Every finding on record at Auburn Rehabilitation & Nursing Center

Based on observations, record review, and interviews during the recertification and abbreviated surveys (NY00364436) conducted 1/2/2025 -1/7/2025, the facility did not ensure residents received adequate supervision to prevent accidents for 1 of 4 residents (Resident #276) reviewed. Specifically, Resident #276 did not have their hydrocollator pack (a device that heats cloth pads filled with a soft clay to provide moist heat therapy) monitored during therapy, causing a blister to their shoulder. This resulted in harm to Resident #276 that was not Immediate Jeopardy. Findings include: The updated facility policy, Applying a hydrocollator Pack, documented the hydrocollator was placed in the pocket of the terry cloth covering, then three (3) double-layer terry cloth towels were applied. The resident was checked for redness after five (5) minutes and if redness found, another layer of protective terry cloth towels was placed to prevent a burn. The hydrocollator was removed after 20 minutes. Hydrocollator temperatures were taken daily to ensure they were between 160 and 166 degrees Fahrenheit and recorded in a temperature log. The John Hopkins University classification of burns documented: - First-degree (superficial) burns affect only the outer layer of skin. The burn site is red, painful, dry, and with no blisters. - Second-degree (partial thickness) burns involve the outer layer and part of the second layer (dermis) of skin. The burn site appears red, blistered, and may be swollen and painful. Resident #276 had diagnoses including arthritis, chronic venous insufficiency (poor circulation), and morbid obesity. The 11/17/2024 Minimum Data Set (an assessment tool) admission assessment documented the resident had intact cognition, required moderate to maximum assistance for most activities of daily living, had constant pain in the last five (5) days, and occasionally was not able to sleep due to the pain. The 7/10/2024 Comprehensive Care Plan documented Resident #276 had pain related to arthritis and decreased mobility. Interventions included monitoring pain, administration of pain medication, and evaluating efficacy of pain medication. The resident had potential/actual impairment to skin integrity related to venous insufficiency. Interventions included educate resident/family/caregivers of causative factors and measures to prevent skin injury. The hydrocollator temperatures for December 2024 were documented between 160 and 162 degrees Fahrenheit. The temperature on 12/11/2024 was documented at 161 degrees Fahrenheit. The 12/11/2024 at 3:18 PM Director of Nursing #2 progress note documented Resident #276 was assessed for a 3.0 by 5.0 (no units of measure documented) deroofed (top layer of skin has rubbed off) blister to the left shoulder. The resident reported it formed after hot pack therapy in their room earlier that day. The resident stated they would notify their adult child. Nurse Practitioner #17 was notified and would be in to evaluate. There was no documented evidence Nurse Practitioner #17 evaluated the resident's skin impairment on 12/11/2024. The 12/11/2024 facility Incident Report, completed by Director of Nursing #2, documented Resident #276 reported a blister on their left shoulder following hot pack therapy (hydrocollator) earlier in the day. They observed a 3.0 by 5.0 (units of measure not documented) deroofed blister on the left shoulder. Certified Occupational Therapy Assistant #23 was the treating therapist and stated they put the hot pack on the resident at 11:00 AM and removed it at approximately 11:25 AM. Certified Occupational Therapy Assistant #23 and therapy staff were educated on the policy and procedure for applying a hydrocollator with demonstration and return demonstration. Certified Occupational Therapy Assistant #23 was suspended pending an investigation. The hydrocollator machine was placed out of service until it could be inspected by maintenance and passed inspection. Nurse Practitioner #17 was notified at 3:18 PM. The 12/11/2024 Incident Report witness statement from Resident #276 documented they were unsure what time it was when the therapist put the heat pack on their shoulder. If it was 9:50 AM, they were to remove it at 10:05 AM. If it was 10:50 AM, they were to remove it at 11:05 AM. They fell asleep and the therapist returned at 20-25 minutes after the hour. Later in the day, they noted pain in their shoulder and observed a blister. The 12/12/2024 witness statement from Certified Occupational Therapy Assistant #23 documented on 12/11/2024 at approximately 11:00 AM, they applied a heat pack to Resident #276's left shoulder and educated the resident to remove it in 20 minutes while they worked with another resident. When they returned 25 minutes later, the heat pack remained on the resident's shoulder and the resident was asleep. The 12/12/2024 counseling memo documented Certified Occupational Therapy Assist #23 was counseled related to not checking the resident 5 minutes after application of the hydrocollator and leaving it on 5 minutes too long. They were educated on the policy and completed the competency. A 12/13/2024 at 1:30 PM Nurse Practitioner #17 progress note documented the resident continued with the area to their left shoulder, which resembled an old, sealed blister-like area. There was some concern it may be infected; area was white and sealed off. It did not resemble an infection to them; however, they would continue to monitor, and treatment course could change. The plan was to continue to monitor and apply Silvadene (topical antimicrobial cream used to prevent and treat wound infections in individuals with second and third-degree burns) to the shoulder. There was no further documented evidence of progress notes addressing the wound on the resident's shoulder. Director of Maintenance #4 documented the hydrocollator was in proper working order when inspected on 12/12/2024. During an interview and observation on 1/7/2025 at 9:15 AM, Resident #276 stated the first time they used the hot pack was on 12/11/2024 and they had not used it since, as they got a blister on their left shoulder. A pea-sized scab was observed on the resident's left anterior (front) shoulder. The skin surrounding the scab was reddened. The resident stated the area was much bigger when it happened, and it was healing well. They stated during the hot pack treatment they were able to remove the hot pack; however, did not believe they were told to remove the hot pack and if they were told, they did not remember that. They were in their room when the heat pack was applied, they did not remove the heat pack, and were asleep when the therapist returned. During an interview on 1/7/2025 at 9:25 AM, Certified Occupational Therapy Assistant #23 stated they did not use the hydrocollator often. They used it in Resident #276's room on 12/11/2024. The resident requested it for shoulder pain. When they applied the hydrocollator they placed it in the terry cloth pouch and used three terry cloth layers. They did not visualize the resident's skin after 5 minutes as per policy but did ask the resident if they had pain. They educated the resident to remove the hydrocollator and left the room to help with another resident. They returned after 25 minutes, and the resident was asleep with the hydrocollator on. It should have been removed after 15-20 minutes. If the hydrocollator was left on too long, a resident could get a burn. During an interview on 1/7/2025 at 9:35 AM, Director of Rehabilitation #5 stated hydrocollator therapy was only used with residents who had intact cognition and could report pain and was never used on a resident who had a decreased skin sensation. They stated residents should be visibly checked for skin redness after five minutes, and the pack should not be left on longer than 20 minutes. Resident #276 was not visibly checked for skin redness after 5 minutes and should have been. The resident's cognition was intact, and they could tell the therapist if they had pain. Since the injury, hydrocollator therapy was no longer allowed in a resident's room and could only be done in the therapy gym under supervision. If the hydrocollator was not checked after five minutes or left on longer than 20 minutes, residents could suffer a burn to their skin. During an interview on 1/7/2025 at 2:36 PM, Director of Nursing #2 stated they expected physical therapy to visually check skin after application of the hydrocollator for five minutes to prevent burns. 10NYCRR 415.12 (h)

