Every finding on record at Absolut CTR for Nursing & Rehab Endicott L L C

Based on record review and interviews (2989447), the facility failed to ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation was made for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Certified Nurse Aide #3 alleged on the evening of 04/18/2026, they witnessed Certified Nurse Aide #4 holding the resident's wrists firmly, banging the resident's fists into their face and bending the resident's fingers backwards. Certified Nurse Aide #3 did not report the abuse immediately and Certified Nurse Aide #4 continued to work with residents. Furthermore, Certified Nurse Aide #3 reported the incident to Certified Nurse Aide #7 and Certified Nurse Aide #7 did not report the abuse allegation timely.Findings include:The facility policy Abuse Policy and Prevention, revised 11/2023 documented employees must always report any abuse or suspicion of abuse immediately to the Administrator. The alleged employee accused of alleged abuse would immediately be removed from the facility and would remain removed pending the results of the investigation. Resident #1 had diagnoses including dementia and psychotic disorder (severe mental illness). The 03/19/2026 Minimum Data Set assessment documented the resident's cognition was severely impaired. The 01/08/2026 Comprehensive Care Plan documented Resident #1 had behaviors of physical aggression and resistance to care. The resident was incontinent of bowel/bladder and they had potential to abuse others. Interventions included: reapproach as needed; avoid overstimulation; provide care out of room ( i.e.: shower room); check and change every two hours and as needed; and if the resident was agitated, cease interaction/activity and return after the agitation had diffused. The 04/20/2026 Incident Report completed by Registered Nurse Manager #5 documented Certified Nurse Aide #3 reported that during the evening shift on 04/18/2026, Certified Nurse Aide #4 was being rough with care with Resident #1. There were no injuries, no signs of pain or verbal complaints. The medical provider and family were notified. Staff statements included:- Certified Nurse Aide #3 documented during incontinence care, they witnessed Certified Nurse #4 grab the resident by the wrists and hit the resident in the face with the resident's own hands every time the resident moved. Certified Nurse Aide #4 bent the resident's fingers backwards and made the resident say uncle before they would let go. They asked Certified Nurse Aide #4 what they were doing and the aide stated they got this. The resident yelled ouch and stop during the incident. They did not know what to do as they had never dealt with a situation like that and they did not report the incident to anyone that night.- Certified Nurse Aide #4 documented they were asked by Certified Nurse Aide #3 to help with a combative resident. While attempting to change Resident #1, the resident became more combative and started swinging (their arms). Certified Nurse Aide #4 held on the resident's wrists to avoid both staff getting hit. While holding the resident's wrist, the resident was jerking themselves back and forth hitting their face into their fists. They denied pushing the resident's hands into their face and denied bending the resident's fingers backward.- Certified Nurse Aide #7 reported to the facility (in a telephone interview), they were not aware of the incident, and nothing was reported to them. The facility's Investigative Summary documented:- The Administrator and Director of Nursing were notified of the incident on 04/20/2026 at 3:41 PM.- Certified Nurse Aide #4 was on duty at the time the incident was reported, and they were suspended.- Certified Nurse Aide #3 was interviewed about why they did not report the incident on 04/18/2026 and stated they were afraid Certified Nurse Aide #4 would confront them.- On 04/23/2026, Certified Nurse Aide #7 was interviewed and stated Certified Nurse Aide #3 told them about the incident when they worked together on 04/19/2026. This was different than what Certified Nurse Aide #7 documented in their statement obtained on 04/20/2026. When questioned why Certified Nurse Aide #7 did not immediately report the incident to a supervisor, they stated they told Certified Nurse Aide #3 to report it to the nurse manager.- Certified Nurse Aide #3 was re-interviewed and questioned why, during their initial interview, they did not report they had spoken to Certified Nurse Aide #7 about the incident. They stated they were upset about the incident and told Certified Nurse Aide #7 because they were not sure what to do. Certified Nurse Aide #3 was educated about the importance of the investigative process and if they reported to any other staff, they needed to know immediately. Certified Nurse Aide #3 denied reporting the incident to anyone else. Certified Nurse Aide #4's time sheet documented on 04/18/2026, they clocked in at 3:12 PM and clocked out on 04/19/2026 at 3:03 AM. During an interview on 04/27/2026, Certified Nurse Aide #3 stated on 04/18/2026, the resident was not agitated during care and was fidgety. Certified Nurse Aide #4 grabbed the resident's wrists and hit the resident in the face with the resident's own hands. They also bent the resident's fingers backwards until the resident said uncle. They questioned Certified Nurse Aide #4 on what they were doing and the aide stated to them they got this. They did not report to anyone that night because they were worried about Certified Nurse Aide #4 retaliating against them as the aide had yelled at them and others in the past. They believed they could report to their unit manager who was not going to be on duty until 04/20/2026. They reported to the manager on 04/20/2026, was suspended for not reporting timely, and was retrained on the facility's Abuse Policy and timely reporting of abuse. During an interview on 04/28/2026, the Administrator stated the investigation was inconclusive because it was one aide's word against the other's, the resident had no injuries and was at their baseline. They terminated Certified Nurse Aide #4 because interviews with staff revealed Certified Nurse Aide #4 was a bully (to other staff) and they felt the aide had the potential to abuse others. Certified Nurse Aides #3 and #7 were suspended for not reporting the incident timely. A full house re-education on their Abuse Policy, Corporate Compliance, with a focus on timely reporting was currently in process. Certified Nurse Aide #4 was not reached for an interview on 04/28/2026 at 8:34 AM and on 05/21/2026 at 9:00 AM. During an interview on 05/27/26 at 9:17 AM, the Medical Director stated they expected staff to report abuse immediately because it was serious, the facility was responsible for taking care of residents, and it needed to be addressed right away. They discussed the incident with the facility and heard the aide delayed reporting the incident because they questioned what they had witnessed. The witnessing staff should have reported it immediately. During an interview with Certified Nurse Aide #7 on 05/27/2026 at 10:40 AM, they stated on 04/19/2026, Certified Nurse Aide #3 reported to them they witnessed another aide holding Resident #1's hands tightly, bending their fingers, and making the resident say uncle. They told Certified Nurse Aide #3 to report the incident on Monday (05/20/2026) morning. Certified Nurse Aide #7 stated they should have reported the allegation immediately and have since been retrained. 10 New York Codes, Rules and Regulations 415.4(b)(3)

37516 48895 Based on record review, observations, and interviews during the recertification and abbreviated (NY00351721 and NY00320653) surveys conducted 10/28/2024-10/31/2024, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 4 of 4 resident units (Units 1, 2A, 2B, and 3) reviewed. Specifically, Units 2A, 2B, and 3 had unclean hallways, bathrooms, and resident room floors; the main kitchen and unit pantry areas had unclean areas; the resident scale on Unit 2A had dried debris; Resident #102's wheelchair had ripped armrests held together with tape; the main dining room toilets were out of order and contained brown liquid; and the facility air temperature was not maintained at a comfortable level on 10/26/2024 and 10/27/2024. Findings include: The facility policy, Cleaning Procedure Residents Rooms, revised 1/2024, documented housekeeping was responsible for cleaning: - Resident rooms and adjoining toilet areas (to be cleaned daily). - Public toilet areas and large bath/toilet areas located on the skilled nursing facility. - Nurses' stations, medicine rooms, and utility rooms. - Resident dining rooms. - Lounges, halls, and corridors. The facility policy, Quality of Life - Homelike Environment, revised 3/2024, documented residents were provided with a safe, clean, comfortable, and homelike environment and were encouraged to use their personal belongings to the extent possible. Characteristics that reflected a personalized, homelike setting included: - A clean, sanitary, and orderly environment. - Clean bed and bath linens that were in good condition. - Pleasant, neutral scents. - Comfortable and safe temperatures (71 degrees Fahrenheit to 81 degrees Fahrenheit). The facility policy, General Kitchen Cleaning, revised 4/5/2024, documented staff would maintain the sanitation of the kitchen through compliance with the cleaning schedule and would be recorded when completed. Resident Equipment: During observations on 10/28/2024 at 12:21 PM, 10/29/2024 at 9:12 AM, and 10/30/2024 at 9:32 AM, Resident #102's Broda (a specialized reclining wheelchair) chair had a ripped vinyl armrest on the right side that had surgical tape across the top. During an interview on 10/31/2024 at 10:43 AM, Licensed Practical Nurse #30 stated therapy issued resident wheelchairs. If there was an issue, they put in a ticket to maintenance and if they could not fix it, they would submit a ticket to therapy or talk to therapy directly. They stated Resident #102's Broda chair wheels did not work properly, and they submitted a ticket, and the Director of Therapy was aware. The right armrest was ripped and coming off. They reported the armrest but did not put in a ticket. During an interview on 10/31/2024 at 11:08 AM, Licensed Practical Nurse Unit Manager #6 stated maintenance and therapy maintained the Broda chairs. The arm rest was ripped because Resident #102 ripped it and they did not know who put the tape on it and did not notice the tape before 10/31/2024. They noticed the rip on 10/28/2024, but did not put in a ticket for repair, as they thought the resident was getting a new chair. The chair should be fixed to prevent any injuries. It did not look good and could be a dignity issue. During an interview on 10/31/2024 at 11:34 AM, Director of Therapy #31 stated Broda chairs were issued by therapy. If there were issues with the chair staff should submit a ticket to get it fixed. Maintenance attempted to repair chairs first, and if a replacement was needed, they would assume responsibility. They had not received any maintenance requests for Resident #102's chair, and they were not aware of the right armrest damage. The armrest needed to be replaced for dignity and safety concerns. During an interview on 10/31/2024 at 11:55 AM, the Director of Nursing stated damaged wheelchairs required staff to place a ticket to maintenance and if they could not fix the chair, they would notify therapy. There was a risk for skin tear, infection, pressure injury, and dignity issues. Staff had been educated on this issue before, and the facility added a new feature to the kiosk for staff to submit work orders. Unclean Environment: The following observations of Unit 2A were made on 10/28/2024: - at 11:22 AM, the floor in resident room [ROOM NUMBER] was unclean with dried debris and large, black scrape marks. - at 11:28 AM, both hallway floors were unclean with dried spills, stains, lint, dust balls and pieces of paper. The paint on the hall walls was peeling and there were black scrape marks on the floors and on the doors to resident rooms. - at 11:45 AM, the floor in resident room [ROOM NUMBER] was unclean with dried spills and crumbs. Bottle caps, empty sugar packets, small pieces of paper, dust balls, and used disposable cups were under and around the resident's bed. - at 12:24 PM, the large table at the end of the hall (near room [ROOM NUMBER]) had a dust film, and a large scrape with exposed splinters and strands of human hair; three vinyl upholstered chairs had crumbs on their seats, unclean armrests, and scraped and dented wooden frames; the resident scale near the table had tan-colored dried debris on the foot of the scale; and the floor under the table and near the resident scale had multiple large dust balls. During an observation on 10/29/2024 at 8:03 AM, room [ROOM NUMBER] had 6 snack wraps at the right side of the bed and stains on the floor. The floor was littered with small black debris. There was scattered debris in the fold of the fall mat. The following observations were made on Unit 2B: - on 10/28/2024 at 10:54 AM, Resident #410's family stated that cleaning was an issue for the facility. The resident's bathroom floor had debris, and there was staining around the toilet and the edges of the floor. - on 10/28/2024 at 11:08 AM, Resident #410's toilet continued to run for 11 minutes after the resident exited the bathroom. - on 10/28/2024 at 11:23 AM, the ceiling vent between rooms [ROOM NUMBERS], had a black substance on the vent louvers. - on 10/28/2024at 11:26 AM, there was a dark colored substance on the floor under the hand sanitizer between rooms [ROOM NUMBERS]. - on 10/28/2024 at 12:27 PM, the flooring between the nurse's station and the northwest stairwell was uneven with cracked and chipped tiles. There was a black leather chair that was ripped in multiple areas across the arms and back with a sign that documented, do not use. The treatment cart across from room [ROOM NUMBER] had a large amount of dust and debris collected around the wheels. - on 10/28/2024 at 1:42 PM, the floor near the nurse's station had brown colored stains and 40-50 dark dried spots. The walls had scrapes and scuffs throughout the hallways. The front of the nurse's station had several large clumps of dust and debris stuck to it. The doorway between units 2A and 2B had multiple scrapes and missing paint. On 10/29/2024 at 1:05 PM and 10/30/2024 at 10:07 AM, the window across from room [ROOM NUMBER], had a towel taped to it and had a bent screen. The window appeared open, but the towel was wedged in the gap. The following observations were made on the 3rd floor: - on 10/28/2024 at 10:31 AM, the shared bathroom for rooms [ROOM NUMBERS] had feces on the front of the toilet. - on 10/28/2024 at 12:04 PM, room [ROOM NUMBER] had an approximate 12 inch by 2 inch dried spill on the floor between the two beds. - on 10/28/2024 at 12:08 PM, the shared bathroom for rooms [ROOM NUMBERS] had a commode with feces on it. - on 10/28/2024 at 12:56 PM, the 3rd floor dining room had unclean and sticky floors. - on 10/28/2024 at 1:32 PM, room [ROOM NUMBER] had many black spots covering most of the floor. - on 10/29/2024 at 8:34 AM, room [ROOM NUMBER] had many black spots covering most of the floor, the heater had rust, and the sink in the bathroom did not have water. The resident occupying the room stated their room was dirty and they did not like it. - on 10/30/2024 at 9:25 AM, the 3rd floor dining room had unclean and sticky floors. - on 10/30/2024 at 1:18 PM, a brown recliner near the 3rd floor nurse's station had rips across the back headrest. An unknown resident sat down in the chair after lunch. The following additional observations were throughout the facility: - on 10/28/2024 at 10:41 AM, the kitchen dish room grease trap had gray color debris on the trap encasement and the floor surrounding the trap. The main kitchen floor had black marks, food particles, and paper products throughout the area. The dry storage area had leaves on the floor. The exit door was blocked by a cart with folded cardboard boxes on top and a large garbage pail. The Assistant Food Service Director stated the kitchen staff were short due to illness. - on 10/28/2024 at 2:45 PM, the men's room in the dining room had a sign that documented, out of order, the door was unlocked, and the toilet was full of foul-smelling brown liquid. The women's room toilet was full of foul-smelling brown liquid. The water fountain between the bathrooms had stagnant brown liquid pooled in the basin. - on 10/28/2024 at 3:22 PM, the elevator floor was uneven and had several chipped flooring pieces. - on 10/28/2024 at 3:25 PM, the conference room had multiple dried black debris stuck to the floor. - on 10/30/2024 at 11:32 AM, the men's room in the second-floor dining room had a sign that documented, out of order, the door was unlocked, the toilet had a brown foul-smelling substance. The water fountain between the 2 bathrooms had a brown liquid at the drain, and dried brown substance that created rings above the water line. The women's room had a sign that documented, out of order, the door was unlocked, the toilet had a brown foul-smelling substance and rings of dried brown substance. The odor from the bathroom was very strong upon opening the door. At 12:51 PM, residents were eating in the dining room with the unclean bathrooms. During an interview on 10/28/2024 at 1:09 PM, Certified Nurse Aide #16 stated they had not seen a housekeeper on the unit (2A) all day. The housekeeper called out a lot. The other unit housekeepers were always there. The floors, walls, and resident rooms on the unit were routinely dirty. During an interview on 10/29/2024 at 9:26 AM, Certified Nurse Aide #32 stated housekeeping was responsible for cleaning the unit. They were there Monday through Friday until 3:00 PM. The rooms did not look clean. Floors were dirty in resident rooms. The black marks on the floor were dirt. They used a washcloth on the dark spots, and they cleaned up easily. The water in room [ROOM NUMBER] did not work. There was a weekend the facility did not have a housekeeper because they were short staffed. During an interview on 10/30/2024 at 9:16 AM, Licensed Practical Nurse Unit Manager #17 stated Unit 2A was not as clean as it could be. The housekeeper was out a lot. They and unit staff usually had to follow behind the housekeeper, especially if there was a new admission going into a room. They cleaned the dust balls and debris from under the beds. They had spoken to the housekeeping supervisor about the lack of cleaning on the unit, but nothing seemed to change. During an interview on 10/30/2024 at 9:25 AM, Licensed Practical Nurse #9 stated housekeeping was on the units Monday through Friday, and there were only 1 or 2 staff for the whole facility. Floors were dirty and sticky at times. Housekeeper #33 was assigned to the third floor, and they were really good if they were told about something. If there was feces on the toilet, it was everyone's responsibility to clean it. If it was not cleaned and another resident used the toilet, it could be an infection control concern. The dirty and sticky floors were not homelike. During an interview on 10/30/2024 at 11:17 AM Housekeeper #18 stated their usual unit to work on was 2A, but since 2B was the rehabilitation unit with more admissions, they would get pulled over to that unit frequently to assist with cleaning. Their usual cleaning routine when they arrived on the unit was the pantry first, then shower rooms, the nurses' station, clean and dirty utility rooms, and then bathrooms. At 9:30 AM they would start cleaning resident rooms. Their supervisor had told them to use the cleaning spray first on the floors, but they dusted the floors then sprayed. They would then go back into the resident room and clean the cabinets and dressers. They were responsible for cleaning rooms for new admissions and room changes. Deep cleaning a room involved moving all equipment and furniture, and cleaning bed frames and mattresses. Normally the facility had extra housekeepers, but they did not always show up for work. Any extra housekeepers were sent to Unit 2B. They let maintenance know about walls that needed painting, scrapes on the walls, and broken equipment. They cleaned resident scales. Nursing was responsible for wheelchair cleanings. They let nursing know if they had any issues with a resident when they attempted to clean a room. If a resident told them to get out they would leave and then reapproach later. Sometimes residents would only let them empty the trash. If they did not get to all the resident rooms on the unit during their shift, their supervisor told them to start all over again on the unit the next day. There were no housekeepers on the evening shift. The facility had some night custodians that were being trained to clean rooms because they were short housekeeping staff. Unit 2A was dirty on 10/28/2024 because that was their day off and there was not another housekeeper who replaced them. During an interview on 10/31/2024 at 7:37 AM, Housekeeper #33 stated they had the same routine every day. They were responsible for the entire third floor. Their routine was to clean every room and make sure the sink and toilets were cleaned, sweep, mop, dust, deodorize the room and take out the garbage. When they were not there the nursing staff would clean up after the residents. They did not recall seeing feces on the toilet in room [ROOM NUMBER]. The housekeeping department was short staffed. They tried to get in and out of every room timely. They did not know if the sink in room [ROOM NUMBER] worked. The black substance on the floor in room [ROOM NUMBER] was sticky from urine with dirt and grime. They stated the floors needed to be waxed, but the facility no longer had someone to do that. If the room was not clean, it was not homelike for the resident. During an interview on 10/31/2024 at 9:39 AM, the Assistant Food Service Director stated the main kitchen floors were cleaned every Friday by a contractor. They were swept and mopped by kitchen staff after every meal. The dietary staff was short on 10/27/2024 and the floors were not cleaned by the time the surveyor observed them. The grease trap under the dishwasher had leakage issues and maintenance was aware. The trap was supposed to be cleaned daily and the debris on it was due to not being cleaned daily. There should not be leaves on the dry storage area floor. During an interview on 10/31/2024 at 10:35 AM the Administrator stated the Laundry Supervisor was currently overseeing housekeeping because the Housekeeping Supervisor was on leave. They had turnover with housekeeping staff. Housekeepers worked day and evening shifts. The custodians on evenings were cleaning resident rooms, sweeping, mopping, and taking out the garbage if the day shift housekeepers could not get to those tasks. The Housekeeping Supervisor would do weekly environmental rounds. They would address unclean areas right away with the housekeepers. The expectation for resident rooms was they should be thoroughly cleaned, including underneath the beds. Rooms were deep cleaned for new admissions and discharges. Maintenance was in charge of painting walls. During an interview on 10/31/2024 at 11:26 AM, Housekeeper #35 stated they were assigned to Unit 2B and started cleaning each day in the pantry and common areas, then took trash from the resident rooms and common areas. This allowed the resident to get morning care. They had a goal to complete one hallway each day but could not always get through the whole hallway. They would do the other side of the unit the following day and rotate back and forth. Some days it was difficult to finish one side of the unit, depending on admissions and discharges. It took about 45 minutes to an hour to deep clean a room after discharge, the unit sometimes had multiple discharges in a day. Cold Environment/Heat Issue: During an interview on 10/28/2024 at 10:54 AM, Resident #410's family stated they visit 6 days a week. The temperature in the facility on Saturday (10/26/2024) and Sunday (10/27/2024) was very cold. They brought Resident #410 winter gloves to wear. During an interview on 10/28/24 at 12:46 PM, Resident #411 stated it was cold this past weekend, very uncomfortable. They asked the nursing staff about the heat and was given extra blankets. They stated nursing handed out extra blankets to everyone. The staff told Resident #411 they reported the outage, but there was nothing else they could do. During an observation on 10/28/2024 at 1:08 PM, an unknown staff member was overheard telling another staff member that it was very cold over the weekend, and they had to wear coats in the building. They stated the certified nurse aides went around and turned up all the thermostats on the unit, with no change. During an interview on 10/29/2024 at 8:35 AM, Resident #119 stated they were told the boiler was turned off on Thursday, but it was so cold over the weekend nursing staff were wearing their outside coats while providing care. They stated that management and maintenance were asking staff for the actual temperature, but the staff stated they had no thermometer on the thermostat, so they did not know what the actual temperature was. Resident #119 was told that maintenance did not work on the weekend so there was nothing that could be done. Resident #119 stated it was bitter colder and they had to wrap up in a blanket all day. During an interview on 10/29/24 at 12:30 PM, the Administrator stated the Maintenance Director was responsible for monitoring the air temperature in the facility and documenting it. He had been out of work since 10/18/2024, and there were no air temperature logs for the dates requested, 10/23/2024 to 10/29/2024. During an interview on 10/29/24 at 2:05 PM, Resident Assistant #15 stated they worked both days over the weekend. It was cold in the building, and they had to wear a long sleeve shirt and a sweatshirt. The residents complained that it was cold. They handed out extra blankets to the residents. It was very cold, under 70 degrees Fahrenheit. During an interview on 10/30/24 at 11:38 AM, Licensed Practical Nurse #14 stated they worked on Saturday and Sunday. The facility was cold. The residents complained that it was not comfortable, and they were cold. The facility should be comfortable and homelike for the residents. During an interview on 10/30/2024 at 2:16 PM, the Corporate Administrator stated there were made aware of the facility being cold at 9:55 AM on 10/27/2024 via text message from the Director of Nursing. The Assistant Maintenance Director came in and restarted the boiler with confirmation provided to the Corporate Administrator via text message at 11:33 AM on 10/27/2024. They did not know why the boilers were off. The Director of Maintenance did not document when the boilers were turned on or off. If there was an issue, they would call the on-call maintenance staff and they would look at the boiler to see if it was on or off. During an interview on 10/30/24 at 2:37 PM, the Director of Nursing stated they were notified by the supervisor that unit 2B was freezing at 9:36 AM on 10/27/2024. The Director of Nursing stated they reported to the Corporate Administrator at 9:49 AM on 10/27/2024 when they were told the facility was 62 degrees Fahrenheit. The Assistant Maintenance Director communicated that the boiler was working at 11:30 AM on 10/27/2024. During an interview on 10/30/2024 at 2:55 PM, the Assistant Maintenance Director stated they received a message from the Director of Maintenance that there was no heat on unit 2B. The boilers were not running, and they were not sure why. They stated that the 3 staff in the maintenance department did not turn them off, the Director of Maintenance could have, but if they did, they did not communicate that to the rest of the department. The Assistant Maintenance Director stated they stayed for about 45 minutes to ensure the boilers were running appropriately. They did not monitor the air temperature while they were here. 10 NYCRR 415.29(j)(1)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00352718) surveys conducted 10/28/2024-10/31/2024, the facility did not ensure residents had the right to a dignified existence for 1 of 2 residents (Residents #411) reviewed. Specifically, Resident #411 was served their meal in their room [ROOM NUMBER] minutes after their roommate was served and had completed their meal. Findings include: The facility policy, Resident Rights, dated 2/2022, documented employees should treat all residents with dignity. Resident #411 had diagnoses including diabetes, adult failure to thrive, and gastro-esophageal reflux disease. The 10/21/2024 Minimum Data Set assessment documented the resident was cognitively intact and ate independently. The 10/22/2024 comprehensive care plan for nutrition documented interventions including a regular consistency diet. During an interview on 10/28/2024 at 11:50 AM, Licensed Practical Nurse #19 stated meals came to the unit on 2 carts, at 12:00 PM and 1:00 PM. The residents did not use the dining room. The carts were divided to help with tray passing. They were supposed to be divided by hallway, but they were a few trays on the second cart for residents in the first hallway, and vice versa. During an interview on 10/28/24 at 12:46 PM, Resident #411 stated breakfast was delivered to them daily after 9:00 AM, and their lunch came on the second cart at 1:00 PM. Their roommate's tray came on the first cart, and they waited at least 30 minutes after their roommate was served before their tray would come. By the time Resident #411's meal tray came they were so hungry they would eat too fast, and it would make them feel uncomfortable. During an observation on 10/28/2024, Resident #411 was sitting in the hallway outside their room. - at 12:44 PM, the first meal tray cart arrived on the unit. - at 12:52 PM, the meal tray for Resident #411's roommate was served in the room. - at 1:25 PM, Resident #411 told an unidentified activities staff their meal tray should have been there 2 hours before. - at 1:30 PM, the second meal tray cart arrived on the unit, and Resident #411 was served their meal tray in their room (38 minutes after the roommate). The resident's roommate had completed their meal. During an observation on 10/29/2024 at 9:05 AM, Resident #411 was in their room. Their roommate had their meal tray and Resident #411 did not. During an observation and interview on 10/29/2024 at 1:06 PM, Resident #411's roommate stated they were served their lunch and refused it, so the staff took it away. Resident #411 stated they had not yet received their meal. Both residents were in the room together. Resident #411 stated they had always stayed in that room and previously got their meal on the first cart, when the roommate moved in their tray started coming on the second cart while the roommate continued to get their food on the first meal cart. Resident #411 stated it upset them to watch their roommate eat or turn away food when she was hungry. They were frustrated their mealtime had changed. During an interview on 10/29/2024 at 1:57 PM, Certified Nurse Aide #21 stated 2 meal carts were delivered to the unit, about 30 minutes apart. Residents should always be served together, especially if they roomed together. The trays in the cart were not always arranged by room. They stated they would try to pair roommate trays together if they could. Dietary was had been putting Resident #411's meal tray on the first cart, but they did not know what happened. They could only pass out trays they had, and it was not dignified for Resident #411 to watch their roommate eat while they waited for their tray. During an interview on 10/29/2024 at 2:05 PM, Resident Assistant #15 stated 2 meal carts were delivered to the unit at 2 different times. Resident #411's roommate's meal came on the first cart. They did not know why the carts were arranged that way. The residents should eat together in the same room. It was not dignified or fair to Resident #411 to have to watch their roommate eat and just sit there. They tried to deliver trays to the same room one after the other, as they should always eat together. During an interview on 10/30/2024 at 11:38 AM, Licensed Practical Nurse #14 stated meal trays should be packed based on the location of the room. Roommates should be served together. It was not dignified for a resident to watch another resident eat, especially when they were hungry. During an interview on 10/30/2024 at 11:11 AM, Registered Nurse Unit Manager #20 stated the dining room on the unit had been empty since they started at the facility about a month and a half ago and none of the residents ate in the dining room. The trays were passed in the order they came on the cart from the kitchen. Trays should come at the same time to residents that shared a room. It was not dignified for one resident to eat while the other waited for their food. The carts should have all the residents from one hallway and the second cart should be all the residents on the other hallway. 10 NYCRR 415.5(b)(1-3)

