this medication was beneficial for quality of life and didn't want to change it. The Pharmacist further stated this drug is not approved for use for dementia and the resident was seen by a Psychiatric Nurse Practitioner (NP) after the mediation was started. The NP recommended to continue the medication. The pharmacist also stated, the ultimate decision is up to the providers, I tell them the guidelines, and tell them if they are not going to GDR, they have to document why. During a telephone interview on 2/11/19 at 11:47 AM, NP #1 stated she is familiar with Resident #3 and she remembers the resident being very resistant to care at times with the aides. The NP stated the resident's behaviors were mostly verbal and I don't know if she had any physical issues with other residents or staff members. When asked if her behaviors were a threat to herself or others, the NP stated the resident would get graphic with her obscenities, so you never know if she was going to get hit by another resident and I don't know of any physical behaviors, I don't think it got to that point. During further telephone interview on 2/11/19 at 12:00 PM, the NP stated she read her notes, the resident has agitation with psychotic features, and wrote no GDR was indicated on her 6/28/18 note. The NP stated the physician saw the resident on 7/24/18 and he documented that nursing staff reported no new concerns except swearing and screaming out loud. When asked if an antipsychotic is indicated for those behaviors, the NP stated the physician documented to continue the medication and she would likely have a relapse. During a telephone interview on 2/11/19 at 1:00 PM, the Physician stated he remembers the resident being on [MEDICATION NAME] because she had problems with hands-on-care with agitation at times and thought there was verbal aggression as well. This medication has an off-label indication for using in people with [MEDICAL CONDITION]. The physician stated the resident was on comfort measures and thought decreasing or discontinuing the medication would provoke her agitation. During an interview on 2/12/19 at 9:22 AM, CNA #1 stated the resident at times can be very verbal (swearing) but I talk to her and she's been better lately. Usually talking to her during care, helps her calm down. During an interview on 2/12/19 at 10:09 AM, the Director of Nursing (DON) stated when they discuss GDRs they do comparative reviews; review from the prior review, look at any new or better behaviors, it's a team decision. Then they discuss with the doctor to see if they want to attempt a GDR. The DON stated she would rely on the Pharmacy Consultant and Physician to guide the decision-making process. Staff should do behavior charting in the electronic medical record. Resident #3 is difficult to do diversional activities with, she usually tells everyone to leave her alone. In summary, there was no documented evidence of ongoing behavioral issues or [DIAGNOSES REDACTED]. 415.12(l)(2)(i)(a-d)(ii)

Based on interview and record review conducted during the Standard survey completed on 2/12/19, the facility did not ensure the resident's right to choose activities, schedules, and health care consistent with his or her interests, assessments, and plans of care; and make choices about aspects of his or her life in the facility that are significant to the resident. One (Resident #12) of two residents reviewed for choices had an issue involving showers that were not provided in accordance with a resident's wishes. The finding is: 1. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a resident assessment tool) dated 11/17/18 documented the resident is cognitively intact. The NRSG: Resident Preferences form dated 10/15/18 documented the resident prefers a shower twice per week. During an interview on 2/6/19 at 2:52 PM, the resident stated he gets one shower per week and would like two or three. The resident further stated, They just tell you what you're going to get. The Follow Up Question Reports dated 10/1/18 through 1/23/19 for the task ADL (activities of daily living) - bathing shower documented the resident did not receive two showers per week. The care plan documented a focus area initiated on 10/16/18 that the resident will make choices as able. An intervention/ task revised on 12/13/18 included prefers shower on Wednesday, days (shift). The Kardex documented the resident prefers a shower on Wednesday, days (shift). An undated Daily Unit Management (DUM) Sheet documented the resident's shower is on Wednesday day shift. During an interview on 2/12/18 at 9:40 AM, the Licensed Practical Nurse (LPN) Resident Care Coordinator (RCC) stated that on admission they talk to the resident about their showers and it is documented on the DUM sheet, the care plan and then the resident preferences are reviewed quarterly. During an interview on 2/12/19 at 10:29 AM, the Registered Nurse (RN) Clinical Reimbursement Specialist stated she was updating the Daily Unit Management sheets for the RCCs but it was their responsibility to let her know if anything changed or needed to be updated. The showers are based on room assignment and are usually once per week to start. The RCCs or the supervisors who are admitting the resident would get the resident's preferences and let her know to update the schedule. Now, it is the RCCs responsibility. If the resident wants more showers we can update it. 415.5(b)(1)(3)