Based on observations, record review, and interviews during the recertification and abbreviated surveys (NY00356805) conducted 1/2/2025-1/7/2025, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 4 of 4 resident halls (North, West, East, and South). Specifically, there was a strong urine smell on North, West, East, and South halls; there was food and debris on the floor in the Northwest common area; Resident room [ROOM NUMBER] was unclean with food debris and spots on the floor and floor mats; and Resident #16 wanted a chair in their room and did not have one. Findings include: The facility policy, Damp Mopping, dated 3/12/2020, documented all areas were maintained in a clean and pleasant manner. Mop heads were placed in a prepared detergent solution. After wringing out the mop, it would be used along the baseboard and then in a figure 8 stroke across the area. Detergent solution was changed after each room. The facility policy, Resident Rights, revised 3/22/2022, documented the facility would maintain a safe, sanitary, clean, comfortable, and homelike environment with adequate and comfortable lighting for the resident. During observations on 1/2/2025 at 9:07 AM and 1/3/2025 at 8:23 AM there was a strong urine smell when entering the facility. During observations on 1/2/2025 at 9:30 AM, the South Hall had a strong urine smell and food debris covered the floor in the Northwest common area where residents were sitting. Observations of room [ROOM NUMBER] were made at the following times: - on 1/2/2025 at 9:47 AM, there were many crumbs on the floor. - on 1/3/2025 at 8:51 AM, the fall mats on both sides of the bed had white circular spots. - on 1/3/2025 at 11:46 AM, there were orange crumbs and a cup, cup lid, and a medicine cup on the floor on the right side of the bed - on 1/7/2025 at 10:21 AM, the fall mats on both sides of the bed had white circular spots. During an observation and interview on 1/6/2025 at 9:03 AM, Resident #16 stated they wanted a chair to sit in, preferably a recliner. There was no chair observed in the room. The resident was eating off their wheelchair as they did not have a tray table. During a telephone interview on 1/6/2025 at 11:13 AM, an anonymous family member stated the facility smelled awful. When they entered the building there was a urine smell. They stated nursing homes should not smell like and urine. During an interview on 1/3/2025 at 10:52 AM, Certified Nurse Aide #7 stated it was everyone's responsibility to clean the facility. They thought they had housekeepers but was not sure what their exact role was. Crumbs and trash on the floor would make the resident feel like it's not clean or homelike. They stated they noticed a strong urine smell in the halls and did not do anything about it. During an interview on 1/6/2025 at 8:33 AM, Housekeeper #35 stated they deep cleaned rooms based on a schedule, but they swept and mopped every day. They cleaned offices, did room changes, set up for new admissions, passed briefs, and did laundry. They sometimes had enough staff to do everything, but it depended on the schedule. They rarely left tasks undone. Housekeeping was only in the building from 7:00 AM to 3:00 PM or 8:00 AM to 4:00 PM. If crumbs were on the floor after they left for the day, nursing staff should clean the floor. They were told by nursing staff that it was a housekeeper's job. They had seen a lot of crumbs in room [ROOM NUMBER]. It could make the resident feel like it was not homelike. It would be helpful if they had housekeepers on at night. During an interview on 1/6/2025 at 1:00 PM, Licensed Practical Nurse Unit Manager #6 stated they smelled urine when they walked in the building and notified housekeeping. It was nursing's responsibility to clean rooms when housekeeping left for the day. If there was food on the floor it could lead to infection control issues and attracted insects. It was not homelike to have a strong urine smell in the building or food on the floors. During an interview on 1/6/2025 at 1:41 PM, the Maintenance Director stated they over saw housekeeping, laundry, and maintenance. It had been reported to them that it smelled of urine in the facility. They would walk around the building to see if residents needed to be changed. They would also look to see if was from the bed or on the floor, this would help narrow down where the smell was coming from and try to fix it. It was not homelike. They had staff working in the building from 7:00 AM to 3:00 PM or 8:00 AM to 4:00 PM. If there were crumbs or food on the floor any staff member could pick it up. The housekeeping staff had reported rooms were messy with crumbs and left for them to clean. During an interview on 1/7/2025 at 10:55 AM, Registered Nurse Unit Manager #14 stated Resident #16 did not have a tray table this morning to set their breakfast tray on and they went and got one. They stated the resident's room was bare and not homelike. They were unaware the resident wanted a chair. During an interview on 1/7/2024 at 2:36 PM, the Director of Nursing stated they expected all areas to be clean. Floor mats should not have spots on them. Food should not be on the floor. It was not homelike for residents to have food and debris on the floor. Food on the floor could lead to pests. 10 NYCRR 415.29(j)(1)