Based on record review and interviews during the recertification survey conducted 9/23/2024-9/26/2024, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries for 2 of 3 residents (Residents #27 and #141) reviewed. Specifically, Residents #27 and #141 remained in the facility after discontinuation of Medicare Part A services and the facility did not provide the resident with timely Notice of Medicare Non-Coverage (Centers for Medicare and Medicaid Services-10123) when Medicare Part A coverage was ending and a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (Centers for Medicare and Medicaid Services-10055) for Medicare Part A as required. Findings include: The Center for Medicare and Medicaid Services form instructions for the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage Center for Medicare and Medicaid Services-10055, expiration date 1/31/26, documented a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (form 10055) must be issued by providers to beneficiaries in situations where Medicare payment was expected to be denied. The Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage must be delivered far enough in advance that the beneficiary or representative had time to consider the options and make an informed choice prior to services ending. The undated facility policy, [Advanced Beneficiary Notice] and [Notice of Medicare Non-Coverage] policy, documented when a resident was no longer eligible for skilled coverage under Medicare Part A, the facility must issue an [Advanced Beneficiary Notice] and [Notice of Medicare Non-Coverage] to the resident or their legal representative with a minimum notice of two days. The resident or legal representative must be notified in person or via phone. Document the representative's name, phone number, date, and time they were spoken to and send certified mail on the same day. 1) Resident #27 had diagnoses including muscle weakness, diabetes mellitus type 2, and osteoporosis. The 9/13/2024 Minimum Data Set assessment documented it was a Skilled Nursing Facility Part A Prospective Payment System (a method of reimbursement used by Medicare that pays a predetermined amount for a service) discharge assessment and the resident had a Medicare-covered stay with a start date of 8/6/2024 and an end date of 9/13/2024. The Notice of Medicare Non-Coverage for Centers for Medicare and Medicaid Services-10123 letter documented Resident #27's effective end date of services was 9/13/2024. Business Office Manager #11's handwritten additional information documented the notice was issued over the phone by speaking with Resident #27's representative on 9/10/2024 at 2:15 PM, and the notice was sent by certified mail on 9/10/2024. Business Office Manager #11's handwritten note on the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage Center for Medicare and Medicaid Services-10055 letter documented Resident #27's representative was spoken to on 9/10/2024 at 2:15 PM, no options were selected regarding the discussion with the representative. There was no documented evidence a United States Postal Service Certified Mail Receipt was sent to the resident's representative. 2) Resident #141 had diagnoses including Parkinson's disease, severe protein-calorie malnutrition, and encephalopathy (disease of the brain). The 10/2/2024 Minimum Data Set assessment documented it was a Skilled Nursing Facility Part A Prospective Payment System (a method of reimbursement used by Medicare that pays a predetermined amount for a service) discharge assessment and the resident had a Medicare-covered stay with a start date of 9/4/2024 and an end date of 10/2/2024. The Notice of Medicare Non-Coverage for Centers for Medicare and Medicaid Services-10123 letter documented Resident #141's effective end date of services was 10/2/2024. Business Office Manager #11's handwritten additional information documented the notice was issued over the phone by leaving a message for Resident #141's spouse on 9/30/2024 at 1:05 PM, and the notice was sent by certified mail on 9/30/2024. Business Office Manager #11's handwritten note on the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage Center for Medicare and Medicaid Services-10055 letter documented Resident #141's spouse was contacted on 9/30/2024 at 1:05 PM. There was no documented evidence a United States Postal Service Certified Mail Receipt was sent to the resident's representative. During an interview on 10/29/2024 at 3:40 PM, Business Office Manager #11 stated they did not have the certified letter slips for Residents #27 and #141. The Advanced Beneficiary Notice was not completed for either resident. The Business Office Manager #11 stated they left a message for the representatives to call them back if they had any questions. They did not call back, and Business Office Manager #11 did not follow up with either representative. During a follow up interview on 10/31/2024 at 10:56 AM, Business Office Manager #11 stated the process for issuing the notification was to explain to the resident or resident representative they had the right to appeal, and they would receive a certified letter per the Medicare guidelines. They mailed the Notice of Medicare Non-Coverage and the Advanced Beneficiary Notice of Non-Coverage together via certified mail. Resident #27's representative was left a message on their machine; they never spoke with them regarding options for the resident. Resident #141's representative was spoken to on the phone, no options were selected, and they should have been. It was important to notify the resident and representative of the change in payor source. It was important to ensure the resident or representative had all their options and knew how to move forward. During an interview on 10/31/2024 at 12:01 PM, Resident #27's representative stated they never received a certified letter from the facility. The facility did not explain the ability to appeal the Medicare non-coverage of services. They were told to bring in as many financial records as they could, and the resident was automatically transitioned to private pay. During an interview on 10/31/2024 at 12:50 PM, Resident #141's spouse stated they never received a certified letter from the facility. The facility requested they bring in financial records for the resident. They were not given any options and did not know they could appeal the determination. They stated they would have appealed the decision if they knew they could. 10 NYCRR 483.10 (g) (18)

Based on observations, record review. and interviews during the recertification and abbreviated (NY00355520 and NY00332658) surveys, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 1 of 10 residents (Resident #9) reviewed. Specifically, Resident #9 was not shaved and dressed as care planned. Findings include: The facility policy, Activities of Daily Living, revised 6/2021, documented staff would assist and encourage all residents to their highest practicable level of independence and provide the necessary support in all activities of daily living functioning. Activities of daily living would be completed daily by the resident with the assistance of the facility resident care staff as needed. If a resident resisted or refused care the nurse would be notified and they would document in the progress notes of the resident's chart. Resident #9 had diagnoses including muscle weakness and need for assistance with personal care. The 9/21/2024 Minimum Data Set assessment documented the resident was cognitively intact, able to make their needs known, and required partial to moderate assistance of one for upper and lower body dressing and personal hygiene. The 10/30/2024 Comprehensive Care Plan documented under the topic of Activities of Daily Living/Mobility the resident required partial to moderate assistance of one for upper and lower body dressing and for personal hygiene, including shaving. The 10/2024 certified nurse aide tasks documented the resident's last shower was on 10/24/2024 and they had a bed bath on 10/29/2024. The resident was observed: - on 10/28/2024 at 1:17 PM, sitting in their chair wearing a hospital gown that had dried food on it. - on 10/30/2024 at 1:37 PM, sitting in their chair wearing a hospital gown. - on 10/30/2024 at 4:21 PM, lying in their bed wearing a hospital gown. They stated they would like to be dressed in street clothes, but they had no clothes. They stated even though they had a beard they would like to be shaved and have a mustache. Staff usually shaved them but did not last night and they were not sure why. During an interview on 10/31/2024 at 7:27 AM Certified Nurse Aide #24 stated Resident #9 was cognizant, their shower day was on Tuesdays, and they did not refuse care. Showers included shaving. The resident did not have a lot of clothes and they had gone to clothing donation and brought in clothes for the resident. The resident got a bed bath on 10/29/2024 but they were not shaved. They should have asked the Unit Manager to shave the resident but did not. During an interview on 10/31/2024 at 7:49 AM Licensed Practical Nurse #9 stated when the certified nurse aides gave showers, they also shaved residents. If a resident did not get shaved or showered it could make them feel neglected and embarrassed. During an interview on 10/31/2024 at 8:00 AM Licensed Practical Nurse Unit Manager #3 stated Resident #9 did a lot of their own care. They were always in a gown, and they did not know why. Residents should be shaved on their shower day or any day if requested. If a resident was wearing a hospital gown all the time and not shaved it could make them feel depressed, sad, and decrease their self-worth. During an interview on 10/31/24 at 11:08 AM the Director of Nursing stated they expected residents that wanted to be shaved or stay in a hospital gown to have it documented in their care plan. They expected residents who wanted to be dressed to be dressed. Any staff could get clothes for a resident. Resident #9's care plan did not document they preferred to be in a gown or not shaved. Wearing a hospital gown or not being shaved was a dignity issue and could make the resident embarrassed and not want to leave their room. 10NYCRR 415.12(a)(3)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00355520, NY00352718, NY00351721, and NY00320653) surveys conducted 10/28/2024-10/31/2024 the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 2 of 4 residents (Resident #3 and #8) reviewed. Specially, Resident #3 was administered the wrong dose of rapid-acting insulin and Resident # 8 did not have their oxygen tubing or humidifier bottle regularly changed. Findings include: The undated facility policy, Insulin Administration and Sliding Scale Management, documented blood glucose levels obtained via fingerstick were done at intervals specified by the primary care provider note. This was done to assess and monitor blood glucose levels of residents with hypoglycemia and those with diabetes mellitus to facilitate prompt and/or continued treatment of diabetic residents. Insulin was administered as ordered by the primary care provider and both finger stick results and the administration site were documented in the electronic medication administration record. The facility policy, Medication Administration, revised 6/2021, documented medications were administered by a registered nurse or licensed practical nurse in a way that ensured the residents safety and documented in the electronic medical record. Medications were administered at the right time, to the right resident, using the right dose, the right medication, and the right route. The facility was unable to provide a policy regarding oxygen use. 1) Resident #3 had diagnoses including chronic obstructive pulmonary disease (lung disease), anxiety, and diabetes. The 10/2/2024 Minimum Data Set assessment documented the resident had intact cognition, was dependent on staff for most activities of daily living and received insulin every day for the last seven days. The Comprehensive Care Plan initiated 2/9/2023 documented the resident had diabetes mellitus and underlying kidney complications. Interventions included monitoring blood sugars, administering insulin, and monitoring for signs of hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar). The 10/17/2024 medical order entered by Nurse Practitioner #22 documented finger sticks every day before meals and at bedtime and administration of Fiasp (insulin aspart, rapid-acting insulin) 100 units/milliliter in 3 milliliter pen injector subcutaneous with the sliding scale (amount of insulin administered was based on finger stick blood sugar results): - For a blood sugar of 201-250 milligrams/deciliter, give 8 units of insulin aspart. - For a blood sugar of 251-300 milligrams/deciliter, give 10 units of insulin aspart. During an initial screening and interview with Resident #3 on 10/28/2024 at 11:37 AM, Licensed Practical Nurse #23 entered the room to administer the resident's insulin. Licensed Practical Nurse #23 administered 10 units of Fiasp (insulin aspart) 100 units/ml in Resident #3's right arm for a blood sugar of 228 milligrams/deciliter. Licensed Practical Nurse #23 showed the surveyor the insulin pen set at 10 units. The 10/28/2024 Medication Administration Record documented Licensed Practical Nurse #23 administered 8 units of Fiasp (insulin aspart) 100 units/milliliter in the resident's right abdomen for the 11:30 AM finger stick result of 228 milligrams/deciliter. During an interview on 10/31/2024 at 8:38 AM, Licensed Practical Nurse #23 stated they were responsible for administration of medications when the units were short staffed, and they administered medications to Resident #3 on 10/28/2024. After they administered insulin, they documented the dose of insulin and the site of administration in the electronic record. They stated they administered 10 units of insulin in the right arm to Resident #3 on 10/28/2024 for a blood sugar of 228 milligrams/deciliter. If they documented 8 units of insulin in the abdomen on 10/28/2024, that was inaccurate and would be a documentation error, because that was not what they administered. If someone documented the wrong dose or site of insulin administration that would be a safety concern for the resident. During an interview on 10/31/2024 at 9:01 AM, Nurse Practitioner #22 stated when they ordered a sliding insulin scale for a resident with diabetes, they expected it to be followed. If a resident received a higher dose of insulin than was ordered the resident could become hypoglycemic (low blood sugar). They were not notified that Resident #3 received the wrong dose of insulin and should have been notified. During an interview on 10/31/2024 at 11:08 AM, the Director of Nursing stated if a resident had an order for 8 units of insulin, they expected 8 units of insulin to be administered. If a resident was prescribed 8 units of insulin and administered 10 units, it was a medication error, and the resident could have a low blood sugar. They expected all medications to be documented accurately. If insulin was administered in the arm the documentation should not say abdomen. 2) Resident #8 had diagnoses including chronic obstructive pulmonary disease (lung disease), chronic respiratory failure, and pneumonia. The 8/7/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, required assistance of one for most activities of daily living, and received continuous oxygen therapy. Resident #8 did not have a Comprehensive Care Plan related to respiratory diagnoses, oxygenation. and supplemental oxygen use. A 3/25/2024 medical order by Nurse Practitioner #22 documented oxygen therapy of 1 liter per minute via nasal cannula, every day, on every shift, with oxygen saturation maintained greater than 92%, change oxygen tubing every and humidifier bottle weekly on Wednesday. The order was discontinued on 5/7/2024 with attempt to use room air. The 5/10/2024 medical order by Nurse Practitioner #22 documented oxygen therapy of 1 liter per minute via nasal cannula, every day, on every shift, with oxygen saturation maintained greater than 88%. The order did not include changing of oxygen tubing or humidifier bottle. During an observation on 10/28/2024 at 11:27 AM, Resident #8 was in bed utilizing supplemental oxygen at 1 liter per minute via nasal cannula. The humidification canister was dated 9/2/2024 and had minimal water at the bottom of the canister that did not completely cover the bottom. The resident's oxygen delivery tubing was not dated. The 10/28/2024 progress note by Nurse Practitioner #22 documented Resident #8 was assessed for increasing shortness of breath, not being able to catch their breath, and not feeling well. Crackles were heard in the left lower right lung and diminished lung sounds in the upper and lower right and left lung. The resident was diagnosed with acute pneumonia. The 10/2024 Medication and Treatment Administration Record documented oxygen therapy at 1 liter per minute via nasal cannula, there was no documented evidence the oxygen tubing or humidifier bottle were changed. During an observation on 10/30/2024 at 1:23 PM, Resident #8 was in bed utilizing supplemental oxygen at 1 liter per minute via nasal cannula, the oxygen delivery tubing was not dated. During an interview on 10/31/2024 at 7:49 AM, Licensed Practical Nurse #9 stated it was the nurse's responsibility to monitor oxygen. They made sure oxygen was on the right setting, the humidification canister had water in it, and the tubing and humidifier bottles were labeled. This was documented every shift on the medication administration record. It was the night shift nurse's responsibility to check and change the oxygen delivery tubing and humidification canister weekly and document on the medication administration record. They stated if the humidification canister was dated 9/2/2024 on 10/28/2024, it was not changed weekly as ordered. If there was no order, it would not be on the Medication Administration Record, and staff would have no way of knowing the tubing and canister required changing. If the tubing and canister were not changed weekly residents could get sick and get a respiratory infection. Licensed Practical Nurse #9 stated Resident #8 was on oxygen and was diagnosed with pneumonia on 10/28/2024. During an interview on 10/31/2024 at 8:00 AM, Licensed Practical Nurse #3 stated all nursing staff monitored oxygen. When a provider ordered oxygen, there was an oxygen template nurses used to ensure that along with the order for oxygen therapy there was an order for the humidification bottle and tubing to be changed and dated weekly. This was done weekly on the night shift for the safety of residents and to prevent infections. If the order was not placed properly, the humidification bottle and tubing would not be changed weekly, and residents could get an infection. Resident #8 should not have had a nearly empty humidification canister labeled 9/2/2024 on 10/28/2024. They were diagnosed with a respiratory infection on 10/28/2024. During an interview on 10/31/2024 at 8:38 AM, Licensed Practical Nurse #23 stated on 10/28/2024 they were notified by Licensed Practical Nurse #28 Resident #8 was having difficulty breathing. They were shown a hole in the humidification canister and changed the canister and dated it. If the humidification canister was not labeled properly or does not have water, residents could be short of breath and get sick. During an interview on 10/31/2024 at 9:01 AM, Nurse Practitioner #22 stated oxygen was maintained by nursing staff with the humidification canister and tubing changed weekly for infection control reasons. Resident #8 wore oxygen and was diagnosed with pneumonia on 10/28/2024. Having outdated and empty humidification canister could contribute to the development of pneumonia. During an interview on 10/31/2024 at 11:08 AM, the Director of Nursing stated oxygen tubing and humidification canisters were changed weekly and labeled. If the oxygen order was not put in properly, it would not populate to the treatment administration record and would not get completed. If the oxygen tubing and canister was not changed weekly a resident could inhale bacteria in their lungs that could cause infection. A resident should not have an oxygen humidification canister dated 9/2/2024 when it was 10/28/2024. 10 NYCRR 415.12

Based on observations, record review, and interviews during the recertification survey conducted 10/28/2024-10/31/2024, the facility did not ensure each resident received food and drink that was palatable, attractive, and at a safe and appetizing temperature for 2 of 2 meal test trays reviewed (10/29/2024 and 10/30/2024 lunch meals). Specifically, food was not served at palatable and appetizing temperatures during the lunch meals on 10/29/2024 and 10/30/2024. Additionally, Residents #18 and #85 stated the food was not flavorful and was cold. Findings include: The facility policy, Food Temperature and Test Tray Audits, revised 4/5/2024 documented test trays would be audited periodically to ensure that food temperatures, food quality, and the overall dining experience was at optimal levels. Minimum temperatures at the time of service were defined as: - Soups, hot entrees, starches, and hot vegetables served greater than 135 degrees Fahrenheit; - Cold beverages, cold desserts (such as pudding and gelatin), and cold entrees served less than 55 degrees Fahrenheit; - Milk and milk products served less than 45 degrees Fahrenheit; and - Hot beverages served greater than 140 degrees Fahrenheit. During an interview on 10/28/2024 at 11:08 AM, Resident #18 stated the food was not good and was not hot. During an interview on 10/28/2024 at 12:20 PM, Resident #85 stated they got their meal trays last, and the food was cold and lacked flavor. During a Third Floor meal observation on 10/29/2024 at 12:50 PM, Resident #18 was served their lunch meal tray. A replacement tray was ordered, and Resident #18's original meal tray was tested . The fried chicken was measured at 129.2 degrees Fahrenheit, the yogurt was 54.5 degrees Fahrenheit, and the cooked carrots were 134.4 degrees Fahrenheit. During an interview on 10/29/2024 at 1:12 PM, Certified Nurse Aide #36 stated Resident #18 usually got their tray last, and their tray was on top of the hot cart and not inside. They delivered the trays on top of the cart first, so they did not get cold. They often heard residents complain about the food being too cold, undercooked, and having no flavor. If the residents did not like the food, they offered them an alternative. The kitchen was short staffed and asked the nursing staff to go down to the kitchen to get the alternative food, but they could not leave the unit because they had other residents to care for. During an interview on 10/29/2024 at 1:57 PM, Certified Nurse Aide #21 stated that residents complained the food did not look or smell good. During a Third Floor meal observation on 10/30/24 at 1:27 PM, the second meal cart arrived on the unit. At 1:31 PM, Resident #85 was served their lunch meal tray. A replacement tray was ordered, and Resident #85's original meal tray was tested . The broccoli was measured at 132.1 degrees Fahrenheit, the pineapple was 47.3 degrees Fahrenheit, the cold water was 59.2 degrees Fahrenheit, and the milk was 52.7 degrees Fahrenheit. During an interview on 10/31/2024 at 9:38 AM, the Assistant Food Service Director stated hot food should be served hot, 180 degrees Fahrenheit coming from the tray line and held above 165 degrees Fahrenheit when served to the residents. Cold food should be cold, 40 degrees Fahrenheit or below when served to the residents. Food should be enjoyable and palatable, so the residents would eat it. The enjoyment of eating starts with the eyes and the appearance of the food. The Assistant Food Service Director stated the broccoli at 132 degrees Fahrenheit was an appropriate temperature; the pineapple at 47.3 degrees Fahrenheit, cold water at 59.2 degrees Fahrenheit, and milk at 52.7 degrees Fahrenheit were all high. The best range for hot food was 130-145 degrees Fahrenheit. They stated the ovens did not always work and heat evenly and had been that way for a couple of years. The maintenance team had worked on the ovens numerous times, but they were old. The Director of Maintenance and Administrator were both aware of the problems with the ovens. 10NYCRR 415.14(d)(1)(2)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00320653 and NY00351721) surveys conducted 10/28/2024-10/31/2024, the facility did not establish and maintain 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 1 staff member (Social Worker #5) and 1 resident (Resident #160) observed. Specifically, Social Worker #5 entered a COVID-19 positive room wearing an N95 mask inappropriately and Resident #160 did not have appropriate transmission-based precautions signage in place. Findings included: The facility policy, Infection Prevention and Control Program, revised 2/2021, documented the program was intended to prevent the transmission of communicable diseases and infections. Prevention of infection included implementing appropriate isolation precautions when necessary and following guidelines such as those of the Centers for Disease Control. Those with potential direct exposure to blood or bodily fluids were required to use appropriate precautions and personal protective equipment. The facility policy, Isolation- Categories of Transmission-Based Precautions, revised 2/2021, documented the 3 types of transmission-based precautions were contact, droplet, and airborne. Any resident on contact precautions required staff to wear a disposable gown and gloves upon entering the room and before leaving the room. The policy did not specifically document enhanced barrier precautions. The facility policy, COVID-19 Action Plan, revised 6/7/2024, documented health care providers entering a COVID-19 positive resident room should wear a N95 mask. 1) Resident #148 had diagnoses including COVID-19 and dementia. The 7/30/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, was independent with ambulation and bed movement, and required moderate to maximum assistance with dressing and hygiene. The 10/21/2024 Licensed Practical Nurse Manager #6 progress note documented unit wide COVID-19 testing was done, and Resident #148 had positive results. Isolation precautions were in place. The 10/21/2024 physician order documented isolation precautions, contact precautions, COVID-19 precautions, and droplet precautions. The 10/21/2024 Comprehensive Care Plan documented the resident had COVID-19. Interventions included obtain cart with personal protective equipment, contact and droplet isolation precautions, and post a sign on the doorway. A 10/28/2024 Licensed Practical Nurse Unit Manager #6 progress note documented Resident #148 was on contact/droplet isolation precautions. During an observation and interview on 10/28/2024 at 11:00 AM, Licensed Practical Nurse Unit Manager #6 stated Resident #148 tested positive for COVID-19 and was on droplet precautions. During the interview, Social Worker #5 was observed wearing a surgical mask covering their nose and mouth and a N95 mask over the surgical mask. Social Worker #5 donned a gown and gloves and entered Resident #148's room with N95 mask over the surgical mask. The resident's doorway had a sign that the resident was on droplet precautions. The 10/21/2024 Social Worker #5 general orientation schedule and sign off documented they received N95 Fit testing (ensuring proper mask and fitting) and donning/doffing of personal protective equipment with N95 competency on day 2 of orientation. The undated Donning and Doffing Personal Protective Equipment with N95 Competency, signed by Social Worker #5, documented they correctly fit the N95 snugly to their face. During an interview on 10/30/2024 at 4:26 PM, Certified Nurse Aide #7 stated all staff were supposed to wear a N95 mask on the unit as there were COVID-19 positive residents who wandered on the unit. The N95 mask was worn to prevent staff and other residents from getting sick. The N95 was to be worn against the face with a surgical mask over it to ensure a good seal against the face thereby not allowing germs to seep through the mask. During an interview on 10/30/2024 at 4:34 PM, Licensed Practical Nurse Manager #6 stated facility policy was for staff to wear a N95 at all times on the unit. The purpose of the N95 mask was to create a tight seal against the face so germs could not get through to the mouth and nose. All unit staff were educated on the proper wearing of N95 masks around 10/21/2024. A surgical mask may be worn over the N95. If the surgical mask was worn between the face and the N95 mask, a tight seal could not be maintained. During an interview on 10/30/2024 at 4:49 PM, Infection Control Nurse #8 stated staff were supposed to wear a N95 mask at all times on the dementia unit as there were COVID-19 positive residents that wandered the halls without a mask on. Staff were educated during orientation, yearly, and as needed. The N95 mask was to be worn tightly against the face to prevent germs from seeping through to the wearer's nose and mouth and prevent inhaling the germs. Wearing a surgical mask between the N95 and the face would not allow a tight seal. All staff were recently educated on proper N95 wearing. Informal audits were being done, there had been staff that were not wearing masks correctly, and reeducation was done on the spot. There was signage on the entry doors to the unit about N95 mask wearing. During an interview on 10/30/2024 at 5:00 PM, the Director of Nursing stated staff were expected to follow the COVID-19 outbreak action plan, which included wearing a N95 mask correctly. The N95 was to be worn against the face to maintain a tight seal to prevent germs from entering the nose and mouth. A surgical mask could be worn over the N95. All staff were recently educated on proper N95 mask wearing. During an interview on 10/31/2024 at 10:06 AM, Social Worker #5 stated they started working at the facility about 3 weeks ago and was educated on proper N95 mask wear during orientation. The N95 was to be put on prior to entering the unit. The N95 was to be worn against the face for a tight seal to prevent pathogens from being inhaled via the nose or mouth. The social worker stated they made a mistake of having the surgical mask between the face and N95 mask prior to entering Resident #148's room. 2) Resident #160 had diagnoses including skin abscess of the buttocks and pressure ulcer of the back, buttock, and hip. The 10/25/2024 Minimum Data Set assessment documented the resident was cognitively intact, was totally dependent for most activities of daily living, was frequently incontinent of bowel and bladder, had a Stage 3 (full thickness tissue loss) pressure ulcer, a surgical wound, an intravenous line for fluids, and received an antibiotic. The 10/23/2024 physician order documented enhanced barrier isolation precautions due to intravenous line and open wounds. The 10/30/2024 Comprehensive Care Plan documented the resident had a Stage 3 pressure ulcer on the left gluteal (buttocks) region, a surgical wound on the right gluteal region, required total dependency with most activities of daily, was incontinent of bowel and bladder, and had open wounds. Interventions included enhanced barrier precautions and post sign on door, check and change every 2 hours, 2 staff assistance with rolling/shower/bathe, monitor wound and dressing, turn and position every 2 hours, and incontinence care after each episode. The 10/30/2024 Licensed Practical Nurse Manager #17 progress note documented Resident #160 had a room change. During an observation on 10/31/2024 at 10:30 AM, there was no sign posted near the entrance to Resident #160's room indicating enhance barrier precautions were in effect. Resident #160 was lying in bed. There were two unidentified certified nurse aides changing the resident's incontinence briefs and performing incontinence care. The certified nurse aides were not wearing gowns or gloves. During an interview on 10/31/2024 at 10:41 AM, Licensed Practical Nurse #19 stated Resident #160 was on enhanced barrier precautions for open wounds. There should be a sign on the doorway, identifying the resident was on contact precautions and staff were to wear a gown and gloves when in the room and performing care. The purpose was to prevent contamination from the wound and potentially spreading an infection to another resident. The resident was moved from another room on 10/30/2024 and their current room did not have signage posted. During an interview on 10/31/2024 at 10:51 AM, Registered Nurse Manager #20 stated the resident had open wounds and was on isolation precautions. There should be signage on the doorway indicating what type of precautions the resident was on and the personal protective equipment required by staff. The risk of not wearing the equipment was spreading infection to the staff member or to another resident. During an interview on 10/31/2024 at 11:08 AM, the Director of Nursing stated if a resident was on enhanced barrier precautions, signage was to be placed on the doorway to communicate to staff what personal protective equipment was required to be worn. If a resident was moved to a different room, the signage should be placed on the doorway to the new room. They stated the resident's room had no signage on the doorway and there should be. 10 NYCRR 415.19(a)(b) 48446

Based on observation, record review, and interview during the recertification and abbreviated (NY 623) surveys conducted 11/15/22 -11/21/22, the facility failed to provide a safe, clean, comfortable, and homelike environment for 2 of 4 nursing units (Units 3 and 2A), 12 resident rooms (Resident rooms 200, 202, 203, 204, 206, 210, 211, 214, 215, 216, 306, and 312), for 6 resident common areas (3rd floor shower room, 2A hallways, 3rd floor main elevator and elevator bank, 3rd floor soiled utility room, and 1st floor TV room common bathroom). Specifically, there were unclean/damaged floor and walls on resident nursing units, and in resident rooms and common areas. Findings include: Unclean/damaged areas: On 11/15/22 the following observations were made: - at 12:15 PM, in the 3rd floor shower room the floors and wall tiles under the shower controls were unclean and soiled. - at 3:07 PM, in resident room 200 there was paint chipped and missing from the door frame, unclean dirt build up in the threshold, and a 3-foot long scuff mark on the floor between both resident beds. - at 3:10 PM, there were unclean and soiled door thresholds in resident rooms 202, 203, 204, 210, 211, 214, 216 - at 3:16 PM, the closet by resident room 206 had multiple areas of missing paint and the wall next to the room was missing paint and plaster with flaking paint around it. - at 3:20 PM, in resident room 215 there was dried grayish/brown smears on floor near the door side bed. - at 3:28 PM, multiple areas throughout all hallways of Unit 2A had chipped paint areas and black scuffed doors and wall below the handrails. - at 5:02 PM, the main elevator floors were unclean with sticky residue. There was a soiled sticky area next to the elevator buttons on the 3rd floor elevator bank. - at 5:04 PM, in resident room 306 the floors were stained, discolored (black/gray) and sticky. - at 5:13 PM, the doorway threshold to resident room 312 was soiled and unclean. - at 5:18 PM, the 3rd floor soiled utility room had pink spills on the left side of the door frame. During an interview on 11/15/22 at 5:04 PM, Resident #50 stated their floor was not getting cleaned. During an observation on 11/16/22 at 9:49 AM, there was a broken toilet bowl tank lid within the common bathroom off the 1st floor TV room. Specifically, the tank lid had a sheared off 1/3 of the lid at a sharp angle. When interviewed on 11/16/22 at 9:49 AM, the Assistant Director of Maintenance stated they did not know about the sheared toilet tank lid. There was no work order, and they were unsure when it happened. It needed to be replaced as it could be dangerous for residents. During an observation on 11/18/22 at 9:50 AM, there were soiled and unclean floors with visible old dark spills within resident room 312 and in the adjacent corridor had dribbled food spillage on the floor. During an interview on 11/17/22 at 12:22 PM, the Director of Housekeeping stated housekeeping staff cleaned units daily. They had task check off sheets for each unit that were filled out and submitted at the end of day. Resident #50's room had been difficult to get the floors cleaned for a while now. The resident did not come out of their bed or room so that the floors could be cleaned properly which included having the floors stripped and waxed. It had been proposed to clean the floors up to the resident's bed then move the bed and clean the rest. The resident did not want to be moved and had issue with the smell of the stripping and waxing. The floors should not look the way they did and stripping and waxing the floors would be the only way to get the gray staining up and protected again. There should be no sticky or unclean areas on the units and housekeeping staff should be cleaning all units. Unit 3 used to be the memory care unit and was more of a challenge to get clean. During an interview on 11/18/22 at 1:25 PM, Laundry Supervisor #8 stated they were also a housekeeper on all units. Resident #50 did not let their floors get cleaned. The floors needed to be stripped and waxed. When the resident used to do therapy there was a short timeframe for housekeeping to get into the room to have the floors stripped and waxed. Unit 3 had been more of a problem with grime and spills on the unit. There was a dedicated employee for stripping and waxing of floors. They had a schedule for the whole month usually floor by floor and 2 rooms per day. Some of the room's floors really needed to be stripped and waxed. When residents did not come out of their rooms anymore, to even eat meals, it was difficult to get everything moved and cleaned properly. Residents should have clean and dust free areas to live in. Maintenance put non-slip strips on the floors for residents and housekeeping should be responsible for cleaning them. A work order could be put in for maintenance if the floor strips were coming up or become a hazard. 10 NYCRR 415.29(j)(1)

Based on observation, record review and interview during the recertification survey conducted 11/15/22-11/21/22, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality for 1 of 2 residents (Resident #6) reviewed. Specifically, Resident # 6 had duct tape wrapped on the arm of their wheelchair for 5 days of survey. Findings included: The undated facility policy, Quality of Life-Dignity documented cognitively impaired residents were to always be treated with dignity and respect to maintain their self-worth and self-esteem, keep the resident informed and oriented to their environment, and demeaning practices and standards of care that compromise dignity were prohibited. The facility policy Work Orders dated 11/1/21 documented the goal was to complete work item orders as soon as possible using the electronic REQQER (maintenance work order) program connected to all maintenance staff phones. Staff in all departments were educated on how to submit work orders. All work order requests would be addressed within 24 hours and completed as soon as possible. Resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/1/22 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, required limited assistance of 1 with transfers, was independent with locomotion on the unit, and used a wheelchair. The 11/17/22 revised comprehensive care plan (CCP) documented the resident required assistance with activities of daily living (ADLs) and used a wheelchair. Resident #6's wheelchair was observed with silver duct tape covering the padding of both the left and right arm rests and the left side arm rest duct tape was worn with no padding on the arm rest on: - 11/15/22 at 12:36 PM the resident was lying in bed with the wheelchair at the bedside; - 11/16/22 at 9:41 AM the resident was sitting in the wheelchair; - 11/17/22 at 8:46 AM the resident was lying in bed with the wheelchair at the bedside; - 11/18/22 at 11:04 AM the resident was wheeling themself down the unit hallway; and - 11/21/22 at 11:24 AM the resident was lying in bed with the wheelchair at the bedside. When interviewed on 11/15/22 at 12:36 PM, the resident stated the duct tape bothered them and made their arms itch. The resident stated the arm rests were too thin, especially in the front of the arm rests. When interviewed on 11/21/22 at 12:10 PM, occupational therapist (OT) #9 stated if therapy could not fix a piece of broken equipment, they would contact maintenance. Wheelchair arm rests could be duct taped but appeared tacky looking and would best be replaced. Any staff member was able to send a maintenance request via the computer system. The OT did not submit a work order on the wheelchair arm rests as they did not notice the duct tape when working with the resident last on 11/11/22. The resident did not inform the OT that the arm rests bothered them. When interviewed on 11/21/22 at 12:28 PM, the Director of Therapy stated unit nursing staff cared for the resident daily, should have been the first to notice the condition of the arm rests, and could have submitted a work order to have them replaced. The duct taped arm rests were a dignity issue for the resident and possibly a safety issue depending on what was under the duct tape. The arm rests were not in that condition when the wheelchair was issued to the resident by the therapy department and should have been replaced. They were not aware of who put duct tape on the arm rests. When interviewed on 11/21/22 at 1:50 PM, the Director of Maintenance stated wheelchair arm rest repairs/replacement could be requested by any staff member via the computer system. Options were to either put a new arm on the wheelchair or just replace the arm rests. Maintenance had extra arm rests. They stated the unit certified nurse aides (CNAs) were supposed to wash the wheelchairs nightly if dirty, saw the resident daily, and should have submitted a work order to replace the arm rests. No work order was submitted. The director stated there had been an issue getting unit staff to submit work orders for things that needed repairs. When interviewed on 11/21/22 at 1:54 PM, licensed practical nurse (LPN) #10 stated maintenance issues were to be submitted via the computer. The duct tape was a dignity and appearance issue as they were not presentable to the resident and others. The arm rests should have been replaced and not duct taped as they could still be broken and could pose a safety hazard. The arm rests should have been replaced within 2 days of being in disrepair. The LPN had not noticed the arm rests were duct taped. The LPN stated the night shift CNAs washed each wheelchair on a weekly basis and should have noticed the arm rests needed replacing. When interviewed on 11/21/22 at 4:08 PM, the Director of Nursing (DON) stated if staff felt a wheelchair was unsafe, it should be immediately taken out of service. The DON expected unit staff to notify therapy and/or place a work order if they noticed torn wheelchair arm rests. It was expected the arm rest be replaced within 2-4 days, even if the area was covered with duct tape. Wheelchairs were washed weekly by night shift unit staff on the resident's assigned bath day, and the resident's duct taped arm rests should have been noticed. Any staff member was able to place a maintenance work order. 10NYCRR 415.3(c)(1)(i)