Based on observations, record review, and interviews during the recertification and abbreviated (NY000325307, NY00035605, and NY000359258) surveys conducted 1/2/2025-1/7/2025, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 of 5 residents (Residents #4, #24, #27, and #178) reviewed. Specifically, Resident #4 was not provided oral care; Resident #24 was not shaved as planned; Resident #27 was not provided toenail care as planned; and Resident #178 was not showered, shaved, or groomed as planned. Findings include: The facility policy, Activity of Daily Living, Range of Motion and Mobility Policy, dated 10/2024, documented care and services for the activity of daily living included: - Hygiene- bathing, dressing, grooming, and oral care - Mobility- transfer and ambulation including walking. - Elimination- toileting - Dining- eating, including meals and snacks. On admission a resident's activity of daily living status was assessed and as part of a Comprehensive Care Plan, efforts were made to maintain the individuals' clinical condition and to avoid any reduction in activity of daily living. 1) Resident #178 had diagnoses including transient ischemic attack (blood flow to the brain is temporarily disrupted), hemiplegia (paralysis on one side of the body), and traumatic brain injury. The 11/272024 Minimum Data Set assessment documented the resident had severely impaired cognition, did not reject care, felt it was important to choose between bed bath, or shower, required partial to moderate assistance with showering, and supervision/ touching assistance for personal hygiene. The Comprehensive Care Plan updated on 11/22/2024 documented the resident had an activity of daily living self-care performance deficit and impaired physical mobility related to activity intolerance and limited mobility. Interventions included limited assistance of one with bathing/showering once a week and as needed and for personal hygiene and oral care. The 12/22/2024 care instructions documented the resident required limited assistance of one with bathing or showering, personal hygiene, and oral care. The 1/1/2025-1/6/2025 certified nurse aide care documentation documented personal hygiene was not applicable or was left blank on 1/1/2025, 1/2/2025, 1/3/2025, 1/4/2025 and 1/6/2025. Resident #178 was observed at the following times: - on 1/2/2025 at 11:12 AM, sitting in their room in their wheelchair with a full beard. The resident was drooling, and their shirt had drool on it. - on 1/3/2025 at 9:40 AM, sitting in their wheelchair looking out the window. They were unshaven. - on 1/6/2025 at 8:02 AM, sitting in the doorway of their room in a wheelchair. They were not shaved. Certified Nurse Aide # 27 and Licensed Practical Nurse Unit Manager #6 were talking to the resident about going to the bathroom. During an observation and interview on 1/6/2025 at 8:58 AM, the resident had a full beard and white flakes in their hair. The resident nodded their head yes when asked if they wanted a shower and to be shaved. During an interview on 1/6/2025 at 8:07 AM, Certified Nurse Aide #27 stated Resident #178 was gotten up by the night shift and they were unsure what the night routine was. They stated the resident's shower day was Wednesday on the day shift. The resident should be shaved daily with their personal hygiene care. During an interview on 1/6/2025 at 10:46 AM, Licensed Practical Nurse Unit Manager #6 stated the resident has not adjusted well to being in the nursing home. The resident should be provided care by the night shift, around 6:00 or 6:30 AM. This care included shaving, oral care, and dressing. The resident should have had a shower last Wednesday and had their hair washed at that time. The resident should not have dandruff in their hair if they were showered. It was important for the resident's quality of life, dignity, and skin integrity to have good personal hygiene and grooming. The resident should be assisted on any shift, by any staff member if requested by the resident. During an interview on 1/6/2025 at 11:13 AM, the Resident #178's family member stated they had concerns with the resident not having their hair washed or being shaved. the resident would not want a full beard and they have always shaved. They stated they had multiple conversations with staff about providing the resident a shower because they did not smell good. 2) Resident #4 had diagnoses including developmental disorder and hemiplegia (weakness to the right side) following a cerebral vascular accident (stroke). The 10/9/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, required moderate to maximum assistance for bathing, oral care, and hygiene, and did not refuse care. The Comprehensive Care Plan initiated 10/25/2019 documented the resident had activities of daily living self-care deficit related to disease processes. Interventions included extensive assistance of one for hygiene and oral care. The undated certified nurse aide resident care card (care instructions) documented the resident required mouth care every shift and extensive assistance of one for oral care. The 9/24/2024 dental consult documented Resident #4 had obvious or likely cavities and broken teeth and recommended staff assist with oral care. The December certified nurse aide task form documented personal hygiene included combing hair, brushing teeth, shaving, applying makeup, washing, and drying face and hands. The December task list did not document any care was completed on: - 12/2/2024 and 12/25/2024 day shift. - 12/1, 12/6, 12/9, 12/14, 12/16, 12/18, 12/19, 12/22, 12/23, 12/26, 12/28, and 12/31/2024 on the evening shift. - 12/1, 12/13, 12/20, or 12/26 on the night shift. Resident #4 was observed: - on 1/2/2025 at 9:52 AM, in their bed with their mouth open. The resident's teeth were brown and the odor from their mouth was foul. - on 1/3/2025 at 8:51 AM, in bed with brown teeth and a foul odor from their mouth - on 1/6/2025 at 10:04 AM, in bed with brown teeth and a foul odor from their mouth - on 1/7/2025 at 8:50 AM, in a chair in front of the TV by the front door with brown teeth and a foul odor from their mouth. During an interview on 1/6/2025 at 10:12 AM, Certified Nurse Aide #10 stated residents were given a bed bath every day as part of their morning care which included oral care. Resident #4 had their morning care already and oral care was not completed as they were busy. If a resident did not get oral care their teeth could decay, and they might not eat as well. During an interview on 1/6/2025 at 1:00 PM, Licensed Practical Nurse #6 stated If residents did not get oral care they could damage their teeth, be unable to chew their food, and lose weight. During an interview on 1/7/2025 at 1:28 PM, Certified Nurse Aide #26 stated they completed all morning care for Resident #4 and did not provide oral care as they were busy and hoped it had been done by the night shift who got the resident out of bed. They stated they should have provided oral care. If residents did not get oral care they could develop gum disease. 3) Resident #27 had diagnoses including chronic obstructive pulmonary disease (lung disease), diabetes, and depression. The 12/2/2024 Minimum Data Set assessment documented the resident had intact cognition, did not refuse care, and required moderate assistance with most activities of daily living. The Comprehensive Care Plan revised 8/28/2023 documented the resident had an activities of daily living self-care deficit related to limited physical mobility and required extensive staff assistance for hygiene needs. The undated certified nurse aide resident care card (care instructions) documented the resident required extensive assistance of one for personal hygiene. Resident #27 was observed: - on 1/2/2025 at 9:47 AM, in their room in bed, they had a left leg amputation. Their right toenails were brown with a black substance around the nail beds. - on 1/6/2025 at 10:12 AM, in their room in bed. Their right toenails were brown with a black substance around the nail beds. During an interview on 1/6/2025 at 10:12 AM, Certified Nurse Aide #10 stated residents were showered once a week on their assigned shower day and included providing nail care. Residents were also given a bed bath every day as part of their morning care and included nail care. They did not clip toenails, however, were responsible for cleaning feet and toenails. They stated Resident #27 had their morning care, did not refuse care, and was not provided toenail care as they were busy. They looked at Resident #27 toenails and stated they were not cleaned and should