Based on observation, record review and interview during the recertification survey conducted 11/15/22-11/21/22, the facility failed to ensure the resident has the right to and the facility must make prompt efforts to resolve grievances the resident may have for 1 of 1 resident (Resident #40) reviewed. Specifically, Resident # 40 had seven (7) pairs of sweatpants misplaced in the laundry and they were not recovered or replaced. The facility policy, Lost and Missing Items dated 8/2020 documented when a resident, resident representative, or any person reports a lost or missing item to staff, the social worker will be contacted immediately. The social worker will start a Lost/Missing Item Report and email it to the registered nurse (RN) Unit Manager or designee, Housekeeping Supervisor, other departments (only as necessary), and the Administrator. The RN Unit Manager would search the resident's room, unit utility rooms, and other appropriate areas on the unit. The Housekeeping Supervisor would search laundry and other appropriate areas. Resident #40 had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An 11/4/2021 missing items form for Resident #40 documented 7 missing handkerchiefs. They were unable to be located in the resident's room or the laundry. The facility would replace the handkerchiefs. The form was signed by the Director of Social Services and the Administrator and did not include missing sweatpants. During an interview on 11/15/22 at 12:27 pm, Resident #40 stated that they kept losing pants, and their spouse had to keep buying them new pairs. Their spouse had bought 7 pairs of sweatpants and now they were down to only 2 pairs of sweatpants. The resident stated they had told staff about the missing pants but could not remember who. The resident was observed on 11/16/22 at 3:52 pm lying in bed watching TV. The resident stated they had not received any new laundry. Two pairs of sweatpants (1 blue and1 gray) were observed in their wardrobe closet. The resident stated their pants were their old sweatpants, and the new pants were missing. During an interview on 11/16/22 at 4:30 pm, certified nurse aide (CNA) #23 stated that the Unit 1 laundry process was to put the resident's dirty clothes into a clear plastic bag and place it into a yellow bin housed in the soiled utility room. At the end of the shift, housekeeping on the day shift and/or CNAs on the evening/night shift removed the yellow bins, pushed them to the laundry room, and emptied the resident's soiled laundry into the red bins. CNA #23 stated the red bins were labeled 1-4, one for each unit in the building. CNA #23 stated that clothes often get mixed up on the dementia unit and that laundry was responsible for returning the resident's personal laundry to their rooms once cleaned. During an interview on 11/17/22 at 11:10 AM with CNA #4, they stated there were a lot of resident's personal clothing items missing, they were mostly pants that were missing and it was possible that personal laundry items got mixed up with the soiled linens or were thrown away. They stated they were not aware if Resident #40 was missing clothing, but the resident usually told social worker # 7 if they were missing items. During an interview on 11/17/22 at 12:22 pm, Laundry Supervisor #8 stated they were aware of resident's personal items being misplaced and stated they were not sure if the nurses were mixing them in with soiled linens or what caused the items to go missing. Laundry Supervisor #8 stated that an outside company laundered the soiled sheets, towels, and washcloths and that 55 pounds of residents' personal clothing items was returned to the facility that was found mixed in with the linens. Laundry Supervisor #8 stated when the personal clothing gets returned, they waited 60 days for the clothing to be claimed and if they were not claimed, the clothing was placed on a lost and found/donation rack for anyone to take. During an interview on 11/17/22 at 12:22 PM, the Director of Housekeeping stated the facility only laundered residents' personal clothes. All linens and towels were sent out to a laundry vendor. Resident laundry was placed in red barrels on each floor to then be taken to the laundry area. Each floor had a specific laundry barrel and was not mixed or washed with other floors laundry. All resident clothing should be labeled. If they came across a piece of clothing that was not labeled, nursing staff would help identify the resident who owns the clothing. When clothes are unaccounted for there was a rack in the laundry area for unlabeled clothes. Each week they would bring that rack around to all units. There were missing items reports that were filled out any time a resident was missing anything personal including clothes. There were resident inventory sheets used when family members dropped off clothes and laundry staff would record and label those items for a resident. There had been personal clothing found that went to the linen laundry vendor. During a second interview with Laundry Supervisor #8 on 11/18/22 at 11:12 AM, they stated they were familiar with Resident #40 and knew the resident was missing some pants and only had old pairs now. The Laundry Supervisor stated they had looked for them and could not find them. Laundry Supervisor #8 stated that the resident filled out a missing items form, and the process was to send the form to Administration, then to social work, nursing, the CNAs and back to the Laundry Supervisor. Laundry Supervisor #8 stated the forms would be missing at times. Last week there missing items forms from the 3rd floor that went missing and the residents were upset. During a follow-up interview on 11/18/22 at 1:25 PM, Laundry Supervisor #8 stated they have seen residents' personal clothes getting mixed in with linens that went out to the vendor to be laundered. When beds and linens were changed any clothes or personal items should be pulled out and separated prior to putting the linens in the laundry containers. The lost and found racks were brought onto the units once a week. After 60 days any unclaimed items become extra clothes or donations. During an interview on 11/21/22 at 11:53 AM with social worker #7, they stated that they were aware that Resident #40 had missing handkerchiefs and some pants, and they thought they were replaced at the beginning of the year. The missing items form was signed by the Administrator and the social worker, and that they could not recall if they made a copy of the report. There was no documentation a missing item report had been completed for the resident's missing pants. 10NYCRR 415.3(c)(1)(i)

Based on record review and interview during the recertification survey conducted 11/15/22-11/21/22, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and timeframes to meet a resident's medical and nursing needs for 1 of 1 resident (Resident #16) reviewed. Specifically, Resident #16's comprehensive care plan (CCP) did include anticoagulant (blood thinner) use. Findings include: Resident #16 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/2/22 Minimum Data Set (MDS) assessment documented the resident had intact cognition, had 1 fall with injury since the previous assessment, and received an anticoagulant for the past 7 days. The 7/6/22 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/6/22 physician assistant (PA) #30 documented the resident's medication list included [MEDICATION(S)] ([MEDICATION(S)]) 5 mg twice daily. The plan included to continue with all current medications. Quality measure documentation measures included the resident had coronary artery disease and was prescribed aspirin or [MEDICATION(S)] ([MEDICATION(S)], a blood thinner). The CCP did not include the use of an anticoagulant and the risk for bleeding. On 7/12/22 nurse practitioner (NP) #31 documented the resident had an unwitnessed fall and complained of hip pain. The ordered x-ray was negative for fractures. Nursing was to monitor post fall. On 7/25/22 physician #32 documented the resident was seen for a routine visit. The resident required long term use of an anticoagulant due to a left ventricular thrombus (blood clot in the left ventricle of the heart) and would follow up with cardiology as needed. The November 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The revised 11/14/22 the comprehensive care plan (CCP) was updated and documented the resident was at risk for falls related to bilateral below the knee amputations and had a prior unwitnessed fall. Interventions included keeping the bed in a low position, a fall mat to the right side of the bed, and therapy evaluations as needed. The CCP did not include the use of anticoagulants and the increased risk for bleeding. On 11/17/22 at 2:07 PM, the resident was observed in their low bed and a fall mat was on the right side of the bed on the floor. During an interview with registered nurse (RN) Unit Manager #15 on 11/21/22 at 12:55 PM, they stated care plans were updated quarterly, annually, and when there was a significant change with the resident. Care plans were discussed with the interdisciplinary team (IDT). If a resident received medications, such an anticoagulant, it should be listed on their care plan so staff knew to monitor for bruising or bleeding. They were unaware Resident #16 received an anticoagulant medication and their care plan did not reflect the use of the medication. It was the responsibility of the charge nurse to ensure the resident's care plans were up to date. During an interview with the Director of Nursing (DON) on 11/21/22 at 4:51 PM, they stated the facility changed electronic medical record systems in July 2022 and when the transition occurred the CCPs did not merge into the new electronic medical record system. The Unit Managers were to ensure the CCPs were updated and accurate in the new system. The IDT reviewed the resident's CCP on a quarterly, annual, and significant change basis and it was expected that the CCPs would be updated during the review. The resident's CCP should have included they received an anticoagulant, and it was important for staff to know to monitor for bleeding and bruising. 10NYCRR 415.11(c)(2)(ii)

Based on observation, record review, and interview during the recertification and abbreviated (NY 0689 and NY 922) surveys conducted 11/15/22-11/21/22, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 5 of 16 residents (Residents #37, 41, 88, 111, and 121) reviewed. Specifically: - Resident #121 was not provided a shower in 2 months. - Resident #111 was observed wearing the same clothes and was unshaven for 3 days. - Resident #37 did not have a documented shower since 9/2022, was observed with a long beard, and unclean/ stained linens and gowns. - Resident #41 did receive ADL assistance in a timely manner to attend a desired activity program, causing a delay in the activity for the residents in attendance. - Resident # 88 was observed with dirty fingernails. Findings include: The facility policy, Activities of Daily Living (ADLs) reviewed 6/2021 documented ADLs were to be completed daily and included bathing, grooming, mobility, nutritional needs, and toileting and the CNA (certified nurse aide) care cards would provide information relative to the level of assistance needed by the individual. 1) Resident #41 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/18/22 admission Minimum Data Set (MDS) assessment documented the resident felt it was important to do favorite activities. The 8/25/22 MDS documented the resident had intact cognition, required extensive assistance of 1 for bed mobility, transfers, and dressing, and had functional limitation of upper and lower extremity on one side. The comprehensive care plan (CCP) initiated 4/11/22 documented the resident had limited physical mobility related to history of [CONDITION(S)] ([CONDITION(S)], stroke) with left sided and general weakness. Interventions included extensive assistance of 1 for bed mobility, dressing, locomotion on unit, and transfers. The CCP initiated 5/25/22 documented the resident was dependent on staff for meeting social needs related to physical mobility. Interventions included provide assistance/escort to activity functions. The resident preferred activities which did not overly demand cognitive tasks, and engage the resident in simple, structured activities. The 9/15/22 CCP documented the resident had limited activity participation with a goal of encourage resident to attend group programs and participate more actively within activity program. Interventions included encourage interaction with long term and short term rehabilitation residents with similar interests. The undated care card (care instructions) documented the resident required extensive assistance of 1 for dressing, bed mobility, and transfers. The resident activity log for 10/27/22-11/21/22 documented the resident had attended Bingo 5 times. During observations on 11/16/22 at 9:59 AM Resident #41 was observed in bed wearing a hospital gown. The resident stated they wanted to go to Bingo at 10:30 AM and had told the staff 3 days ago. At 10:56 AM the resident's call bell was on, and two unidentified certified nurse aides (CNA) were observed walking past the resident's room. At 10:58 AM CNA #17 entered the resident's room, shut off the call bell, and stated We are coming for you next. They did not start Bingo yet; they are waiting for you. At 11:07 AM an unidentified CNA told the resident they were coming to you next. The resident replied you said that an hour ago. [expletive] this place!. The CNA apologized and told the resident their CNA had to give someone a shower. At 11:11 AM registered nurse (RN) Unit Manager #15 asked the activity staff to wait and hold Bingo until CNA #34 got the resident up. At 11:15 CNA #34 entered the resident's room and at 11:24 AM the resident was brought to the Bingo activity in the dining room. The 11/16/22 ADL care log did not include documentation of care provided to the resident. During an interview on 11/17/22 at 10:25 AM with CNA #19 and CNA #17 they stated they were able to get the resident up daily and the resident never refused. CNA #34 was in late at 10 AM on 11/16/22 and was assigned to get the resident up. They had to get the resident up later, but the resident was still able to go to Bingo. All 40 residents wanted to get up for activities and they had several residents who required assistance of 2 with mechanical lifts. When there were just 2 aides it was difficult to get everyone where they wanted to be on time. During an interview with the Director of Nursing (DON) on 11/21/22 at 4:26 PM they stated resident preferences should be honored and if a resident wanted to go to an activity, they should be up, dressed and at the activity on time. Any nurse or CNA could get the resident up and dressed. Resident #41 should have been up on time for BINGO which was on the schedule for 10:45 AM on 11/16/22. They stated the resident was late getting up because of a Hoyer pad issue. The pads were ordered, and they did not get up to the unit until late morning. During a telephone interview with CNA #34 on 11/21/22 at 4:46 PM they stated they came in at 10:00 AM on 11/16/22 and was giving another resident a shower when the Nurse Manager and the social worker came to tell them to get Resident #41 up for Bingo. The resident was soaked. They were not aware the resident wanted to go to Bingo before being told. Anyone could have provided care to the resident before that. 2) Resident #111 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/26/22 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment and required supervision with set up help for dressing and personal hygiene. Resident # 111 was observed: -On 11/15/22 at 2:54 PM walking in the hallway with facial hair approximately 1/2 inch (in) to 1 in long on their face. The resident was wearing a green shirt with the words [NAME], blue jeans, black sneakers with a neon green logo, and a black baseball cap with a sporting goods company logo. -On 11/16/22 at 9:15 AM walking in the hallway with therapy staff wearing the same clothes as 11/15/22, and facial hair approximately 1/2 in to 1 in long. At 3:49 PM walking in the hall wearing the same clothes with facial hair approximately 1/2 in to 1 in long. -On 11/17/22 at 9:28 AM and 1:46 PM walking in the hallway wearing the same clothes and length of facial hair as 11/15/22 and 11/16/22. The ADL Care Log documented: -On 11/15/22 there was no documentation that ADLs were completed for Resident #111. -On 11/16/22 at 1:00 PM CNA #29 documented personal hygiene was provided with limited assistance and the resident was not shaved. -On 11/17/22 at 11:00 AM CNA #5 documented the resident refused a shower. The 11/16/22 updated comprehensive care plan (CCP) documented the resident's had self-care deficits due to cognitive impairment and required physical assistance of one person with their activities of daily living (ADL's), facial hair removal, and choosing clothes in clean and good repair. There was no CCP for ADLs available before 11/16/22. On 11/17/22 at 5:04 PM the CNA daily routine sheets documented the expectation of the CNAs was to ensure morning bathing was completed by 9:30 AM so the residents could attend activities and therapy. The 11/18/22 care instructions documented Resident #111 required assistance of 1 person with bathing, personal hygiene, shaving, dressing and toileting. During an interview on 11/17/22 at 2:38 pm with CNA #5, they stated Resident #111 was on their assignment sheet, that it was their shower day, and the resident was already dressed when they arrived to work at 9:30 AM. They stated they did not give the resident a shower, the resident did not normally refuse care, and required limited assistance with ADLs. CNA # 5 stated the resident refused their shower that day. CNA #5 did not think it was dignified to be in the same clothes as the previous day or to have facial hair when care planned to be shaved. During an interview on 11/17/22 at 5:04 PM with the Director of Nursing (DON), they stated they had put together a daily routine expectation list for the CNAs regarding resident care and expected them to be followed through daily. The DON stated that they would expect a resident to be bathed or showered after breakfast and if a resident was care planned for shaving, it was expected they be assisted. 3) Resident #121 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/4/22 Minimum Data Set (MDS) assessment documented the resident was cognitively intact and felt that choosing bathing methods was somewhat important. The 8/18/22 MDS documented the resident did not reject care, required supervision with assistance of 1 for personal hygiene, and physical help with transfers only for bathing. The comprehensive care plan (CCP) reviewed 10/20/22 documented the resident had activities of daily living (ADL) deficits and was totally dependent on 2 with toileting, required extensive assistance of 2 with transfers, and assistance of 2 or more with bathing/showering. The 9/1/22 through 11/18/22 care log did not document the resident was provided a shower or bath. The 9/6/22 through 11/18/22 nursing progress notes did not document the resident refused a bath or shower. The undated care instructions documented the resident required physical help of 1 with bathing. The instructions did not include the days showers/baths were to be provided. The resident shower list in the certified nurse aide (CNA) assignment book at the nursing station documented the resident was to receive a bath/shower weekly on Fridays during the day shift. During an observation and interview on 11/15/22 at 1:47 PM, Resident #121 stated they had not received a shower in 2 months. The resident was sitting in a wheelchair in their room wearing a hospital gown. The resident stated they preferred to wear the hospital gown and to wash themselves. They needed staff to wash their hair and had not been to the hairdresser in a long while. The resident's hair was greasy in appearance and was in a ponytail. During an observation on 11/18/22 at 11:04 AM, the resident was sitting in their room in a wheelchair. The resident's hair appeared greasy. The resident stated they performed daily hygiene by themselves. When interviewed on 11/17/22 at 11:17 AM, certified nurse aide (CNA) #12 stated they usually cared for the resident and the resident's bath day was scheduled for Fridays on the day shift. Resident bath days were listed on a bath schedule located in the CNA task book at the nursing station. The resident was able to take a shower whenever they wanted. The CNA stated they were not assigned the resident the previous week, as CNA assignments changed daily based on who was assigned the unit each day. The CNA stated the resident told them when they wanted to take a shower and staff unlocked the shower room door for the resident. The CNA stated they had not seen or were aware of the resident taking a shower in at least 2 weeks. The resident sometimes refused a shower and that should be documented. The CNA stated the resident had not asked them to unlock the shower area door in the last 2 months. When interviewed on 11/21/22 at 4:26 PM, the Director of Nursing (DON) stated resident preferences should be honored and any CNA could provide care to a resident, whether the resident was on their assignment sheet or not. CNA documentation should be done in real time but at least by the end of the shift. 10NYCRR 415.12(a)(3).

Based on observation, record review, and interview during the recertification survey conducted 11/15/22-11/21/22, the facility failed to ensure a resident who displayed or was diagnosed with a mental disorder received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychological well-being for 1 of 5 (Resident #31) residents reviewed. Specifically, Resident #31 expressed complaints of worsening irritability and depression, and had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: The undated facility policy Out of Facility Appointment documented it was the policy of the facility to provide care to all residents. When needed, the facility would seek medical assistance from physicians in the community and would alert the resident and resident families/health care proxy (HCP)/power of attorney (POA) of upcoming appointments. Resident #31 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/16/22 Minimum Data Set (MDS) assessment documented the resident had intact cognition and received antianxiety and antidepressant medications daily. The 8/5/22 physician assistant (PA) #20 progress note documented the resident, and their spouse reported the resident was experiencing increased irritability, tremors, depressed mood, and anger. [MEDICATION(S)] (antianxiety medication) had been discontinued, and it was to be restarted at a dose of 5 milligrams (mgs) twice daily for anxiety. The plan included to continue current use of [MEDICATION(S)] (antidepressant) at bedtime and a referral to behavioral health services for psychotherapy was made. The 8/5/22 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] There was no documented evidence a psychology consult was completed as ordered. Progress notes by PA #20 dated 8/8/22, 8/11/22, 8/16/22, 8/22/22, 8/23/22, 8/29/22, 9/12/22, 9/13/22, 9/16/22, and 9/19/22 did not address follow up with psychotherapy for the resident's prior complaints of irritability, depressed mood, and anger. The 9/26/22 PA #20 progress note documented the resident had eventful months with several acute complaints that were all addressed accordingly. The resident had increased anxiety and [MEDICATION(S)] ([MEDICATION(S)]) was added. The resident had no recent consults. The progress note did not include documentation of a psychology consult. The 10/10/22 PA #20 progress note documented the resident reported increased stress recently and felt the current dose of [MEDICATION(S)] was not effective. The resident was anxious. The plan was to increase [MEDICATION(S)] from 5 mg to 10 mg twice daily, monitor tremors and mood changes and re-evaluate in 1-2 weeks. The progress note did not include documentation of a psychology consult. The 10/10/22 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/18/22 PA #20 progress note documented the resident tolerated the increased dose of [MEDICATION(S)] with improvement of their symptoms. The plan was to continue current dosage of [MEDICATION(S)], monitor for now, and reassess as needed. The progress note did not include documentation of a psychology consult. Nursing progress notes from 9/1/22-11/16/22 did not include documentation of a psychology consult. The 11/17/22 comprehensive care plan (CCP) documented the use of [CONDITION(S)] drugs related to anxiety and depression, with risk for drug related side effects. Approaches included to assess the need for psychological evaluation, and observe for changes in sleep pattern, behavior, mood, and level of alertness. On 11/21/22 the facility was unable to provide documentation of psychological consults for the resident. During an interview on 11/21/22 at 2:54 PM, the resident reported a history of post-traumatic stress disorder, depression, has had increased tremors, and some increases in anxiety recently. They stated the PA had told them their medications would be changed, but was not sure when, or if it was done. They stated they had not talked to a mental health professional and would if one was made available. During an interview on 11/21/22 at 3:00 PM, registered nurse (RN) Unit Manager #15 stated they had been the unit manager on the resident's floor since September. Orders for outside consults for psychology went through social work. The provider would tell department heads when a consult was ordered, and appointments were made by the medical records department. They were not aware there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The RN was aware of the change in [MEDICATION(S)] in October but was not sure if it was an increase or a decrease. The RN did not remember any report of psychosocial problems for the resident. All recommended consults should be scheduled to make sure residents get the follow up care they needed. During an interview on 11/21/22 at 3:16 PM, the Director of Social Work stated psychology consults were ordered and then communicated to social workers to facilitate scheduling of appointments. They were not aware of the consult ordered for the resident, as they had not been employed at the facility at the time. The Director of Social Work was not aware of the increase in [MEDICATION(S)] on 10/10/22 and would expect to be notified by nursing to update the care plan. The scheduling of psychology consults was important to residents for optimal psychosocial health. During an interview on 11/21/22 at 3:33 PM, PA #20 stated orders for consults were put in the computer, and then communicated to the Unit Manager via a follow up log. The Unit Managers called medical records who made the appointments. Behavioral health consults usually went through social work. There was a psychologist who came to the facility for initial evaluations. The PA stated they assumed that this appointment had happened. They had adjusted medications but were not sure why the psychology consult was not done. The resident's psychosocial comfort was important to be maintained. During an interview on 11/21/22 at 4:09 PM, the Assistant Director of Nursing (ADON) stated consult orders were entered into the computer by the provider. They should be communicated to nursing and emailed to medical records who would make appointments. When Unit Managers were oriented, they were taught the process to schedule consults. A resident's psychosocial comfort should be maintained, and all follow up consults should be done timely. During an interview on 11/21/22 at 4:24 PM, medical records specialist #27 stated behavioral health consults were handled by social work and they were not sure how that was communicated. 10 NYCRR 483.40(b)(1)