have been. If toenails were not cleaned as planned residents could get an infection. During an interview on 1/6/2025 at 1:00 PM, Licensed Practical Nurse #6 stated all nursing staff was responsible for providing toenail care and diabetics required more attention to toenail care. If toenail care was not completed the resident could get an infection. During an interview on 1/6/2025 at 4:56 PM, Resident #27 stated before coming into the facility, they showered every day and were told by staff that they could only shower weekly when here. They stated it was unclean to shower only once a week and wished their foot and toenails were cleaned every day. This was the only day since admission their foot and toenails were washed. During an interview on 1/7/2025 at 2:36 PM, Director of Nursing #2 stated they expected residents received oral care, shaving, shampooing of hair, nail care, toenail care, and bathing unless they refused. They did not expect to see female residents with chin hair, residents did not have to ask to be shaved, and if a resident wanted their chin hair shaved and it was not it could be a dignity issue. If a resident did not have oral care teeth could breakdown and they could get an infection. It was more important to provide toenail care with residents diagnosed with diabetes because they had decreased feeling in their feet and if toenails were not cleaned the resident could get an infection. 10NYCRR 415.12(a)(3)

Based on observations and interviews during the recertification survey conducted 1/2/2025-1/7/2025, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles and includes the expiration date when applicable for 1 of 2 medication carts and 1 of 1 treatment cart on the East Hall. Specifically, the East Hall medication cart was left unsecured; contained an expired insulin pen and an insulin pen without an opened or expired/discard date for Resident #27; and an insulin pen without any resident identifiers or opened/discharge date . Additionally, the East Hall treatment cart was left unsecured and contained medications and scissors. Findings include: The facility policy, Storage-Labeling-Maintenance of Medications, revised 11/8/2023, documented medications were stored safety, securely, and properly, following manufacturer's recommendations. The medication supply was accessible only to licensed nursing personal, pharmacy personnel, and staff members lawfully authorized to administer medications. All drugs were to be stored in the locked designated cabinets. Medication carts must be locked at all times when not in use, including during medication passes when the nurse stepped away from the cart. Medications with shortened expiration dates (i.e. insulins) must be dated when opened. Expired medications were removed from use and returned to the Pharmacy. Medication labels must be legible at all times and include resident name and expiration date when applicable. During an observation on 1/6/2025 at 8:24 AM, medication cart three was in the East Hall against the wall near room [ROOM NUMBER]. The cart was unlocked and had resident information visible on the computer. No staff were observed in the hall or around the medication cart. During an observation and interview on 1/6/2025 at 8:48 AM with Licensed Practical Nurse #8, the East Hall medication cart three contained the following: - Toujeo Max Solostar (insulin glargine) 300 units, with an opened date of 12/2/2024 for Resident #27. Licensed Practical Nurse #8 stated some insulins expired in 28 days and others were 30 days, but either way that medication was expired. They stated there were no other Toujeo pens for that resident and it was administered to Resident #27 on the evening shift of 1/5/2025. - Insulin glargine 100 units/milliliter, without a resident label or opened date. Licensed Practical Nurse #8 stated they were not sure which resident the insulin belonged to or when it was opened. They stated when a new resident was admitted , or a resident ran out of insulin they would get a new insulin pen from the stock. It should have had a resident's name on it and the date it was opened so they knew when it expired, and to ensure it was only used on one resident. If it was administered to another resident, it could contaminate the resident with another resident's blood. - Insulin aspart 100 units/milliliter, without an opened date for Resident #27. Licensed Practical Nurse #8 stated if there was no open date, they would not know when it expired. They stated they were not sure when Resident #27 received this medication last, but thought it was 1/5/2025. If the resident was given an expired medication, they were not getting the full dose as it was not as effective after the expiration date. Licensed Practical Nurse #8 stated that resident information should be protected. They felt they were behind and rushing to complete tasks which was why they left the medication cart unlocked. The medication cart should always be locked for safety reasons. During an observation on 1/7/2025 at 1:27 PM, the East Hall treatment cart was in the hall near room [ROOM NUMBER], unlocked. The door for room [ROOM NUMBER] was shut. Residents were observed in the hall. There were no staff present in the hall or around the treatment cart. During an observation and interview on 1/7/2025 at 2:07 PM, Licensed Practical Nurse #9 provided access to the treatment cart which included medications, dressing supplies, and scissors. They stated the treatment cart should be locked at all times for the safety of the residents as it contained creams and scissors. They stated they should not have left the cart unlocked, but they did not have a key for the cart, so they had to keep it unlocked. Medication cart one and the treatment cart used the same key, they were not sure why there was not an additional key available for the treatment cart. During an interview on 1/6/2025 at 1:00 PM, Licensed Practical Nurse Unit Manager #6 stated the medication cart should not be unlocked when unattended as any staff member or resident could get into it. It was supposed to be locked for safety reasons. The resident information should not be on the screen as it violated the resident's privacy. Insulin was good for 28 days. The medication dated 12/2/2024 should no longer be in the cart as it was not effective. If it was given to the resident they could have high blood sugar. Insulin should never be in the cart without a resident's name. When insulin was taken out from stock a resident label and date should be applied. During an interview on 1/7/2025 at 2:36 PM, the Director of Nursing stated the medication cart should always be locked when unattended. Residents could access the medications if it was unlocked, and this could be harmful. There were scissors in the treatment cart and medicated creams that could also be harmful if swallowed. The treatment cart had a key, and it was not the same as the medication cart. Every cart had a key, and they had spares, so the treatment cart should always be locked. 10 NYCRR 483.45 (g)(h)