Based on observation, interview, and record review during the recertification survey conducted 11/15/22-11/21/22, the facility failed to ensure that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 1 emergency medicine storage area (nursing supervisor's office) observed; and failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles and included the expiration date when applicable for 1 of 4 medication carts (Unit 2A B side) and 2 of 2 medication storage rooms (Units 1 and 2). Specifically, the emergency medication storage area in the nursing supervisor's office contained a vial of [MEDICATION(S)] (sedative, Scheduled IV controlled substance) that was not accounted for. Additionally, the Unit 2A B side medication cart had expired stock medications, 1 insulin pen, and 2 insulin vials; and the Unit 1 medication room had an expired stock bottle of medication. Findings include: The facility policy Medication Storage revised 6/2021 documented medications would be stored in a manner that maintained the integrity of the product, ensuring the safety of the residents. Expired medications would be removed from the medication storage areas and disposed of in accordance with facility policy. The facility policy Inventory Control of Drugs revised 6/2021 documented controlled drugs were inventoried and documented under proper conditions with regard to security and state/federal regulations. Schedule IV controlled medications, which included any backup medications in the facility, were counted per facility policy and in accordance with state regulations During a medication storage observation and interview on 11/17/22 at 11:45 AM of the Unit 2A B side medication cart with graduate practical nurse (GPN) #24, there was: - an opened bottle of cetirizine (antihistamine) 10 milligram (mg) that had a handwritten date of 9/20/22 and an illegible (rubbed off) manufacturer's expiration date. The GPN stated they were unable to find the manufacturer's expiration date, the medication was considered expired without one, and the bottle should have been discarded; - Resident #48's opened [MEDICATION(S)] N insulin (intermediate acting insulin) 10 milliliter (ml) vial did not have an opened date on the vial; - a vial of opened [MEDICATION(S)] R insulin (short acting insulin) with no opened date and no resident identification. The GPN stated the insulin was Resident #48's as the resident took it at the same time as the [MEDICATION(S)] N. The GPN was not sure how long the insulin was good for once opened; and - Resident #42's opened [MEDICATION(S)] insulin pen (long acting insulin) with no opened date. The GPN stated they were unsure of the expiration dates of opened vials. Licensed practical nurse (LPN) #25 who was in the vicinity interjected that insulin was only good for 30 days once opened. The GPN stated the insulin should have been discarded as there was no way to determine how long ago they had been opened. During a medication storage observation of the Unit 1 medication room on 11/17/22 at 2:30 PM with LPN #10, there was an opened stock bottle of sodium chloride 1 gram with a manufacturer's expiration date of 10/2022. The LPN stated whoever puts the medication in the medication room was to check the expiration dates. The LPN was unsure if routine checks were done for expired medications. The LPN stated the medication was expired and should have been discarded the last day of 10/2022. During an emergency medication storage observation and interview on 11/17/22 at 12:42 PM with the Director of Nursing (DON), in the nursing supervisor's office adjacent to the DON's office, there was a vial of [MEDICATION(S)] in the locked medication box next to the Pyxis (automated medication dispensing machine). The DON took the locked box key from the side of the Pyxis, began to unlock the storage box, and stated they did not think there were any medications in the box. When the storage box was opened there was a vial of injectable [MEDICATION(S)] inside. The DON stated the [MEDICATION(S)] was for a resident with a history of seizures. The DON stated they had told the pharmacy in the past they did not want any controlled substances in the box and that there was no record of accountability for the [MEDICATION(S)]. The DON stated the [MEDICATION(S)] was to be accounted for on a controlled substance accountability form every shift like any other controlled substance. The DON showed an email sent to the pharmacy documenting the request to remove the [MEDICATION(S)] and the DON did not know why it was still there. The DON stated they expected evening unit staff to check the medication carts and medication rooms for expired medications prior to administering the medication. The Unit Managers and/or each unit's night shift nurse were responsible for checking for expired medications at least monthly, but preferably weekly. Those medications should be discarded the last day of the expiration month or the day before the expiration date if a specific date was mentioned. Quality assurance audits for expired medications were done quarterly by the pharmacy. Insulin was good for 28 days once opened and was considered expired if no opened date was recorded on the insulin container as there was no way to know how long it had been opened. Any medication that did not contain a legible manufacturer's expiration date was also considered expired. When re-interviewed on 11/21/22 at 4:39 PM, the DON stated the [MEDICATION(S)] should have had a narcotic count sheet and been tracked. Accountability of controlled substances prevented medication diversion and staff would not know if the medication was available in the event it was needed. 10NYCRR 483.45 (g)(h) 10NYCRR 415.18 (a)

Based on observation, interview and record review during the recertification survey conducted 11/15/22-11/21/22, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the main kitchen, 2 of 3 unit pantries, and 1 of 2 test trays. Specifically, potentially hazardous foods (PHF) were not stored and/or discarded properly (frozen raw chicken stored over other meats and ground beef was past the documented use by date) in the main kitchen; the floors in the main kitchen were unclean; the ice machines in Unit 2's and 3's pantry were unclean; and a test tray was not served at palatable and appetizing temperatures. Findings include: The facility policy Food Storage reviewed 1/2022, documented all foods should be covered, labeled, and dated. All food would be checked to assure that foods would be consumed by their safe use by dates or discarded. Frozen meat, poultry, and fish should be defrosted in a refrigerator for 24 to 48 hours and should be used immediately after thawing. The facility policy Labeling and Dating System Protocol revised 11/18/19, documented follow manufacture's expiration date on all un-opened product. If there was no printed manufacture's date on the product, follow dating protocol. All frozen foods allow 3 days to defrost in the cooler. Add those 3 days to the expiration date on the open/prep and expiration label; beef, pork, poultry raw 3 days. The facility policy Food and Nutrition Services Test Tray Evaluation revised 3/26/20, documented hot food items on resident trays should be 135 Fahrenheit (F) or greater. Food storage: During an observation on 11/15/22 at 11:16 AM, there was a Ziploc bag of raw chicken breasts stored on top of a box of hamburgers within the walk in freezer. The box of hamburgers was not sealed and not labeled with the date they were opened. During an observation on 11/15/22 at 11:20 AM, there were ten 10 pound tubes of ground beef thawing on two trays on the bottom shelf of a green baker's rack within the walk in cooler in the main kitchen. On one tray there were 5 tubes of ground beef labeled with a date of 11/9/22. Those tubes were not labeled with a use by date. The second tray contained 5 thawing tubes of ground beef in the opened original box and the tray was labeled 11/3/22 with a use by date on the box of 11/13/22. During an interview on 11/15/22 at 11:20 AM, the Food Service Director stated staff go by the used by date to determine when food should be discarded. They did not realize the use by date had passed on the ground beef. During an observation on 11/16/22 at 11:44 AM, there were three 10 pound tubes of ground beef left in the walk in cooler on a tray on the bottom shelf with the tray labeled 11/9/22. During an interview on 11/16/22 at 11:44 AM, the Food Service Director stated the original box of tubes of ground beef had a use by date of 11/20/22. Sometimes the boxes were destroyed so they just remembered the dates when to discard. The date on the trays referred to the date the tubes of beef were transferred from the freezer into the walk in cooler for thawing. Cleanliness: During an observation on 11/15/22 at 11:28 AM, the floors under and behind the stoves and ovens and under and behind the dish machine in the main kitchen were unclean and soiled with food debris. During an interview on 11/15/22 at 11:37 AM, the Food Service Director stated the kitchen was cleaned daily and there was a separate cleaner once a week that handled deep cleanings. Equipment was moved and cleaned behind and under. It has been two weeks since the deep cleaning as staffing had been an issue. During an observation on 11/15/22 at 12:10 PM, the ice dispensing machine in the 3rd floor pantry room was soiled and unclean with white stained residue on the dispensing cone, the back splash, and the drain tray/grate. During an interview on 11/15/22 at 12:10 PM, the Assistant Director of Maintenance stated they fixed the machines, but they thought that the nurses or housekeepers would have to clean the ice machines. They were unsure if that was documented. During an observation on 11/15/22 at 2:51 PM, the 2B pantry ice machine was soiled and unclean with white stained residue on the dispensing cone, the back splash, and the drain tray/grate. The microwave was soiled and unclean with orange mashed food debris. During an interview on 11/16/22 at 11:46 AM, the Food Service Director stated housekeeping cleaned unit ice machines and microwaves. The annual Control Measures Log documented the ice machines were cleaned on a biannual basis (1/25/22 and 8/15/22). No issues were noted on the log. Test tray: Resident #50 was admitted with diagnoses of [CONDITION(S)] ([CONDITION(S)]) and pneumonia. The 8/19/22 Annual Minimum Data Set (MDS) assessment documented the resident had intact cognition and required setup assistance with meals. The 8/12/22 physician orders documented the resident received a regular diet. During an interview on 11/15/22 at 11:55 AM, Resident #50 stated the food did not always taste good and the food was always cold. During an interview on 11/16/22 at 11:53 AM, the Food Service Director stated test trays were conducted 3 times a week with a random resident tray picked. During an observation on 11/17/22 at 1:08 PM, a test tray was conducted on Resident #50's lunch meal served to their room. The resident received a replacement tray. The following temperatures were measured using an internal probe of a thermocouple thermometer, chicken parmigiana measured 126 F, broccoli measured 119 F and pasta measured 130 F. During an interview on 11/18/22 at 10:51 AM, the Food Service Director stated the pellet warmer has been a constant issue. For the last 3 months maintenance kept fixing it. The oven was set at 350 F and the pellets were heated up to help keep the resident meal plates warm. 10NYCRR 415.14(h)

Based on observation, record review and interview during the recertification survey conducted 11/15/22-11/21/22, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside, toilet, and bathing facilities for 1 of 4 nursing units (Unit 3). Specifically, the call bell system panel for Unit 3 was missing/removed from the nursing station desk. Findings include: The facility policy Call Light System initiated6/2018 documented to respond to resident's request for assistance in a timely manner and meet their immediate needs. Assure call system was in proper working order. Maintenance was to be alerted to any call light issues immediately for intervention. Log defective call lights, with exact location, on maintenance request forms and notify maintenance for need of the priority repair. The call bell audit dated October 2022 for Unit 3 documented four categories to be checked. One category Call bell audible from the nurse's station documented all resident rooms passed for that function. During observations on 11/15/22 at 12:20 PM through 11/21/22 at survey exit there was no call bell panel present at the Unit 3 nursing station desk. During an interview on 11/15/22 at 12:20 PM, the Assistant Director of Maintenance stated they did not know where the call bell panel was and that it should be at the nursing desk like all the other units. They were not aware of how long the panel had been missing or why it was missing. They had no knowledge of the unit being fixed or replaced. During an interview on 11/15/22 at 12:20 PM, registered nurse (RN) Unit Manager #15 stated they were on the unit since September and there had not been a call panel at the desk for that period. Nurses used the overhead lights in the corridor outside the resident rooms to know if residents needed assistance. The RN Unit Manager stated they sent an email to the Administrator a few weeks ago about the call bell panel missing but was not sure if anything came from it. During an interview on 11/15/22 at 12:25 PM, the Director of Social Work stated they had been on the unit since August and had not seen a call bell panel at the desk during that time. They stated staff just go down the halls and look for corridor over head lights to see if residents needed assistance. During an interview on 11/15/22 at 12:20 PM, certified nurse aide (CNA) #17 stated there was no call bell panel at the Unit 3 nursing desk like the other units. They stated CNAs had to look down the halls for overhead lights because there was no panel. That was the only way to know if a resident needed assistance as there was no tone that was heard. There was no panel at the desk for the past 6 months they had worked on Unit 3. Staff did frequent rounds on the unit. The call bell could not be heard going off so getting up and looking for lights was the only way to know residents needed assistance. During an interview on 11/17/22 at 10:20 AM, the Administrator stated call bell audits should be done weekly. They stated they were aware of the panel missing on Unit 3. It had been removed 6 months ago due to staff responses. It was omitted to get staff up and to go around and physically answer the call bells. The system still worked, and the overhead lights lit up. The tone would still go to the buzzer within the pantry and the utility rooms on the unit. The Administrator stated staff should be able to hear the tone going off from those rooms. During an observation on Unit 3 on 11/17/22 at 11:19 AM, a call bell of a random resident room was tested . The pantry and the clean and soiled utility rooms had a call bell relay buzzing that was heard only inside the rooms. The rooms were maintained closed and locked. During an interview on 11/17/22 at 11:19 AM, with resident assistant #14 they stated they were always on their feet and always looking to see if residents needed help. They were never trained or briefed on the call bell system on Unit 3 versus the other unit's call bell set up. They stated during the call bell test they were unable to hear the buzzers in the pantry or the utility rooms unless they were physically inside the rooms. During an interview on 11/17/22 at 11:31 AM, the Director of Social Work stated they could did not hear the call bell test unless they were in the pantry. Only the tone could be heard at those buzzers and there was no room location identified. The call bell in the pantry and utility rooms could not be heard when the doors were closed. 10NYCRR 415.29

Based on observation, record review, and interview during the abbreviated survey (NY 343) the facility did not ensure residents were free from abuse and that staff reported abuse immediately to the Administrator of the facility for 1 of 3 residents (Resident #2) reviewed. Specifically, - The facility did not prevent Resident #2 from being abused by certified nurse aide (CNA) #1. - LPN #9 did not report abuse immediately to facility Administration and CNA #1 was not suspended immediately and continued to care for residents in the facility. This resulted in actual harm that was not immediate jeopardy to Resident #2 who was evaluated and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: The facility Abuse Policy and Prevention reviewed/revised 3/2022 documented all residents would be free from abuse. Abuse was defined as the willful infliction of injury. Reports of abuse were to be promptly and thoroughly investigated. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The comprehensive care plan (CCP) initiated on 4/15/2022 documented the resident had impaired thought processes related to dementia, had the potential to be a victim of abuse related to cognitive disabilities, was at risk to abuse others, and had aggressive behaviors towards staff and residents. The resident required assistance of 1 with their activities of daily living (ADLs). Staff were to invite the resident to activities of their choice, encourage rest periods, offer reassurance, calm fears, provide a calm, quiet environment, and protect the resident from being a victim of abuse. If the resident became agitated staff were to stop and return. The facility Incident Report completed by LPN #9, on 7/14/2022 at 7:30 AM, documented Resident #2 had bruising and swelling on the right forehead and eye that was found during morning care. Staff were interviewed and signed statements were obtained. The family and medical provider were notified. The bruising was self-inflicted, due to the tray table at the resident's bedside, the tray table was moved, and the incident did not support abuse. Statements included in the facility investigation documented: - by LPN #9 untimed and dated 7/13/2022, no swelling or bruising was noted to Resident #2's face and there were no reports of an incident. -by CNA #10 untimed and dated 7/14/2022, they observed a bruise on Resident #2's forehead while in the dining room at breakfast. - by LPN #12 untimed and dated 7/14/2022, they last visualized Resident #2 on 7/13/2022 at lunch, and no changes were found. On 7/14/2022 it was reported to them, that morning Resident #2's right eye was bruised and swollen. - by CNA #1 untimed and dated 7/19/2022, they provided care to Resident #2 that morning (7/14/22), the resident was last observed lying on the bed crying and a bruise was found on Resident #2's right forehead and eye. There was no documentation of how the facility determined the injury was caused by the tray table. The untimed licensed practical nurse (LPN) #9 progress note dated 7/14/2022 documented they were informed Resident #2 had a bruise on the right forehead and eye. The area was noted above the eyelid, was purple in color and no complaints or discomfort was voiced. The resident's bedroom was evaluated for safety and the bed side table was noted to be located next to the bed. New interventions included to relocate the table. The physician assistant (PA) assessed Resident #2 without new orders and the family was notified. The 7/14/2022 untimed PA #7 progress note documented Resident #2 was seen for reported [CONDITION(S)] (redness) and swelling of the right eye. A semi-circular bruise and swelling were found along the inner orbital (eye)/nasal bridge. The area appeared to be from the corner of the resident's tray table and the resident was up in the chair without acute distress. There was no documentation how the PA determined the injury was caused by the tray table. The untimed progress note by LPN #15 dated 7/15/2022 documented Resident #2 was noted with [CONDITION(S)] (fluid swelling), blue/purple bruising around the forehead, right eye, and nose. The resident became weepy when asked if their head hurt, nodding yes. Tylenol was offered and administered. The resident's family were in and were concerned regarding the injury to the resident's face. The family requested an x-ray be obtained and an investigation be completed due to repeated instances of bruising during the resident's stay. The family had several questions about the incident and LPN Unit Manager #9 and the medical provider were notified. The untimed progress note by LPN Unit Manager #9 dated 7/18/2022 documented they received a call from the family regarding Resident #2's facial bruising and concerns of a possible fracture. The PA was in to see the resident with no new orders. The bruising was fading with yellow edges and the resident did not have pain. The untimed investigative summary dated 7/20/2022 by the Director of Nursing (DON) documented on 7/19/2022: -LPN #9 alerted the DON at an unknown time Resident #2's family member voiced concerns about Resident #2's care, wanted X-rays to be done, and discussed their concerns with social worker (SW) #16 on 7/15/2022. The family requested CNA #1 not be allowed to care for Resident #2. SW #16 assured the family they would investigate and did not. LPN #9 also informed the DON that housekeeper #11 mentioned an interaction between CNA #1 and Resident #2. Housekeeper #11 was contacted, asked to come to the facility to provide a statement and did not report to the facility that day. In addition, LPN #9 reported during a phone call to the family they received information that housekeeper #11 witnessed an interaction between CNA #1 and Resident #2. The facility synopsis report completed by the DON, dated 7/20/2022 and revised on 7/22/2022 documented: Investigation #1; - On 7/14/2022 at 9:30 AM, LPN #9 reported Resident #2 had facial bruising found that morning, and the cause was unknown. LPN #9 initiated an incident/accident report with witness statements. Resident #2 denied discomfort, and the medical provider was in to see the resident. A follow up discussion on 7/14/2022 with LPN #9 at an unknown time was conducted with the DON and Administrator. LPN #9 concluded the root cause of the bruise was from the bedside table. Investigation #2 (reinvestigated with additional information): - On 7/19/2022, at an unidentified time LPN #9 reported to the DON and Administrator, unidentified staff were overheard discussing Resident #2's facial bruising. Housekeeper #11 overheard an unidentified CNA and Resident #2 having a disagreement on 7/14/2022. The investigation was reopened, and additional interviews and statements were obtained and documented. -On 7/20/2022 in an untimed statement, LPN # 9 documented they initiated an investigation on 7/14/2022 when the bruise was identified. Witness statements were obtained, and the bruise was reported by LPN #9 that morning during the facility morning report. The obtained statements did not identify any cause for alarm. Resident #2 was evaluated by the PA without discomfort, no environmental hazards were found, and the tray table was thought to be the cause of the bruise. The tray table was moved, and the family was notified of the bruise. -On 7/21/2022 CNA #1 documented in an untimed statement they assisted Resident #2 with toileting, the resident was swinging their arms and calling them names. CNA #1 yelled for help, housekeeper #11 arrived and they told the housekeeper to get help. CNA #2 arrived to assist CNA #1 and they completed the residents care and walked the resident to the dining room. CNA #10 saw the residents face while in the dining room and asked what happened. CNA #1 responded they did not see that. CNA #10 reported the bruising to the nurse. -On 7/22/2022 at 2:15 PM, LPN #9 was re-interviewed and reported they knew there was an incident on 7/14/2022 between CNA #1 and Resident #2, they were aware before morning report that CNA #1 placed their arm across the resident's body, pinning the resident against the bathroom wall. -On 7/20/2022 LPN #12 reported in an untimed statement on 7/14/2022, CNA #10 inquired about Resident #2's facial bruising. LPN #9 and 12 observed Resident #2's right side of the face, their eye and nose were beginning to bruise, and LPN #12 stated it looked like the resident was punched in the face. When first questioned CNA #1 denied knowing what happened and after being questioned by LPN #12 a second time that morning CNA #1 reported Resident #2 beat [their] ass had them in a corner while they performed care and they did not notice the residents face. Later that day, at an unknown time, CNAs #2 and 10 and LPN #12 discussed Resident #2's bruising and CNA #2 provided a demonstration. The demonstration showed, someone holding a person, by the neck, hitting the resident, with an elbow in the face. CNA #2 stated they did not want to be involved, they did observe what happened and did not want their name involved. LPN #9 was notified at that time, listened to CNA #2's report of what occurred, stated they would figure out how to approach it without CNA #2's written statement and they were going outside to cook. LPN #12 was concerned with that approach and had RN #14 tell the DON. -On 7/20/2022 at 1:21 PM CNA #2 reported in a signed statement, on 7/14/2022 they witnessed CNA #1 hold Resident #2 against the wall by the throat and hit the resident in the eye with their elbow. Resident #2 kicked CNA #1 and CNA #1 kicked Resident #2 in the leg. They helped CNA #1 wash the resident and then left the room. They walked to the nursing station and CNA #1 went to smoke. CNA #2 reported to LPN #9 CNA #1 was witnessed hitting Resident #2 and LPN #9 told them they would handle it. -On 7/21/2022 in a second untimed statement CNA #2 reported housekeeper #11 told them an unidentified CNA needed help on 7/14/22. When they arrived in Resident #2's room they heard Resident #2 yelling for help. They observed Resident #2 pinned up to the wall, CNA #1's back was against Resident #2's front side and CNA #1's elbow was lifted twice striking Resident #2 in the face. CNA #2 yelled stop what are you doing and pulled Resident #2 towards them and saw Resident #2 required incontinence care. CNA #2 instructed CNA #1 to clean the resident up while they held them. Resident #2 kicked CNA #1 and CNA #1 responded by kicking Resident #2. CNA #2 yelled at CNA #1 to stop and get out, they did not see any apparent bruising or redness, went to the nursing station where LPN #9, 12 and housekeeper #11 were standing and discussed the incident. CNA #1 left the unit after using foul language. LPN #9 was aware of the incident and CNA #2 was told by LPN #9 they would handle the issue. -On 7/20/2022 at 1:01 PM in a signed documented statement by housekeeper #11 they worked on 7/14/2022 and heard CNA #1 yell for help and told CNA #2. Later that day at an unidentified time they asked CNA #1 what happened. CNA #1 reported Resident #2 was aggressive and CNA #1 put their elbow to the resident's throat and held the resident against the wall. -On 7/20/2022 at 4:00 PM a head-to-toe assessment of Resident #2 was completed by the DON. No injuries other than the facial bruising were found. The facility investigation revealed discrepancies in statements. All employees consistently reported the interaction on 7/14/2022 between Resident #2 and CNA #1 to LPN #9. LPN #9 denied knowing about the incident between Resident #2 and CNA #1. -On 7/20/2022 the police were notified, arrived at the facility, and conducted interviews. The facility reported the incident to NYSDOH as required. CNA #1 denied harming Resident #2 and was suspended from the facility. Housekeeper #11 was reinterviewed, their story was inconsistent, a reenactment was completed, and housekeeper #11 denied witnessing the interaction. Housekeeper #11 was suspended and terminated from employment for failure to report the incident timely and giving false statements during the investigation. - On 7/20/2022 LPN #9 admitted to knowing there was an incident between CNA #1 and Resident #2 that occurred on 7/14/2022 and allegations of abuse were made. They did not investigate or report the incident to the DON or Administrator. LPN #9 was suspended on 7/20/2022 and terminated for failure to accurately report an incident, purposefully re-directing an investigation for the bruising, and giving false statements on 7/21/2022. -CNA #1 was suspended on 7/20/2022, called for interview, did not show up at the appointed time of the interview and stopped answering the facilities calls. CNA #1 was terminated on 7/22/2022, and the police were notified. -The facility documented based on interviews with staff and the resident bruising, the police were notified on 7/20/2022. The police arrived, initiated an investigation, and conducted interviews. The NYSDOH was notified per the incident reporting manual and the investigation continued expanding interviews of the employees. All residents in the facility were assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . CNA #1 worked in the facility per the time clock report as follows: 7/14/2022 from 6:55 AM-3:04 PM 7/15/2022 6:54 AM - 3:01 PM. There were no time clocks punches from 7/16/2022-7/21/2022 On 9/26/2022 at 1:14 PM the District Attorney stated during a phone interview CNA #1 was being charged with a felony and an arrest warrant had been issued for endangering the welfare of a vulnerable elderly person. On 9/29/2022 at 9:52 AM the DON was interviewed via phone and stated the facility process for allegations of abuse, was once the allegation was made it was immediately reported to the DON or Administrator and an investigation was initiated. The accused individual would be placed on suspension pending the outcome of the investigation and they followed the NYS incident reporting manual for guidance for reporting to the NYSDOH. On 7/14/2022 at approximately 9:30 AM during the facility morning meeting LPN #9 reported Resident #2 had bruising on the right eye and forehead. LPN #9 reported Resident #2 often rested their head on their arm and used the tray table for support and slipped and hit their face on the tray table. An investigation had been initiated and LPN #9 was directed to obtain statements. The resident was seen by the medical provider and the family was notified. On 7/20/2022 LPN #9 approached them at 11:00 AM and reported CNA #1 hit Resident #2 in the face and the CNA needed to be terminated. They reopened the investigation from 7/14/2022, assessed all residents on the unit for any injuries or allegations of abuse, CNA #1, and housekeeper #11 were not in the facility at the time of the report. They interviewed multiple staff and LPN #9 and CNA #2 were suspended at the completion of the interviews. Phone interviews were initiated with CNA #1 and housekeeper #11. The police department was notified at approximately 6:30 on 7/20/2022 and NYSDOH was contacted on the alleged abuse as required. More statements and interviews were conducted. On 7/21/2022 at 6:00 AM a facility wide Inservice was conducted on abuse and reporting allegations of abuse. 10NYCRR 415.4(b)

Based on observation, interview, and record review during the abbreviated survey (NY 166), the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment for 2 resident rooms observed (Rooms 210 and 310). Specifically, in Room 210, the floor was unclean and discolored and a wall was unclean with water damage on the acoustic ceiling tiles, and in Room 310, the acoustic ceiling tiles were water stained and damaged. Findings include: A work order dated on 7/20/21 documented mold clean up on the wall of room 210. The work order was documented as closed on 2/3/22. Observations on 4/22/22 included: - at 10:50 AM, there were water stained and damaged acoustic ceiling tiles within the drop ceiling of resident room 210. The wall opposite the resident's bed (where the TV was mounted) had red rusty drip marks coming down from the frame of the drop ceiling. The paint was peeling and chipped in various areas of the wall. There was a 10 inch x 12 inch black speckled unclean section on the wall. The floor was unclean and discolored black. - at 12:05 PM, there were water-stained acoustic ceiling tiles within the drop ceiling of resident room 310 in the corner of the room. When interviewed on 4/22/22 at 12:30 PM, the Maintenance Director stated they were not sure why there was a work order dated 7/20/21 for the 10 inch x 12 inch black speckled area on the wall in room 210. The Maintenance Director stated that area was mold. The work order for the mold clean up on the wall was not closed out until 2/3/22 and it should have been taken care of right away. They stated there was no policy for mold removal. When interviewed on 4/22/22 at 2:35 PM, the Maintenance Director and Administrator stated they were not aware of the condition of resident room 210. The cleanliness of the room was not acceptable and they were going to move the resident until they could address the walls and the unclean floors. They stated the floors needed to be replaced as they could not be cleaned any further. When interviewed on 4/22/22 at 3:05 PM, the Administrator stated they believed the roof needed replacement and they had a bid out for replacement. They stated the roof has been an issue since they had been at the facility for about a year. 10NYCRR 415.29(j)(1)

Based on observation, interview, and record review during the abbreviated survey (NY 166), the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 2 resident rooms observed (Rooms 210 and 310). Specifically, - Resident room 210 had a wall mounted TV come free from the wall due to improper installation and there was water damage on the ceiing tiles in the room. - Resident room 310 had a large (approximately 3 foot x 6 foot) section of the cinder block wall above the drop ceiling that contained loosely stacked, irregularly shaped cinder blocks with broken and missing grout lines and open sections missing blocks all together. Findings include: 1) When observed on 4/22/22 at 10:50 AM, there was a wall mounted TV in Room 210 that came free from the wall when it was checked for a secure installation by the surveyor. The surveyor put their hands on the outside of the TV to give a tug downward and check the security of the installation and the TV came off the wall into the surveyor's hands. There were only 2 screws noted to be installed into the wall with the wall mount. There were water damaged ceiling tiles noted and when inspecting the wall above the drop ceiling for where the water damage had come from there was a one foot long L shape crack into the cinder block and concrete wall. When interviewed on 4/22/22 at 2:40 PM, the Maintenance Director stated when installing resident room televisions they used concrete drill bits to drill holes into the walls then hammered in the plastic anchors from the assorted drywall anchor kit. They stated the screws and anchors from the drywall kit were all they used. Review of the TV wall mount manual revealed there should be 3 lag bolts used to install the mounting bracket to a concrete wall. The steps indicate concrete wall anchors can be used when being installed into a concrete wall. It further noted 3 lag bolts should be securely tightened prior to continuing installation of mount. Review of wall anchor assortment kit used to install TV [NAME] to walls in resident rooms, revealed the kit was for dry wall anchors and not concrete. No lag bolts were included or masonry fasteners were included in the kit as needed for installation into the concrete walls. There was no evidence that correct masonry hardware and fasteners were used when installing [NAME] into a concrete wall. When interviewed on 4/22/22 at 2:30 PM, the Maintenance Director stated the roof was a rubber and mesh insulated roof. They had had to install many of the small rubber patches on the roof since they started working at the facility. They did not know about the leaking and water damage into resident room 210. When interviewed on 5/27/22 at 12:07 PM, the Administrator stated they were not aware of the water damage of the ceiling or wall within resident room 210. It was known on 4/6/21 that the TV had to be reinstalled after coming loose from the wall. At that time they did not notice any water damage in the room and no one brought the water damage issues to their attention or to maintenance. On 4/22/22, that was the first time they knew about the condition of the room. They would have expected the condition of the water damage to be reported to maintenance with a work order put in place. They were not aware the facility was using an anchor kit to install the TV that was to be used on drywall and th facility walls were brick and concrete. 2) When observed on 4/22/22 at 12:05 PM, there were water-stained acoustic ceiling tiles within the drop ceiling of resident Room 310 in the corner of the room. When inspecting above the drop ceiling there was a large (approximately 3 foot x 6 foot) section of the cinder block wall with loosely stacked irregularly shaped cinder blocks with broken and missing grout lines and open sections missing blocks all together. The third floor was the top floor or the building. When observed on 4/22/22 at 2:30 PM, there were many rubber patches in place all over the roof in various areas when inspecting the roof. Specifically, over the area of resident room 310 roof location was a large approximately 3 foot x 20 foot long loosely fit rubber patch on the roof that was holding a puddle of water on and under it. When interviewed on 4/22/22 at 2:35 PM, the Maintenance Director and Administrator stated they were not aware of the condition of the block wall above the ceiling in resident Room 310. They stated the residents from room 310 should be relocated and the blocks should not have spaces between them like that. When interviewed on 4/22/22 at 3:05 PM, the Administrator stated they believe the roof needs replacement and they have a bid out for the replacement of the roof. They stated the roof has been an issue since they had been at the facility for about a year. When interviewed on 4/22/22 at 3:20 PM, the Maintenance Director stated during the last 3 weeks they used an infra-red camera to identify areas that need to be patched on the roof. There were a lot of patches on the roof and they stated they likely installed 15 to 20 of them. 10NYCRR 415.29

Based on interviews and record review during the abbreviated survey (NY 900), the facility did not ensure residents had the right to be free from abuse for 2 of 3 residents reviewed for abuse (Residents #1 and 2). Specifically, Resident #1 was forcibly pushed in her locked wheelchair by RN #1, causing her to fall to the ground. The resident complained of emotional distress, worsening pain requiring narcotic [MEDICATION NAME] and an X-ray. Resident #2 was forcibly pushed in her wheel chair by RN #1 causing her right hand to lose acrylic nails and bleed from the nail bed resulting in pain requiring pain medication; anxiety and emotional distress. This resulted in actual harm to Residents #1 and 2 that was not immediate jeopardy. Findings include: The facility investigation initiated by RN #2 on 10/30/2018 at 7:45 PM and completed on 10/31/2018 at 12:55 PM documented the following: -RN (registered nurse) #1 had an altercation with Residents #1 and 2 when they were found outside the facility in the gazebo area smoking. RN #1 was observed to forcibly push Resident #1 and 2 from the outside patio into the facility. Resident #1 had her brakes on while RN #1 continued to push the wheel chair, resulting in Resident #1 falling out of the chair and hitting her left side on the door casing. -Resident #2 was observed to be forcefully pushed to her room resulting in her acrylic nails being dislodged from her hand. Both residents were visibly upset, and the incident was reported to the police department, the Administrator and the Director of Nursing (DON). -The investigative report documented an RN assessment was completed on both residents. Resident #2 had acrylic nails missing with dried blood on the nail bed of her right hand and she complained of pain. Pain medication was administered to the resident and emotional support was provided. -Resident #1 complained of neck, back, left shoulder and knee pain. She received pain medication for discomfort. -On 10/30/2018 between 8:00 PM and 8:40 PM, RN #1 was brought to the Administrative offices and dismissed from the facility by the Administrator and the DON. The facility concluded based on interviews, review of internal documents and investigation RN #1's employment had been terminated. -Both residents were to be monitored, psychological services were notified for consult, the resident's care plans were updated, the staff and residents were re-educated on the facility smoking policy and managing resident's behaviors. Pain, fall and wandering assessments were completed on both residents. 1)Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had intact cognition, did not require staff assistance for activities of daily living (ADL) and used a walker or wheel chair for mobility. The documented interview of Resident #1 included in the facility investigation on 10/30/2018 at 7:45 PM reported she was outside smoking with Resident #2. The RN Supervisor (RN #1) came out and told them no smoking and hurry up and finish. He returned before they completed their cigarette and started pulling her wheel chair. Resident #1 stated her brakes were on and she could get inside herself. RN #1 grabbed her left arm and she told him not to twist it. He then lifted the back of her chair and she fell out hitting her left side on the door casing. She complained of neck, left shoulder, back and knee pain. She was assisted by 2 CNAs. RN #1 denied lifting the chair. RN #2 assisted her with calling 911. She did not know what occurred with Resident #2. RN #2's progress note dated 10/30/2018 at 11:00 PM, documented the resident reported her neck, left shoulder, back and left knee were aching. The resident stated these were chronic problem areas and the incident made them worse. The licensed practical nurse (LPN) was notified of the request for prescribed pain medication and ice packs to the affected areas. The resident was visibly emotionally upset and requested the police be called. Resident #1's Medication Administration Record [REDACTED]. She received [MEDICATION NAME] (a narcotic) 5 mg per physician's orders [REDACTED].>The Licensed Practical Nurse (LPN) progress note dated 10/30/2018 at 11:38 PM, documented Resident #1 requested Tylenol 325 mg 2 tablets for pain and discomfort for body aches. Resident #1's X-ray report dated 10/31/2018 documented the resident had an X-ray of the left shoulder and found to have no fracture or dislocation. The comprehensive care plan (CCP) was updated on 10/31/2018 and documented the resident was at risk for victimization due to being the victim in an altercation. The RN progress note dated 10/31/2018 at 3:00 AM documented Resident #1 verbalized feelings of being shook up and frazzled over the altercation. An LPN progress note dated 10/31/2018 at 6:56 AM documented the resident had complained of a headache at 11:30 PM on 10/30/2018 and had been weepy. During an interview on 11/6/2018 at 10:00 AM, Resident #1 stated she reported what had occurred to the facility and the police department and did not wish to go through it again. 2)Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had intact cognition and required extensive assistance from 1 staff for her activities of daily living (ADLs). The comprehensive care plan (CCP) dated 8/7/2018 documented the resident had limited physical mobility related to [MEDICAL CONDITION] and she was verbally and physically aggressive. Interventions included staff were to adjust their voice tone, analyze her triggers and what de-escalated her behavior. Staff were to approach her from the front and when agitated guide her away from distress and engage her calmly in conversation. If her response was aggressive staff were to calmly walk away and re-approach later. The documented interview of Resident #2 included in the facility investigation on 10/30/2018 at 7:45 PM reported Resident #1 and she were outside smoking when RN #1 told them to finish. He returned a few minutes later, yelling and approached Resident #1 and began pushing her wheel chair. Resident #1 told RN #1 she could do it herself. She was not sure if Resident #1 put her foot down, but RN #1 flipped her out of her chair onto the ground. He then approached Resident #2 and began to push and pull her chair while the brakes were on. She told him to stop and the brakes were on. RN #1 hit her face on the right side and she tried to defend herself. RN #1 brought her into the elevator and pushed her against the wall. He then pushed her into her room and slammed the door. Her nails were broken and bleeding. RN #2's progress note dated 10/30/2018 at 11:15 PM documented the resident was very emotional and anxious. Her right hand 1st, 2nd, 3rd fingers and pinky had visible dried blood. The artificial nails appeared to have come off of the 1st, 2nd and 3rd right fingers. She notified the LPN the resident had complained of pain and would medicate for pain per current orders. The resident requested the police be notified. RN #2's progress note on 10/31/2018 at 12:45 PM documented the resident complained of difficulty moving her right pinky finger and the physician was notified. Resident #2's X-ray report dated 10/31/2018 documented there was no fracture or dislocation of the resident's hand. When interviewed on 11/6/2018 at 10:15 AM, Resident #2 stated she could recall the incident and her right eye and hand still bothered her. She reported the information and confirmed her statement documented in the facility investigation. When interviewed via phone on 1/25/2019 at 1:59 PM CNA #3 stated, on 10/30/2018 on the 3:00 PM - 11:00 PM shift she was approached by RN #1. He requested she assist him with Residents #1 and 2 in the gazebo. She observed Residents #1 and 2 sitting in their wheel chairs with unlit cigarettes in their hand. RN #1 told them to come inside the facility and approached Resident #1's wheel chair. He began to push the chair and the brakes were locked. Resident #1 kept telling him she would do it, but RN #1 would not listen. He lifted and pushed the chair and it tipped forward and Resident #1 fell out of the chair on to her left side. He left the resident on the ground and did not assist her. CNA #3 went to assist Resident #1 and RN #1 went over to Resident #2 and began pushing her wheel chair. Resident #2 kept yelling for RN #1 to stop but he did not. She tried to intervene. RN #1 continued to push Resident #2's wheel chair into the building. He used foul language and racial slurs several times. When she tried to grab the wheel chair he pulled it away from her and would not let her take Resident #2 back in the building. CNA #9 came out to the gazebo and assisted her with Resident #1. When interviewed on 1/25/2019 at 3:16 PM CNA #9 stated on 10/30/2018 around 8:00 PM she assisted Resident #1 and CNA #3 when they were outside in the gazebo area. She observed RN #1 tip Resident #1's wheel chair forward expelling the resident out and to the ground. When Resident #1 was on the ground crying, RN #1 used foul language stating, he did not push her out of the [***] ing wheel chair. After he pushed Resident #1 he approached Resident #2 and began to push her wheel chair in the facility. Resident #2 kept telling him she could do it and she began scratching his arms. RN #1 would not let go and took her into the building. The incident was reported to RN #2 and she continued to assist Resident #1 to her room. Resident #1 complained of pain in her side and was crying and upset at the altercation. When interviewed on 1/25/2019 at 2:11 PM LPN #5 stated she was in the break room on 10/30/2018 at 7:45 PM and she observed RN #1 push Resident #2 as Resident #2 was grabbing and scratching RN #1's arms. She was swearing and yelling to let her go. RN #1 forcefully continued to push the resident in the elevator so hard she hit the back wall in the elevator. She attempted to intervene many times but RN #1 would not let her. She stayed on the elevator with Resident #2 and RN #1. During the ride he held down Resident #2's arms on the handles of the wheel chair to stop her from scratching him. He told Resident #2 to go ahead and continue to scratch him. Her nails broke in the elevator and her nails were bleeding. When interviewed on 1/25/2019 at 2:40 PM, LPN #7 stated on 10/30/2018 she was on the phone (unsure of the time) when she heard Resident #2 yelling. RN #1 was behind Resident #2's wheel chair. Resident #2 was screaming and crying to leave her alone. RN #1 continued to forcefully push the wheel chair down the hall to her room. Once Resident #2 was in the room he slammed her door closed. He never said anything and left the unit. She reported the issues to RN #2 who went to assess the resident. She observed Resident #2's nails were broken, and she was bleeding from her fingernails. She complained of hand pain and was visibly upset. When interviewed on 1/25/2019 at 12:35 PM, RN #2 stated she worked as the Unit Manager on 10/30/2018 on the 3:00 PM - 11:00 PM shift. RN #1 was the nursing supervisor. LPN #7 reported to her there was an issue between Residents #1 and 2 and RN #1. She and LPN #7 went down the hall and saw RN #1 exiting Resident #2's room. RN #1 slammed the door closed and did not say anything. Before they reached her room, Resident #2 opened the door and was screaming and crying hard. The resident had difficulty communicating she was so upset. Resident #2 reported RN #1 hit the right side of her face and she tried to defend herself. RN #1 then brought her in the elevator and pushed her against the wall. She observed the residents hand and saw 3 of her acrylic nails missing. The nail beds were torn off and blood was present. She did not identify any other apparent injuries. After talking to Resident #2, RN #2 went to assess Resident #1 who was very upset and requested to call the police. She used her cell phone and contacted the police. Resident #1 reported left arm and shoulder pain and no other injuries were identified at that time. When interviewed on 1/18/2019 at 12:22 PM RN #1 stated via phone that he worked on the 3:00 PM - 11:00 PM shift on 10/30/2018. Resident #1 and 2 were outside in the gazebo area smoking. He went outside and explained that they needed to finish their cigarettes and come inside as this was a non-smoking facility. Several minutes later he returned to the gazebo and it appeared the residents lit another cigarette. He told them to come inside. Resident #1 put out her cigarette and she was facing away from the door. He went to assist the resident and turned her wheel chair around to face the door. At that time the resident put her feet down and they began to get caught in the wheel chair. He attempted to pull the wheel chair backwards when she scooted to the edge of the seat and threw herself out of the wheel chair. He had CNA #3 with him in the gazebo area and she assisted the resident back to her wheel chair. He did not perform an assessment as the resident did not appear to be injured and he did not notify anyone that he needed assistance. He then went to get Resident #2 and brought her inside. Resident #2 began to scream and began to scratch and pinch him. He continued down the hallway when he passed CNA # 4. CNA #4 offered to help, and he stated, no I got this. He did not feel he needed any help and continued to push Resident #2 to her room. He then returned to Resident #1's room to check on her and Resident #1 refused to be assessed. He did not know if he documented that information in the computer. He did not assess Resident #2 as she was fine. Someone contacted the police and they came and talked with the residents and he provided a statement. He then finished his shift and left the facility. He denied hitting, pinching, or harming the residents. RN #1's personnel file was reviewed and identified other incidents of abuse towards residents in the facility. He had received re-education on abuse, neglect and mistreatment as a result of those incidents. An abuse prohibition policy and procedure was signed by RN #1 and the DON on 6/28/2018. When interviewed on 1/18/2019 at 10:30 AM the Director of Nursing (DON) stated both she and the Administrator were notified of the incident on 10/30/2018 by staff. She stated the police were notified and obtained statements from Residents #1 and 2 as well as RN #1. When she arrived to the facility on [DATE] RN #1 was in the supervisors office. He was brought to the conference room for an interview with herself and the Administrator. She stated the facility identified RN #1 behaved inappropriately towards the residents when he found them smoking and sent him home as his shift was almost over. She stated the investigation continued, staff were interviewed and due to his history of counsels for inappropriate behavior towards residents and family members the facility terminated his employment. She stated the facility made attempts to obtain a police report and were unable. When interviewed on 1/18/2019 at 12:00 PM, the Administrator stated the facility completed the investigation the following day after the incident occurred on 1/30/2018. The facility found that due to RN #1's prior history of inappropriate behavior and the current incident the facility decided to terminate him from employment. He stated all the staff were upset at what had occurred and reported the incident at the time it occurred. The police were notified and obtained statements from the residents. 10NYCRR 415.4(b)(2)(3)