Based on observations and interviews during the recertification survey conducted 1/2/2025-1/7/2025, the facility did not ensure each resident received and the facility provided food and drink that was palatable, flavorful, and at an appetizing temperature for 2 of 2 meals reviewed (1/3/2025 and 1/6/2025 lunch meals on the East Hall). Specifically, food was not flavorful and was not served at palatable and appetizing temperatures during the lunch meals on 1/3/2025 and 1/6/2025. Additionally, two residents (Resident #24 and #53) interviewed stated the food did not taste good and was cold. Findings include: The facility policy, Food and Nutrition Services, dated 10/2023, documented each resident was provided with a nourishing, palatable, well-balanced diet that met their daily nutritional needs. Food and nutrition services staff would inspect food trays to ensure the food appeared palatable and attractive and was served at safe and appetizing temperatures. Food palatability was evaluated by data collection from resident surveys, focus group sessions, meal observations, staff feedback, and taste testing. During an interview on 1/2/2025 at 10:35 AM, Resident #24 stated the food was not hot and lacked flavor. During an interview on 1/2/2025 at 2:53 PM, Resident #53 stated the food was cold and did not taste good. During an interview on 1/3/2025 at 10:52 AM, Certified Nurse Aide #7 stated the residents complained about the food. They said it was not good, bland, and cold. They offered to heat the food in the microwave or offer an alternative. If a resident did not eat, they could lose weight. During a lunch meal observation on the East Hall on 1/3/2025 at 12:48 PM Resident #24 was served their lunch meal tray. A replacement tray was ordered, and Resident #24's original meal tray was tested . At 12:48 PM, food temperatures were taken and verified by Certified Nurse Aide #7. The applesauce was measured at 49 degrees Fahrenheit, the orange juice was 64.8 degrees Fahrenheit, and the milk was 53 degrees Fahrenheit. During a lunch meal observation on the East Hall on 1/6/2025 at 12:41 PM, Resident #53 was served their lunch meal tray. A replacement tray was ordered, and Resident #53's original meal tray was tested . At 12:41 PM, food temperatures were taken and verified by Certified Nurse Aide #10. The hamburger stew was measured at 131.9 degrees Fahrenheit, the milk was 59.2 degrees Fahrenheit, the beans were 118 degrees Fahrenheit, the coffee was 125.6 degrees Fahrenheit, and the banana was bruised with 2 inches of brown discoloration at the end. During an interview on 1/6/2025 at 1:00 PM, Licensed Practical Nurse Unit Manager #6 stated the residents complained about the food. They changed the menu, and the residents were not complaining as much. The food served for lunch on 1/6/2025 did not look good. The residents complained the food was bland. If they did not eat, they would not get proper nutrition, and could get sick or lose weight. During an interview on 1/6/2025 at 2:45 PM, Resident #53 stated they did not eat their lunch because it did not look appetizing. During an interview on 1/6/2025 at 2:33 PM, Dietary [NAME] #11 stated hot food should be served to the residents at temperatures between 140-165 degrees Fahrenheit, and cold food should be between 30-34 degrees Fahrenheit. If food was served at temperatures outside of those ranges the residents could get sick. If a resident did not eat the food served, they should be offered an alternative like grilled cheese, peanut butter and jelly or tuna salad sandwiches. During an interview on 1/6/2025 at 2:37 PM, Food Service Director #12 stated hot food should be greater than 165 degrees Fahrenheit when served to the resident, and cold food should be under 41 degrees Fahrenheit when served to the resident. The temperatures from the test tray on 1/6/2025 were outside the recommended temperature range. If a resident ate that food, they could get food borne illness. They stated residents said the food was not good, lacked flavor, and they did not like it. If they did not eat, they could lose weight and get sick. The food should look appetizing. They stated they did not think the food looked appetizing on 1/6/2025, they did not like that meal, and it should be replaced. During an interview on 1/7/2025 at 2:36 PM, the Director of Nursing stated residents used to complain about the food, but it was getting better with the new staff. They also had complained about the food temperatures, but they were also improving. They expected food to be at the appropriate temperatures and palatable when served to the residents. 10NYCRR 415.14(d)(1)(2)

Based on observations, record review, and interviews during the recertification survey conducted 1/2/2025-1/7/2025, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for 1 of 1 main kitchen, and 1 of 2 (Northwest Unit) kitchenette nourishment areas. Specifically, the main kitchen had soiled and poorly maintained equipment, improper food and food product storage, and the lack of access to proper hand washing facilities; and the nourishment area on the Northwest Unit had unclean equipment. Findings include: The facility policy, Food Preparation Service, dated 9/2022, documented Food and Nutrition Services employees prepare and serve food in a manner that complied with safe food handling practices. The food preparation area was large enough to meet the needs of the facility. The department had a rotating cleaning list created by the Director to ensure the department was kept in proper sanitary compliance with all federal and local health codes. Food preparation staff adhered to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Handwashing sinks were located near food preparation and clean dish areas and were separate from ware washing sinks. Bare hand contact with food was prohibited. Gloves were worn when handling food directly and changed between tasks. Disposable gloves were single-use items and were discarded after each use. The undated facility policy, Cleaning and mopping of Floors ([NAME] Tile and Walk in Cooler), documented all floor areas of the department were swept and mopped 3-times daily. Food and Food Product Storage During an observation on 1/2/2025 at 9:26 AM, a cart with several racks of bread was outside the kitchen back entrance on the loading dock. Racks of paper products for the food service, single service dishware, and cleaning products were also stored outside on the loading dock. The loading dock had a roof that projected out from the building The area was open on the sides, not protected from elements and pests, and was not an enclosed storage area that was smooth and easily cleanable. The area was littered with packaging debris, plastic debris, and cigarette butts. The bread remained outside on the loading dock at 12:37 PM, 1:07 PM (with the Administrator and Director of Environmental Services present), and 4:44 PM. During an observation on 1/3/2025 at 9:56 AM the food service items, single service items, paper products, (garbage, debris, cigarette butts), and cleaning products were on the back entrance loading dock. During an interview on 1/3/2025 at 10:58 AM, Food Service Director #12 stated deliveries should be put away as soon as they arrived, they usually put the bread away when they arrived at work. They stated bread should not be left outside for eight hours. The paper products and chemicals had always been stored outside on the loading dock, but that area was not protected from pests or the elements. They were not sure if the cleaning products were okay left outside in the freezing temperatures. Lack of Handwashing Facilities The following observations were made: - on 1/2/2025 at 12:09 PM, the only hand washing sink in the kitchen was blocked by a service tray with coffee cups. The only other sink in the kitchen was the three bay sink which was in use for dishwashing and not equipped for handwashing. Four dietary