Based on record review and interview conducted during the standard survey, it was determined for 1 of 24 sampled residents (Resident #3), the facility did not ensure residents received the necessary care and services to attain or maintain the highest practicable physical well-being. Specifically, Resident #3 experienced pain with a dislocated shoulder and the dislocation was not addressed timely. This resulted in actual harm that was not immediate jeopardy for Resident #3 with prolonged pain and increased confusion related to the delay in treatment. Findings include: Resident #3 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) initiated on 4/18/2013, documented the resident had altered cognition and was at risk for falls. The CCP was updated on 4/19/2013, and documented the resident had impaired balance related to cognition. The 5/17/2013, monthly physician orders [REDACTED]. The 6/6/2013 physician orders [REDACTED]. The 6/6/2013 nursing progress note written at 4 PM, documented the x-ray results were received and the resident had a dislocation of the right shoulder. The physician was contacted and instructed nursing to call the resident's family, and determine if she had a doctor who saw her in the past, when she dislocated her shoulder, if not then refer to an orthopedic group, and continue using pain medication. The resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated pain" and the [MEDICATION NAME] was administered for shoulder pain and/or dislocated shoulder. The 6/7/2013 nursing note written at 7 AM documented the resident was "wincing and crying" related to right shoulder pain and was medicated with [MEDICATION NAME]. The 6/7/2013 nursing progress note written at 8 PM documented the resident was medicated for right shoulder pain. The MAR indicated [REDACTED]. The Treatment Administration Record (TAR) documented on 6/7/2013, the resident began using a sling for the right arm/shoulder. The nursing progress notes documented the resident was transferred to another unit on 6/7/2013 at 3 PM. The 6/8/2013 nursing note written at 6 AM, documented it was a late entry for 6/7/2013. The note specified the resident's sling was readjusted as she was in pain, she was medicated with [MEDICATION NAME], and had limited range of motion (ROM) in the right arm. The 6/8/2013 nursing progress note written at 1:45 PM, documented the resident complained of right shoulder pain, was medicated with [MEDICATION NAME], and had a sling in place. The 6/8/2013 nursing progress note written at 4 PM, as an addendum, documented that on the evening of 6/6/2013 the resident's husband was asked if they had a regular orthopedic doctor and they did not. An appointment was scheduled for the resident on 6/25/2013. The note documented the physician was not "as concerned" about the dislocated shoulder as it was not related to a fall and she had this happen in the past. The plan included the use of a sling and medications for pain control. The 6/8/2013 nursing progress note written at 7:35 PM, documented the resident's right shoulder was in a sling and hand was warm to touch. The 6/8/2013 nursing progress note written at 10:25 PM, documented the resident complained of right shoulder pain and was medicated with [MEDICATION NAME]. The MAR indicated [REDACTED]. Both were documented as administered for shoulder pain. The 6/9/2013 nursing progress note written at 5 AM, documented resident had increased confusion, was repeatedly ringing the call bell, and said she did not know why. The 6/9/2013 nursing progress note written at 2:40 PM, documented the resident's right hand was red with [MEDICAL CONDITION] (swelling) noted. The resident complained of pain and was medicated with [MEDICATION NAME]. The 6/9/2013 nursing progress note written at 10:25 PM, documented the resident was medicated for right shoulder pain. The 6/10/2013 nursing progress note written at 6 AM, documented the resident had right shoulder discomfort, a sling in place, and her hand was red with [MEDICAL CONDITION]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The 6/10/2013 nursing progress note written at 9 AM, documented the resident complained of shoulder pain, had a sling in place, and was given [MEDICATION NAME] with mild relief. The nurse documented she spoke with the orthopedic surgeon's office, and asked for an appointment sooner then 6/25/2013, as the resident needed to be "seen very soon." The nursing note dated 6/10/2013, at 10:30 AM documented nursing spoke with the orthopedic office, who instructed to send the resident to the hospital emergency room for reduction (manipulate shoulder back into place) of the right shoulder. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The 6/13/2013 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition and memory impairment. The resident needed extensive assistance for transferring, bed mobility, dressing, toileting, hygiene, and bathing. On 8/14/2013 at 11:25 AM, the registered nurse (RN) manager of the unit, the resident resided on when she dislocated her shoulder, stated in an interview, when the resident initially dislocated her shoulder no one knew as she was not in pain. She stated after it happened, the resident's spouse told the physical therapist, who no longer worked at the facility, and the physical therapist informed nursing. She stated the physician was called and an orthopedic surgeon appointment was made for the end of June 2013. She stated after 2 more days, the resident's pain increased and the resident was transferred to her current nursing unit. On 8/14/2013 at 12 PM, the RN manager of the resident's current nursing unit stated in an interview, when the resident transferred to her unit, she had an "obvious dislocated shoulder." She stated she called the physician and the resident was immediately sent to the emergency room to have it reduced. She said the resident was in pain and someone should not have to wait to have a dislocated shoulder addressed. She stated the resident had the dislocation reduced in the emergency room . On 8/14/2013 at 3:05 PM, the physician stated in an interview, when the resident was found with a dislocated shoulder he would expect pain management to be the top priority. He stated the staff medicated her and called him when her pain was not managed. He stated he received multiple phone calls in regards to the resident's shoulder pain. He stated it was his opinion that sending someone to the emergency room for a dislocated shoulder was not effective as many times there was not an orthopedic surgeon in the emergency room to address the dislocation. He stated for some people, a dislocated shoulder was a chronic condition and those people lived their lives with the dislocation and did not need to have it reduced. 10NYCRR 415.12

Based on observation, record review, and interview conducted during the standard survey, it was determined for 1 of 21 sampled residents (Residents #23), the facility did not provide an environment free of accident hazards or adequate supervision to prevent accidents. Specifically, for Resident #23 a low bed was not provided, as planned, after the resident was transferred to a new unit, the resident experienced a fall from bed, resulting in a fractured neck, a facial laceration and a contusion (soft tissue injury). This resulted in actual harm that is not immediate jeopardy. THIS IS A REPEAT DEFICIENCY FROM THE SURVEY 10/07/2009, 11/05/2010, 11/21/2011 and 11/29/2012 Findings include: Resident #23 had [DIAGNOSES REDACTED]. The resident's Minimum Data Set assessment, dated 6/26/2013, documented the resident's cognition was severely impaired, and he was totally dependent on staff for bed mobility and transfers. The resident's Fall Risk assessment dated [DATE] documented the resident was at high risk for falls. The comprehensive care plan (CCP), dated 7/26/2013, documented the resident was to have a bed alarm, a personal alarm and a floor mat alarm. The CCP recorded the resident fell out of bed on 7/26/2013, had no injury and the care plan was followed. The resident's Care Guide (used to direct care), dated 8/7/2013, documented the resident was confused. The guide recorded the resident had experienced falls, was to be assisted out of bed if not resting, and was not to be left alone in bedroom. The resident was to have a low bed, in the lowest position, a scoop mattress, and an alarming floor mat. Nursing notes, dated 8/7/2013 at 10:45 PM, documented the resident was moved from Unit 2B, was adjusting to the new unit, had no complaints, and would continue to be monitored. Nursing notes, dated/timed 8/8/2013 at 6:33 AM, documented the resident was transferred from Unit 2B and was "adjusting." The note recorded the resident was up most of the night, and continued to attempt to transfer/ambulate without assistance. The physician order [REDACTED]. The resident's Transfer Form, dated 8/8/2013, at 7:30 AM, documented the resident fell out of bed and hit his head on the floor and was bleeding. The resident was transferred to the hospital via ambulance. The registered nurse's (RN) note dated 8/8/2013 at 8:30 AM, documented when she arrived on the unit the resident was on the floor complaining of a headache, and hand/arm pain. The resident was alert and confused. The RN recorded, when asked what happened the resident stated he was going to the bathroom. The resident was incontinent of bowels at that time. The note documented the resident was "cleaned up" and sent to the hospital at 8:20 AM. The Incident Documentation Tool dated 8/8/2013 documented the certified aide (CNA), responded to the resident's alarm, and found him on the floor in his room. The resident was lying on his right side and was bleeding from the head. The documented interventions in place at the time of the occurrence included an alarming floor mat, a bed alarm and a "low bed." The plan to prevent re-occurrence was "will request bedside table be padded." The facility's investigation dated 8/8/2013 documented the resident had a [DIAGNOSES REDACTED]. The resident was found on the floor, was trying to get out of bed without help, and was incontinent. The resident's alarm was in place and functioning. The plan of care was followed as indicated, and the follow up actions were documented as "resident's low bed to be brought to unit," and will request maintenance pad bedside furniture. Hospital records, dated 8/8/2013, documented the resident had an unwitnessed fall out of bed with injury to his head/face. The resident complained of neck pain, numbness in his right hand, and a headache. The records documented the resident sustained [REDACTED]. The resident was to wear an Aspen cervical collar (neck brace) when out of bed and a soft cervical collar when in bed. The CCP dated 8/8/2013 documented the resident fell out of bed, sustained injury and was sent to the hospital emergency room . On 8/12/13 at 10:30 AM, the resident was observed sitting in a wheel chair wearing an Aspen cervical collar. On 8/14/13 at 8:55 AM, the resident was observed in the dining room feeding himself wearing an Aspen cervical collar. During an interview on 8/15/2013 at 12:45 PM, the resident's family member stated the resident used a low bed on his previous unit. The resident was in a regular bed when he fell out of bed on 8/8/2013. The family member stated the resident's low bed was moved to his current unit after his fall. When interviewed on 8/15/2013 at 1:45 PM, the registered nurse (RN) Unit Manager stated she did not work the day the resident was transferred to the unit. The RN said the resident fell the day after his transfer, and when the resident fell he was in a regular bed, which was in the lowest position. The RN said the resident's low bed was not sent with him at the time of his transfer, and was brought to the unit after his fall. When interviewed on 8/15/2013 at 1:55 PM, the Assistant Director of Nursing (ADON) stated the low bed should have been sent with the resident when he transferred to the current unit, and this information should have been included in the resident's unit transfer report. The nursing staff involved in the resident's transfer were not available for interview. When interviewed on 8/15/2013 at 2:20 PM, LPN(licensed practical nurse) #3 stated she worked the 11 PM - 7 AM shift on 8/7/2013. The LPN stated the resident was non-compliant with staying in bed, and was up in a wheelchair most of the night. She stated she was aware the resident was supposed to have a low bed, and she told the supervisor, that night, that he did not have one. When interviewed on 8/15/2013 at 2:35 PM, the 11 PM - 7 AM, RN supervisor for 8/7/2013 stated he was aware the resident was supposed to have a low bed, and he made a note to report that to the 7 AM - 3 PM supervisor. The RN stated he observed the resident sleeping in a regular bed at 2 AM, on 8/8/2013. He said he was not aware that the resident was climbing out of bed during the night. When interviewed on 8/15/2013 at 2:05 PM, the Director of Nursing (DON) stated the resident's low bed should have been transferred with him. The DON stated she did not think the resident's care plan was followed. She stated she expected the nursing staff would ensure the resident had a low bed as planned. 10NYCRR 415.12(h)(1)(2)

Based on observation, record review and staff interview conducted during the standard survey, it was determined the facility failed to provide food in a form designed to meet individual needs for 26 of the facility's 141 residents, who received pureed diets, including 6 sampled residents (Residents #12, 16, 19, 20, 21, and 23) and 20 residents outside of the sample (Residents #25, 26, 27, and 31 - 47). Specifically, the facility: - failed to ensure the correct consistency of food was provided to Residents #12 and 19; - failed to ensure pureed foods were prepared, monitored, and served to residents in the appropriate consistency for Residents #12, 16, 19, 20, 21, 23, 25, 26, 27, 31 - 47; - failed to educate staff on the preparation and identification of altered consistency foods for Residents #12, 19, 26, and 27; - failed to thoroughly investigate Resident #19's choking episode to determine how the wrong consistency food was provided; and - failed to communicate to dietary when Resident #12 received the improper consistency soup during survey. This resulted in no actual harm with the potential for serious harm to resident health and safety that was Immediate Jeopardy for Residents #12, 16, 19, 20, 21, 23, 25-27, and 31 - 47. The Immediate Jeopardy situation was removed on November 21, 2011 prior to the survey exit. Findings include: 1) Resident #19 was admitted to the facility with [DIAGNOSES REDACTED]. The Speech Screening by the speech language pathologist (SLP) dated February 7, 2011 documented the resident was at risk for choking/aspiration due to impaired swallowing. The screen recommended the resident's diet be changed to pureed food with nectar thick liquids. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was severely impaired cognitively, sometimes understood others and sometimes was understood. The MDS noted the resident was able to feed himself with set up assistance, and had no problems with swallowing. The resident's vision was moderately impaired, he was not able to see newspaper headlines, but could identify objects. The physician order [REDACTED]. The comprehensive care plan (CCP) dated October 11, 2011 documented the resident had altered vision related to cataract surgery and could see only shadows. The plan included staff telling the resident what he was eating to help with his perception. The CCP recorded the resident had altered nutrition and hydration related to difficulty chewing and swallowing, poor dentition, and poor vision. The plan instructed the resident would sit at the "restorative" table in the dining room and receive a pureed diet with nectar thick liquids. The Incident Documentation Form dated October 31, 2011 at 1 PM, documented the resident was in the dining room when a certified nurse aide (CNA) who was going out the door, heard the resident gurgling and saw him "turning purple." The resident was coughing up phlegm. The form recorded the resident had "regular bananas" with a fruit plate, and was "able to cough up what was in his airway." The Investigation Summary dated October 31, 2011 documented that the facts of the investigation supported the allegation of choking. The summary noted the resident did not receive a pureed banana for his afternoon meal, was given a whole banana, which he ate causing him to choke. The summary recorded the CCP was updated to reflect instructions for staff to check every meal tray to assure only pureed foods were present. The Speech Screening note by the SLP, dated November 1, 2011, documented the screen was requested after the resident experienced a choking episode. The SLP recorded the resident had impaired swallow, and was a choking risk with solid foods. The recommendation was to continue with pureed consistency diet was nectar thick liquids. On November 3, 2011, the Director of Nursing (DON) documented on the incident report "variances noted" staff discipline and education completed on November 7, 2011. The dietary Supervisor was re-educated on the importance of tray line check and accuracy. The incident investigation did not document who gave and set-up the resident's meal tray with a regular consistency banana. The Inservice Record/Summary Report of Meeting documented the food service director gave himself, the dietary supervisor and the assistant food service director education regarding the accuracy of food consistency served to residents. The CNA Care Guide (used by the CNAs to direct care) dated November 14, 2011, documented the resident had special feeding instructions and was blind. The guide instructed the resident was to sit at the restorative dining table and staff were to tell the resident what he was eating. On November 18, 2011 at 10:50 AM the facility's two registered dietitians (RD) were interviewed. RD #1 stated she was aware the resident choked on a banana. RD #2 stated she thought nursing staff caught the error prior to the resident eating the regular consistency banana. Both RDs referred the surveyor to the Food Service Director and nursing management as they were not aware if a plan was implemented to prevent re-occurrence after the resident choked. The RDs stated they did not provide training to non-nursing staff regarding meal pass. They said to their knowledge nursing staff were the only staff who passed resident meals. During an interview on November 18, 2011 at 11:50 AM, the RDs stated non-nursing departments did regularly pass resident meals including the business office, social workers, activities, and administration. RD #1 stated staff were trained on passing meals during their initial orientation to the facility, and whenever she was in the dining room. On November 18, 2011 between 12:30 and 12:50 PM, the Administrator stated, in an interview, staff were educated regarding passing resident meals after the resident's choking episode. He said the staff who received education were the CNAs and kitchen supervisors. On November 18, 2011 at 12:30 PM the DON was interviewed and stated the dietary Supervisor was spoken to by the Administrator and the Food Service Director after the resident's choking incident. She said there was nothing documented regarding that. The DON stated she did not know who passed the meal to the resident on October 31, 2011. She said to her knowledge nursing "caught it" as she thought nursing noticed the banana was the wrong consistency and removed it when the resident "coughed." She said she did not know who passed the meal tray to the resident and stated the dietary Supervisor was the only one educated after the incident as she "focused on dietary." On November 18, 2011 at 3:00 PM, the registered nurse (RN), who acted as Staff Educator for a few months during the past year, was interviewed. She stated when she conducted initial employee orientation, she did not train staff on passing resident meals as non-nursing staff did not pass meals. On November 18, 2011 at 3:15 PM, the current RN Staff Educator stated in an interview, she spent "about 5 minutes" of orientation time discussing dietary. She stated orientation was a half day and she had to limit the discussion regarding dietary or she would not cover all of the required material. She stated she thought dietary provided their own education to staff on dietary issues. On November 18, 2011 at 4:15 PM the Assistant Director of Nursing (ADON) was interviewed and said when the incident occurred, she had only worked at the facility for a short time. The ADON stated the DON did not ask her who passed the meal to the resident, or to do any education with staff. The ADON said she was told how to fill out the investigation report and how to update the resident's CCP. She stated she was not aware she needed to do anything else. In summary the facility: - failed to provide the resident with the consistency food ordered by the physician; - failed to determine if staff knew the proper consistency diet for the resident; - failed to determine if the staff followed the care plan and assisted the resident verbally during the meal; - failed to conduct a thorough investigation to determine how the resident received the incorrect consistency meal; and - failed to educate all staff, who passed meals to residents, regarding proper food consistency. 2) Resident #12 had [DIAGNOSES REDACTED]. The Dysphagia Evaluation dated March 10, 2011, documented the resident was seen by the speech pathologist (SLP) for a "recent coughing/choking episode." The evaluation recorded the resident had a history of [REDACTED]. The resident was totally fed by staff and received a pureed diet with nectar thick liquids. The recommendations included feeding the resident small bites/sips at a slow rate. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognitive status was severely impaired. The resident required total assistance with activities of daily living (ADLs), including eating, and was on a mechanically altered diet. A nutrition note dated September 1, 2011 noted the resident's intake was 42%. Staff reported the resident was sleepy all the time and difficult to wake up. On September 28, 2011, the SLP documented staff requested an evaluation due to "observed difficulty during meals." The resident's dysphagia evaluation, by the SLP, dated September 29, 2011 documented recommendations including speech therapy for 30 days to increase safety, decrease aspiration risk, and increase ability to take oral nutrition/hydration. The evaluation instructed the resident was to remain on a pureed diet with nectar thick liquids. Feeding recommendations included feeding slowly, watching for swallow before giving more, and alternating liquids and solids. The Minimum Data Set (MDS) assessment dated [DATE] documented no signs or symptoms of possible swallowing disorder and the resident continued to be on a mechanically altered diet. The "updated plan of progress" by the (SLP) on November 4, 2011, documented the resident was required to be fed small amounts at a decreased rate with frequent presentation of liquids to clear the oral cavity of residue. The resident's diet remained pureed solids with nectar thick liquids and the SLP documented the resident did not open her mouth consistently. The resident had no overt signs of aspiration on the pureed diet, and oral residue was to be kept to a minimum with frequent sips of liquids. On November 16, 2011 at 7 PM, the resident was observed in the dining room during supper. The resident was coughing as the licensed practical nurse (LPN) fed her soup. When the surveyor asked the LPN about the consistency of the resident's soup (cream of broccoli) the LPN placed the spoon in the soup and large, regular consistency pieces of broccoli were observed. The LPN stated she was a float nurse to the unit, and thought maybe the resident was able to have the regular consistency soup. She said some residents on pureed diets were able to have some regular consistency foods. The LPN then reviewed the menu slip, that was on the resident's tray, which noted the resident was to have only pureed foods. The LPN stated, since the resident was eating poorly, she was not going to request a replacement soup and continued to feed the resident by skimming the thin (not nectar thick) liquid from the top of the soup. At 7:35 PM on November 16, 2011, the evening Dietary Supervisor observed the soup served to the resident, she stated the resident did not receive pureed soup as ordered. She stated there were two tray lines in the kitchen, one for regular and mechanical soft, and one for pureed, and the server "must have picked up the wrong soup." The current undated comprehensive care plan (CCP) documented the resident was at risk for aspiration, had a history of [REDACTED]. The plan included: a pureed diet with nectar thick liquids; providing small bites alternating with liquids/solids; feeding the resident slowly; giving small amounts; and watching for a complete swallow before giving more food. On November 18, 2011 at 10:45 AM, the facility's two registered dietitians (RDs) were interviewed and stated if the wrong consistency food was served to a resident it would be removed immediately, the unit staff would call the kitchen for the correct consistency, and the staff would let the RDs know about the problem. The RDs stated they were unaware the resident had received the wrong consistency soup at supper on November 16, 2011. They stated they were both in the facility that evening. On November 18, 2011 at 2:15 PM the evening Dietary Supervisor was interviewed and stated she checked the tray line and all food items served to residents on November 16, 2011 at supper. The Supervisor said she removed covers from the soup bowls and looked to make sure soups were the right consistency. In summary the facility: - failed to serve pureed soup at the proper consistency; - failed to report the improper consistency to the kitchen/supervisory staff; - failed to replace the improper consistency when identified, and continued to feed the resident the wrong consistency soup; and - failed to ensure staff knew the consistency of food residents were to be served/fed. 3) On November 16, 2011, the evening meal was observed on the 3rd floor between between 6:45 PM and 7:30 PM. Residents #12, 26 and 27 were observed with a scoop of white substance on their plates. Staff assisting in the dining room were unable to identify the food item. A pureed consistency test tray was obtained at 7:10 PM, on November 16, 2011, the food item was tasted, and found to be white rice. The rice was a thick, gummy consistency with grains of whole rice present. A breakfast tray was tested on [DATE] at 9 AM. The pureed sausage was ground into small, dry particles, that did not stick together. The sausage was dry and the particles left a gritty residue on the tongue that was not easily cleared without taking a drink. The sausage was not a cohesive, smooth consistency. The registered dietitian (RD #2) was interviewed on November 17, 2011 at 9:05 AM. She stated the sausage was sent from the kitchen and it was an appropriate consistency for pureed diets. The day shift cook was interviewed on November 17, 2011 at 9:30 AM. She stated she took some of the ground mechanical soft sausage, added chicken broth and mixed it in the commercial food processor. The cook said bread was no longer added to the puree meats making it difficult to get a smooth product. She stated the white rice was gummy last night and it got thicker as it sat on the trayline. Observation made during breakfast on November 18, 2011 from 9 - 9:15 AM showed the bread had a dried "skin", pieces of crust and unprocessed pieces of bread ranging in size from 1/8 to 1/4 of an inch. The day cook was interviewed on November 18, 2011 at 9:45 AM. She stated she used the recipe for pureed cinnamon toast. The day cook said she did not stir the product when it was on the trayline or add any liquid to it during the trayline service. She reviewed the recipe with the surveyor and the recipe noted "adjust liquid as needed to create a smooth, pudding consistency." The speech pathologist (SLP) was interviewed on November 18, 2011 at 10:30 AM. She stated she observed residents at meals and looked at the food consistency when she did those observations. The SLP said she checked meal tickets and informed the RDs if there was a concern. The SLP described a pureed diet to be the consistency of pudding or applesauce, and should be "cohesive." She stated if a food product was dry, a liquid might need to be added and she often recommended extra gravy or sauces. She stated pureed consistency should not have any pieces of food in it. The SLP said she was always in the dining rooms for breakfast and lunch, and if someone had a complaint, she passed it on. She was not involved in the kitchen, had not reviewed recipes for the kitchen, had not provided any training to dietary staff on pureeing food, and was not aware of any problem with food consistency. At 10:45 AM on November 18, 2011, the two facility RDs were interviewed. They both stated their role in the kitchen included checking meal tickets for current diets, monitoring food quality and alerting staff of special requests or complaints. RD #2 stated they did not oversee the functions of the kitchen as food service and clinical were separate and their function was mainly clinical. RD #1 stated she did test trays about twice a week, she said she chose what consistency food she was going to test and tested the food after the last person was served. RD #1 stated she had not done test trays recently, however the facility did meal rounds regularly on all floors for all 3 meals. RD #1 stated management did test trays on the weekends and were to notify the Food Service Director if there were issues. RD #2 stated the RDs did not check the pureed food for proper consistency and would not check it unless there was a "complaint." She did not think there was an issue with the pureed sausage as prior to the survey, no one (staff or residents) had voiced a problem. During the interview with both RDs on November 18, 2011 at 10:45 AM, they stated if the wrong consistency food was served they expected staff to remove the food and notify the kitchen immediately. They said they would be notified after the food was replaced. The RDs stated they were both working when supper was served on November 16, 2011 and were not aware there was a concern with the pureed rice. The Food Service Director was interviewed on November 18, 2011 at 11:30 AM, and stated there was no written policy regarding food consistency or checking of food on the tray line for accurate consistency. He said the dietary staff, at the beginning of the trayline,called out the diet consistency and the Supervisor, at the end of the trayline, checked the food for accuracy. The Supervisor, who was present during the interview, stated he was not aware of concerns with food consistency until he spoke with the surveyor the morning of November 18, 2011. During an interview on November 18, 2011 at 2:55 PM, the Food Service Director provided undated corporate policies that were not included in the facility's dietary Policy and Procedure Manual. He stated the policies were sent to him with his menus seasonally and addressed preparation of pureed food. All training/education records for dietary staff during the past year were requested by the surveyor. Review of the training records revealed dietary staff did not receive training on preparation or identification of altered consistency food during the past year. On November 18, 2011 at 3:25 PM the registered nurse (RN) Educator stated in an interview she discussed dietary for about "5 minutes" during initial general orientation. She stated she did not discuss pureed food consistency as most staff had children and knew what pureed food looked like. She stated she thought the dietary department conducted their own training when needed. In summary, the facility, - failed to prepare and monitor pureed consistency food properly; and - failed to educate staff on the preparation and identification of pureed food. ******************************************************************************************* The Immediate Jeopardy situation was removed on November 21, 2011 based on the following corrective actions taken by the facility: - dietary staff were trained on the proper preparation of pureed foods; - inservices were conducted with nursing, dietary and ancillary staff regarding the ability to identify proper food consistencies; and - quality checks were implemented, on the resident meal tray line, to ensure food served was properly pureed. 10NYCRR 415.14(d)(3)