staff members (two who wore gloves and two without gloves) were serving lunch. - on 1/2/2025 at 12:24 PM, [NAME] #36 changed gloves without performing hand hygiene. - on 1/2/2025 between 12:09 and 12:30, unidentified staff serving lunch did not perform hand hygiene after exiting and returning to the kitchen. During an interview on 1/3/2025 at 10:58 AM, Food Service Director #12 stated staff were expected to wash their hands when they arrived in the kitchen for work, when they returned from smoking, between dishes, whenever they changed their gloves, and whenever they touched raw food. They stated there was a hand wash sink next to the coffee pot in the kitchen. The handwashing sink should not have been blocked by the coffee set-up during meal service. Unclean Areas (Main kitchen and Northwest kitchenette) The following observations were made: - on 1/2/2025 at 9:37 AM, the drink cooler in the hall (just outside the kitchen) had rings of white liquid on the bottom of the cooler from previous spills. The cooler interiors in the kitchen were heavily soiled with dried food debris and spills. - on 1/2/2025 at 11:12 AM, the interior of the Northwest Kitchenette refrigerator was soiled with food spills and dried debris. - on 1/2/2025 at 12:16 PM, the floor in the main kitchen, behind and under equipment, was soiled with built up and dried on grease and grime, food debris, and broken dishware fragments. - on 1/3/2025 at 11:15 AM, the main kitchen coolers were heavily soiled with dried food debris and spills. The floors in the kitchen were soiled with grease and grime, dried food debris, and broken dishware fragments. - on 1/3/2025 at 1:25 PM, the Northwest Kitchenette refrigerator was soiled with food spills and dried on debris. The facility's Clean Jobs for Cooks documented the kitchen coolers and freezer were last cleaned 12/25/2024 and 12/26/2024. The floor under the steam table was last done on 12/25/2024. The facility's cleaning jobs for PM Aides documented the middle cooler was last cleaned on 12/24/2024. The floor under the coffee maker was listed as a task, but not documented as completed. The facility's cleaning jobs for AM Aides documented the juice and dessert cooler was last cleaned on an unspecified Monday. During an interview on 1/3/2025 at 10:58 AM, Food Service Director #12 stated the kitchen was cleaned daily, and designated staff had specific cleaning assignments. Cleaning tasks included cleaning the inside of the coolers as well as the floors under the equipment. Staff were expected to clean what they were assigned and sign off when the cleaning task was completed. The kitchenette refrigerators were supposed to be checked and cleaned daily by dietary staff. The Food Service Director stated they had been out the prior week, and the cleaning tasks were not completed as required. The refrigerators throughout should not have dried food spills and debris present. They stated it was important the kitchen was kept clean to prevent contamination and the spread of foodborne illness. Equipment Maintenance During an observation on 1/2/2025 at 12:26 PM, the two-door upright freezer just inside the main kitchen, had ripped door seals that dragged on the floor. Both doors did not seal completely and were loosely closed. Some contents inside the freezer were frozen solid, others (butter, ice cream and bread) were soft to the touch. The external thermometer read 20 degrees Fahrenheit. During an interview on 1/3/2025 at 10:58 AM, Food Service Director #12 stated there were no issues with the equipment in the kitchen and they were not aware the seals on the door of the freezer were ripped. They stated that neither the bread, butter, nor ice cream stored in the freezer should have been soft to the touch. If there was a problem with any equipment they would put in a work order for maintenance, but they did not think that anyone had done that. There was no documented evidence of work orders for the kitchen freezer from the past three months. 10NYCRR 415.14(h)

Based on observations and interviews during the recertification survey conducted 1/2/2025-1/7/2025, the facility did not ensure that garbage and refuse was disposed of properly. Specifically, garbage was not properly contained outside on facility grounds. Findings include: The facility policy, Garbage and Refuse Disposal, dated 3/7/2022, documented garbage would be stored in a manner that was inaccessible to pests. Storage areas would be kept clean at all times and shall not constitute a nuisance. Outside dumpsters provided by the garbage service would be kept closed and free of surrounding litter. During an observation on 1/2/2025 at 9:51 AM, two dumpsters located outside the facility were open with plastic bags at the top blowing in the breeze. Wet cardboard boxes, broken equipment, and debris were piled outside of the Southwest exit by the activity room. Mattresses were piled between the dumpsters. Wooden pallets with debris were located behind a shed by the dumpsters, and more equipment and debris were collected outside of a garage at the end of the parking lot. Boxes, garbage, plastic bags, and debris (used gloves, masks, etcetera) were visible on the lawn and in the brush line around the building. During an observation and interview on 1/2/2025 at 10:47 AM, the Director of Environmental Services stated the pile of wet cardboard boxes and broken equipment outside the Southwest exit were garbage. The exterior's various piles of garbage, broken equipment, gloves, and plastic debris were observed with the Administrator and Maintenance Director. The Administrator stated the dumpsters should have been closed and there should not have been any garbage piled or strewn about outside. During an observation and interview on 1/2/2025 at 1:07 PM, the loading dock outside the kitchen had packaging debris and plastic bags, and numerous cigarette butts (cited under K741) were strewn amongst the pallets of deliveries and cardboard boxes stored under the roof that extended over the loading dock. The Director of Environmental Services stated there should not have been any garbage left out there and staff should have taken it to the dumpsters. During an observation and interview on 1/3/2025 at 11:15 AM, the loading dock outside the kitchen had debris and cigarette butts around the pallets of deliveries, stored chemicals, and cardboard boxes. The Food Service Director stated there should not have been any garbage left outside on the loading dock. Garbage was taken out after each meal and daily when the deliveries left outside on the loading dock were put away. During an interview on 1/8/2025 at 8:38 AM, the Director of Environmental Services stated the dumpsters were emptied of trash on Mondays and recycling was picked up on Tuesday or Wednesday. They stated the furniture piled by the garage was received from another facility, but they did not have anywhere to store it. The furniture was not usable, and they were waiting on a dumpster. The dumpsters should have been kept closed to prevent debris from blowing out and there should not have been any piles of garbage and debris around the facility. They stated it was important the garbage was properly contained because when left strewn about it was a hazard. 