Based on observation, staff interview, and record review conducted during the standard survey, it was determined the facility failed to provide a quality assessment and assurance program (QA) that readily and effectively identified issues with the potential to cause serious harm to the health and safety of residents related to food form, which affected 26 of the facility's 141 residents, including 6 sampled residents (Residents #12, 16, 19, 20, 21, and 23), and 20 residents out of the sample (Residents #25, 26, 27, and 31 through 47). Specifically, the QA Committee failed to monitor and resolve concerns with the food delivery system to ensure residents on modified consistency diets received food that was the proper consistency, in accordance with their diet order, after the wrong consistency food was served to a resident on a pureed diet (Resident #19) resulting in a choking incident. This resulted in Immediate Jeopardy to resident health and safety for residents on pureed consistency diets. The Immediate Jeopardy situation was removed on November 21, 2011 prior to the survey exit. Findings include: Resident #19 had [DIAGNOSES REDACTED]. The physician order [REDACTED]. An incident report documented on October 31, 2011, at lunch, that the resident received a whole banana, consumed part of the banana and choked. 2) Resident #12 had [DIAGNOSES REDACTED]. The current undated comprehensive care plan (CCP) documented the resident was at risk for aspiration, had a history of [REDACTED]. The plan included: a pureed diet with nectar thick liquids; providing small bites alternating with liquids/solids; feeding the resident slowly; giving small amounts; and watching for a complete swallow before giving more food. On November 16, 2011 at 7 PM, the resident was observed in the dining room during supper. The resident was coughing as the licensed practical nurse (LPN) fed her soup. When the surveyor asked the LPN about the consistency of the resident's soup (cream of broccoli) the LPN placed the spoon in the soup and large, regular consistency pieces of broccoli were observed. The LPN stated she was a float nurse to the unit, and thought maybe the resident was able to have the regular consistency soup. She said some residents on pureed diets were able to have some regular consistency foods. The LPN then reviewed the menu slip, that was on the resident's tray, which noted the resident was to have only pureed foods. The LPN stated, since the resident was eating poorly, she was not going to request a replacement soup and continued to feed the resident by skimming the thin (not nectar thick) liquid from the top of the soup. 3) A test tray was obtained at 7:10 PM, on November 16, 2011, the white rice served as pureed was a thick, gummy consistency with grains of whole rice present. A breakfast tray was tested on [DATE] at 9 AM. The pureed sausage was ground into small, dry particles, that did not stick together. The sausage was dry and the particles left a gritty residue on the tongue that was not easily cleared without taking a drink. The sausage was not a cohesive, smooth consistency. Observation made during breakfast on November 18, 2011 from 9 - 9:15 AM showed the pureed bread had a dried "skin", pieces of crust and unprocessed pieces of bread ranging in size from 1/8 to 1/4 of an inch. The Administrator/QA Coordinator was interviewed on November 18, 2011 between 12:30 PM and 1 PM. He stated there was a Manager on duty 7 days per week and the weekend Manager audited a meal on the weekends, including checking a test tray. The Administrator said the Manager on duty chose which meal they audited and which food consistency they tested . He stated he was not aware of any problems with food consistency from the test trays, and did not know if any pureed test trays were audited following the incident with Resident #19 on October 31, 2011. The Administrator stated after the choking incident management staff were assigned to each resident unit during breakfast and lunch. He said they helped serve meals and monitored during meals to ensure there were no problems. The administrator stated staff were trained in meal pass, including checking meal tickets during general orientation. He said the certified nurse aides (CNAs) and kitchen supervisors were re-educated following the incident with Resident #19. The Administrator stated he had not known of any problem with the consistency of pureed food. He said he was aware there was a problem with pureed sausage, bread, and rice consistency during the survey. On November 18, 2011 at 3:55 PM, the Administrator stated in an interview, the RDs had not completed any test trays during November, 2011. He said the trays/meals tested by the weekend Managers during November 2011, did not include pureed consistency food. Multiple staff interviews were conducted, regarding staff education on food consistency, following Resident #19's choking incident, on November 18, 2011 at the following times: the RDs at 10:45 AM; the previous acting Staff Educator registered nurse (RN) at 3 PM; the current RN Staff Educator at 3:15 PM; and the Assistant Director of Nursing (ADON) at 4:15 PM. Each person interviewed stated there was no further education provided in response to Resident #19's choking incident. The Director of Nursing (DON) was interviewed on November 18, 2011 at 12:30 PM, and stated the Dietary Supervisor was spoken to, by the Administrator and Food Service Director, regarding food consistency and accuracy of meals served to the residents. Review of inservices for the past year revealed the Food Service Director educated 2 dietary Supervisors on checking meal trays for accuracy following Resident #19's choking episode. No education was provided to nursing or interdisciplinary staff related to identification of altered consistency foods and passing meal trays. In summary, the facility failed to provide a QA program that readily identified significant quality issues with consistency of pureed food that had potential to cause serious harm to the health and safety of residents. ******************************************************************************************** The Immediate Jeopardy situation was removed on November 21, 2011 based on the following corrective actions taken by the facility: - dietary staff were trained on the proper preparation of pureed foods; - inservices were conducted with nursing, dietary and ancillary staff regarding the ability to identify proper food consistencies; and - quality checks were implemented, on the resident meal tray line, to ensure food served was properly pureed. 10NYCRR 415.27(a-c)

Based on observation, staff interview, and record review conducted during the standard survey, it was determined the facility did not ensure the resident was provided with sufficient fluid intake to maintain proper hydration and health. Specifically, the physician and nutrition staff were not notified timely when Resident #6's daily fluid intake decreased significantly below the assessed fluid needs. Interventions were not adequately developed or revised timely regarding the resident's decreased fluid intake, resulting in a hospital re-admission for dehydration. This resulted in actual harm that is not immediate jeopardy for Resident #6. Findings include: Resident #6 was admitted with [DIAGNOSES REDACTED]. The nutritional screen, dated March 3, 2011, by registered dietitian (RD) #1 documented the resident's daily fluid needs were 1750 cubic centimeters (cc)/day. The September 26, 2011 laboratory (lab) report documented the resident's BUN (blood urea nitrogen, a measure of hydration and kidney function) was 28 mg/dl (milligrams per deciliter; normal = 7 - 23 mg/dl). The resident's creatinine (a measure of kidney function) was 1.4 mg/dl (normal 0.7 - 1.5 mg/dl). The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively impaired, required extensive assistance with activities of daily living, could feed herself after set-up, was easily distracted and had physical behavioral symptoms towards others. The Dehydration Risk assessment dated [DATE] documented the resident was at high risk for dehydration related to a history of dehydration within the past year and a history of refusing fluids. The October 18, 2011 RD quarterly assessment documented the resident consumed approximately 2400 cc/day which exceeded her assessed fluid needs. The comprehensive care plan (CCP) dated October 25, 2011, documented the resident was a hydration risk related to her [DIAGNOSES REDACTED]. There was no rationale documented on the CCP for the diuretic therapy. The CCP documented the resident would be provided 1700 cc of fluid per day. The Meal/Fluid Intake Log and the Nourishment Intake Log documented on October 30, 2011 the resident consumed 1080 cc of fluid. On October 31, 2011 the resident consumed 840 cc of fluid. The October 31, 2011 lab report documented the resident's BUN was "critical high" of 92 mg/dl, her creatinine was high at 1.9 mg/dl and her sodium was high at 150 mmol/l (millimols per liter, normal = 135-148 mmol/l). The October 31, 2011 nursing progress note documented the physician was called at 5 PM due to the resident's "critical high BUN." The nursing note dated November 1, 2011 at 2:30 PM documented the physician ordered the resident's labs to be repeated on November 3, 2011 and nursing was to "push fluids." The Meal/Fluid Intake Log and the Nourishment Intake Logs documented on November 1, 2011 the resident consumed 1320 cc of fluid. The hospital transfer form dated November 2, 2011 documented the resident was being transferred to the hospital for evaluation. The transfer form recorded the resident had a decreased appetite, was consuming adequate fluids "per dietary", her BUN was critical at 92 and she had a history of [REDACTED]. The hospital's history and physical dated November 3, 2011 documented: - The resident had abnormal lab values. - The nursing facility reported the resident was eating and drinking. - The resident was on [MEDICATION NAME] (a diuretic) "for some unknown reason." - The resident was hydrated with 2 liters of fluid while in the emergency room and her lab work did not improve. - The resident was admitted to the hospital for further hydration. The plan included not giving the resident [MEDICATION NAME] and determining if there was a medical need for it. An addendum to the hospital's history and physical dated November 3, 2011 documented the resident was "extremely dehydrated because of the decreased oral intake secondary to dysphagia (swallowing difficulty). Her acute [MEDICAL CONDITION] is secondary to dehydration with prerenal azotemia (retention of excessive amounts of nitrogen compounds in the blood) which improved with intravenous fluids." The plan included to hydrate the resident, hold the [MEDICATION NAME], decrease the [MEDICATION NAME], obtain a swallowing evaluation, and place the resident on a "dysphagia diet" with aspiration precautions. The hospital's discharge summary dated November 4, 2011 documented the resident's labs were improved at the time of discharge with the creatinine at 1.4 mg/dl, BUN at 40 mg/dl and sodium at 145 mmol/l. The summary noted the resident was seen by the speech language pathologist and discharged on a dysphagia pureed diet with aspiration precautions. On November 4, 2011 at 3 PM, nursing notes documented the resident was readmitted to the facility. The re-admission physician's telephone orders, dated November 4, 2011, documented the resident was to receive "[MEDICATION NAME] 40 mg every day for [MEDICAL CONDITION]"; "must have at least 1500 cc of fluid daily; needs assistance with all meals; on aspiration precautions"; and ordered a "mechanical soft" consistency diet. The resident's admission history and physical, by the physician, dated November 5, 2011, documented the resident was "actually dehydrated" when hospitalized . The physician documented the resident was currently on [MEDICATION NAME] 20 mg daily (not 40 mg as ordered), with a plan to "maintain hydration" and "continue medication." The H&P did not address the hospital's plan from November 3, 2011 to hold the [MEDICATION NAME]. Review of the resident's CCP revealed there were no documented changes to the planned interventions to prevent a recurrence of the resident's dehydration upon her re-admission to the facility. Review of the most current physician orders [REDACTED]. The Meal/Fluid Intake Log and the Nourishment Intake Log documented the resident consumed 1080 cc/day and 840 cc/day, respectively for November 5 and 6, 2011 from meals and nourishments. On November 7, 2011, RD #1's re-admission assessment documented the resident had a history of [REDACTED]. On November 7, 2011, 2:45 PM, nursing notes documented the resident was "crying out during the day". At 11 PM that evening, nursing notes specified the resident was "crying without any explanation of reason." On November 8, 2011 at 3:25 PM, nursing notes wrote that the resident was "very weepy and upset this morning; refused all morning medications." The nursing progress note documented the resident refused supper on November 8, 2011. On November 9, 2011 at 2:30 PM, the nursing note documented the resident refused breakfast and morning medications. At 11 PM that evening, the nurse documented the resident's appetite was poor at supper and she was throwing her food and drinks on the floor. The Meal/Fluid Intake Log and the Nourishment Intake Log documented the resident consumed 1560 cc of fluid on November 9, 2011, and 1360 cc of fluid on November 10, 2011. The Meal/Fluid Intake Log and the Nourishment Intake Log documented the resident's fluid intake was: - 540 cc on November 11, 2011; - 240 cc on November 12, 2011; - 390 cc on November 13, 2011; and - 90 cc on November 14, 2011. Review of the resident's CCP (last printed October 25, 2011) revealed there were no changes to the interventions to address her hydration status, when her intake consistently was below her assessed needs. Review of the 24-hour nursing reports from November 11 - 14, 2011 revealed residents' names were documented who consumed less than 1000 cc/24-hour period. These 24 hour reports contained no documentation regarding Resident #6's intake. The nursing notes dated November 11-14, 2011 contained no documented evidence the physician or RD were notified of the decline in the resident's fluid intake. There was no documented evidence the resident was assessed by a registered nurse (RN) or a physician when she consumed less than 1000 cc for 4 consecutive days (a total of 1260 cc in 4 days). The November 15, 2011 RN Manager's progress note documented the physician was notified of the resident decreased oral intake with increased lethargy. The note recorded the physician ordered lab work. The Meal/Fluid Intake Log and the Nourishment Intake Log documented on November 15, 2011 resident consumed 30 cc of fluid. During the initial unit tour of the facility on November 16, 2011 at 11 AM, the resident was observed in bed lying on her back. When the surveyor attempted to engage the resident in conversation, the resident did not respond. The nursing note dated November 16, 2011 at 1 PM documented the resident's BUN was elevated at 65 mg/dl and she was being sent to the hospital. The surveyor observed the resident on November 16, 2011 at 1:20 PM and she did not respond when spoken to by the surveyor. On November 16, 2011 at 1:30 PM, the surveyor interviewed the RN Manager. The RN Manager stated the resident used to be verbally and physically aggressive and was now a psychiatric resident with dementia. She stated the resident chose to "go down hill." the RN Manager said she spoke to the physician about end of life care for the resident. Review of the 24 Hour Nursing Services Report, dated November 16, 2011, revealed the resident consumed less than 1000 cc in 24 hours; had a decline in condition; and was admitted to the hospital with [REDACTED]. On November 21, 2011 at 11:35 AM, the surveyor interviewed the facility's 2 RDs. RD#1 stated when she assessed the resident on November 7, 2011, the resident was meeting her fluid needs. They said an intake study was done from November 9 - 11, 2011 that showed the resident was consuming 1570 cc of fluid daily. After that, the resident had a decline in her fluid intakes. RD #1 stated she would have been notified of the decline in intake from reviewing the 24-hour report. She stated when the resident had the decline, it was not documented on 24-hour report. Both RD #1 and RD #2 stated they were not aware of the decline in the resident's intake. Both RDs said they did not reassess the resident or make changes to the plan of care as they were not aware her intakes had declined since November 7, 2011. During an interview with the attending physician on November 21, 2011 at 12:10 PM, he stated he would expect to be notified if a resident was drinking poorly within 48-72 hours, with 72 hours being the maximum amount of time nursing should go before notifying him. He stated prior to the resident's first hospitalization (November 2, 2011), he found out the resident was not eating or drinking and her BUN was 92 mg/dl. He stated when she came back to the facility, she became dehydrated again. The physician said the nurse told him "I don't know what to do." The physician said the nurse asked him for end of life care for the resident and stated the resident would not eat or drink. He stated the next day, the resident's BUN was 65 mg/dl and she was sent to the hospital again and admitted with dehydration. The physician stated the resident had a history of [REDACTED]. In summary the facility caused harm to the resident as the facility:: - did not ensure fluid interventions were revised to prevent a recurrence of dehydration after readmission to the facility following the first episode of dehydration in November 2, 2011; - did not ensure the physician and nutrition staff were notified timely when the resident's daily fluid intakes from November 11-15, 2001 averaged 258 cc, and dropped significantly below the resident's assessed fluid needs; - did not take adequate and timely interventions to address the resident's suboptimal fluid intakes resulting in the resident being readmitted to the hospital with [REDACTED]. 10 NYCRR 415.12 (j)