10 NYCRR 415.14(h)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00356805 and NY00362194) surveys conducted 1/2/2025-1/7/2025, the facility did not ensure residents had the right to a dignified existence in a manner and an environment that promoted the maintenance or enhancement of quality of life for 2 of 2 residents (Resident #29 and Resident #282) reviewed. Specifically, Resident #29 was visible from the hallway in bed with their incontinence brief exposed; and Resident #282, who was continent of urine, urinated in bed when their call light was not answered timely. Findings include: The facility policy, Resident Rights, revised 3/22/2022, documented all residents had the right to a dignified existence, to be treated with dignity and respect, and had the right to privacy, and confidentiality. The facility policy, Maintaining Resident Dignity, revised 3/2024, documented residents were provided loving care in a timely manner that bespeaks dignity, respect, compassion, sensitivity, and concern. They respected the resident's choice of having their door open or closed. The facility policy, Quality of Care, revised 10/2023, documented the facility ensured the residents received treatment and care in accordance with professional standards of practice. The provided care within reasonable timeframes, minimizing wait times when possible. 1) Resident #29 had diagnoses including cerebral infarction (stroke) with hemiplegia (paralysis) on the left side, anxiety disorder, and dementia. The 10/15/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, did not reject care, did not have physical or verbal behaviors, and required supervision or touching assistance for most activities of daily living. The Comprehensive Care Plan updated 10/7/2024 documented Resident #29 required assistance with self-care related to aging and disease processes. Interventions included assisting with activities of daily living and clean clothes daily. The resident required extensive assistance of one for dressing and sometimes required 2 staff for dressing. Additionally, they had left sided weakness related to a cerebral vascular accident (stroke). The resident care instructions documented Resident #29 required extensive assistance of one and sometimes two, for dressing. During an observation on 1/2/2025 at 11:19 AM, Resident #29 was in their room in bed and was seen from the hallway wearing a hospital gown that was hiked above their belly button and a blue incontinence brief. The privacy curtain was partially open. During an interview on 1/3/2025 at 9:25 AM, Resident #29 stated they did not want to be seen from the hallway in a brief as it was embarrassing. During an interview on 1/3/2025 at 12:28 PM, Certified Nurse Aide #7 stated Resident #29 liked being dressed and not left in a gown. They stated if Resident #29 stated they were embarrassed because they were not dressed, had their privacy curtain open, and could be seen in a brief from the hallway, that was believable. Residents that want to be dressed should be dressed and no resident should be seen from the hallway in a brief as it was not dignified. They stated Resident #29 was not able to open or close their privacy curtain as they did not have use of their left side. During an interview on 1/6/2025 at 1:00 PM, Licensed Practical Nurse Unit Manager #6 stated a resident should not be visible from the hallway wearing incontinence briefs. Resident #29 was always dressed and if they were not and was in a brief and seen from the hallway it was a dignity concern. 2) Resident #282 had diagnoses including cerebral infarction (stroke), hemiplegia (paralysis) on the left side, and hypertension (high blood pressure). The Minimum Data Set assessment had not yet been completed. The Comprehensive Care Plan updated 12/27/2024 documented Resident #282 had an activity of daily living self-care deficit related to aging, limited mobility, and disease processes. Interventions included assisting with activities of daily living. The resident required extensive assistance of one for toileting using squat pivot on the good (right) side to toilet. The resident care instructions documented Resident #282 required extensive assistance of one for toileting using the stand pivot technique on the good (right) side. The 12/28/2024 at 8:29 AM Registered Nurse #13 progress note documented Resident #282 was alert and oriented and transferred to the bathroom with assistance from staff and use of the wheelchair. That morning the resident could not find their call bell and was incontinent of stool. The 12/30/2024 at 1:36 PM Assistant Director of Nursing #3 progress note documented resident #282 was continent of bladder. During an observation and interview on 1/2/2025 at 12:06 PM, Resident #282 was in their room and stated sometimes they wet the bed because it took so long for staff to come to take them to the bathroom. They stated they were embarrassed and knew staff was busy, however wished they answered their call bell sooner. During an interview on 1/3/2025 at 9:11 AM Resident #282 stated they wet themselves on 1/2/2025 because it took too long for staff to answer their call bell and they wished staff answered their call bell sooner. During an interview on 1/6/2025 at 10:42 AM Certified Nurse Aide #19 stated Resident #282 required assistance to go to the bathroom. They were unaware the resident wet themselves because their call bell was answered timely. They stated Resident #282 was believable and if they said it took a long time for staff to answer their call bell, they believed it. If a resident wet themselves because their call bell was not answered timely, they might feel embarrassed and ashamed. They stated some staff did not answer call bells and other staff ignored the call bells. During an interview on 1/6/2025 at 1:00 PM, Licensed Practical Nurse Unit Manager #6 stated residents should not have to wait so long for a call bell to be answered that it causes them to urinate on themselves. That was also a dignity issue. Resident #282 was able to ring their call bell when they needed to use the bathroom. During an interview on 1/7/2025 at 2:36 PM Director of Nursing #2 stated they expected call bells to be answered timely by all staff and did not expect a resident to wet themselves when waiting for their bell to be answered. It could make them feel depressed, like they are not being taken care of, and was a dignity issue. 10 NYCRR 415.5(b)(1-3)

Based on observations, record review, and interviews during the recertification survey conducted 1/2/2025-1/7/2025, the facility did not ensure residents received adequate supervision to prevent accidents for 2 of 4 residents (Residents #50 and #57) reviewed. Specifically, Residents #50 and #57 had medications at their bedsides and did not have orders for self- medication administration. Findings include: The facility policy, Administration of Medications, revised 9/2022, documented medications were administered to residents in a timely and accurate manner by a licensed nurse or physician. Medications were never to be left at a resident's bedside and if a situation occurred that necessitated the nurse had to step away from the resident prior to administration of all medications, medications were removed from the room and secured in the locked medication cart until they were administered to the resident. 1) Resident #57 had diagnoses including hepatic encephalopathy (loss of brain function), depression, and diabetes. The 10/4/2024 Minimum Data Set admission assessment documented the resident had severely impaired cognition and required partial to moderate assistance for most activities of daily living. The resident received antianxiety, antidepressant, and diuretic medications. The 6/28/2024 Self Administration of Medication assessment tool documented the resident was not approved for self-administration of medications and could not keep medications at their bedside. The 7/7/2024 Comprehensive Care Plan documented Resident #57 was dependent on staff for meeting emotional, intellectual, and social needs related to physical limitations. During an observation and interview on 1/2/2025 at 10:07 AM, Resident #57 was observed in their room in bed sleeping with a medication cup on their over the bed table. The cup contained seven medications. The resident awoke and stated they were not sure how long the medications had been there. The Medication Administration Record documented Resident #57 received the following medications in the morning at 8:00 AM: famotidine (acid controller) 20 milligrams daily Lasix (diuretic) 40 milligrams daily losartan Potassium (antihypertensive) 100-12.5 milligrams daily sertraline (antidepressant) 25 milligrams daily Tamiflu (treats flu)30 milligrams daily buspirone (antianxiety) 5 milligrams twice daily potassium chloride (nutritional supplement) 20 milliequivalents twice a day During an observation and interview on 1/2/2025 at 10:42 AM, Licensed Practical Nurse #21 identified the medications at Residents #57 bedside as famotidine, Lasix, Tamiflu, sertraline, buspirone, potassium, and Losartan. They did not believe anyone in the facility was on a self-medication administration protocol. Resident #57 did not have an order for self-medication administration. They stated Resident #57 was sleeping when they administered the medications and was woken up, however they did not wait for the resident to take the medications before they left the room. They stated they should have made sure the resident took their medications for their safety and for the safety of all residents as they had wandering residents that could take the medications. 2) Resident #50 had diagnoses including nicotine dependence, hypertension (high blood pressure), and depression. The 11/10/2024 Minimum Data Set admission assessment documented the resident had mildly impaired cognition, required set up assistance for most activities of daily living, and received an antidepressant medication. The 11/4/2024 Self Administration of Medication assessment tool documented the resident was not approved for self-administration of medications and could not keep medications at their bedside. During an observation and interview on 1/3/2025 at 10:02 AM, a Breo inhaler (used to control respiratory symptoms) was observed at Resident #50's bedside. Licensed Practical Nurse #20 removed the inhaler from the resident's bedside and stated medications were not supposed to be left at the resident's bedside as the resident was not on self-medication administration. During an interview on 1/3/2025 at 10:52 AM, Certified Nurse Aide #7 stated they observed medications on the floors in resident rooms and would tell the nurse when they saw the medications on the floor. The unit had wandering residents and if medications were at the bedside, one of the wandering residents could enter the room and take the medications. Taking the wrong medications or not taking medications was a safety concern. During an interview on 1/6/2025 at 1:00 PM, Licensed Practical Nurse Unit Manager #6 stated medications should never be left at a resident's bedside because they wanted to make sure the resident received necessary medications. Additionally, they did not want one of the wandering residents to take medication that were not theirs. They did not have any residents on self- medication administration. During an interview on 1/7/2025 at 2:36 PM, Director of Nursing #2 stated medications should not be left at the resident's bedside, including inhalers, as it was a safety concern for wandering residents. There was an assessment for self- medication administration and there were no residents that could currently self-administer medications. 10NYCRR 415.3(e)(1)(vi)

Based on observations, record review, and interviews conducted during the recertification survey conducted 1/2/2025-1/8/2025, the facility did not ensure residents were provided the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living including functional communication systems for 1 of 1 resident (Resident #13) reviewed. Specifically, Resident #13 was deaf and was not consistently provided a communication board as planned. Findings included: The facility policy, Resident Rights, effective 3/22/2022, documented employees should treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all resident of the facility. These rights include the resident right to a dignified existence and the right to communication with and access to people and services, both inside and outside the facility. Resident #13 had diagnoses including moderate intellectual disabilities and deaf non-speaking. The 10/31/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, had highly impaired hearing, did not speak, was sometimes understood, rarely/never understood, and felt it was very important to do things with groups of people. The 10/25/2023 physician order documented a white board for communication. The Comprehensive Care Plan initiated 10/25/2023 and revised 2/2/2024 documented the resident had impaired communication and communicated by making sounds and hand gestures. The resident used a white board for communication due to being deaf and did not always carry the white board with them. Interventions included allow adequate time for resident response, educate resident /staff, anticipate the residents needs until an alternate means of communication was established, incorporate visual prompting, cues, gestures, and provide clear simple instructions. The undated care instructions documented ask yes and no questions to determine the resident's needs; the resident required a white board to communicate; face the resident when communicating; make eye contact; reduce any distractions; use communication board; and present one idea at a time. Resident #13 was observed at the following times: - on 1/2/2024 at 10:03 AM, propelling themself up and down the hallway, moaning and unable to verbalize their needs. They tried to show staff their right arm by tapping their right shoulder. At 10:08 AM, the resident grabbed at the health surveyor's computer and arm. Certified Nurse Aide #24 walked by and did not intervene or attempt to communicate with the resident. - on 1/2/2025 at 10:20 AM, attempting to speak (speech was garbled) to anyone walking down the hallway. They appeared to be in pain, grimacing and tapping their right shoulder. Several unidentified staff walked by the resident and did not attempt to determine what was wrong. At 10:09 AM, Registered Nurse Unit Manager #14 took the resident into their room and came right out. They did not attempt to use a white board to communicate with the resident. At 11:33 AM, Certified Nurse Aide #24 walked by the resident multiple times while the resident was moaning and did not attempt to stop and try to communicate with the resident. - on 1/3/2025 at 9:00 AM, in their wheelchair and attempting to stop the Administrator near the front door. They appeared to be using sign language. There was a laminated picture book on the back of their wheelchair. The Administrator did not refer to the picture book or attempt to locate the communication board. The Administrator said, I will let them know and I will talk to them. At 9:02 AM, the resident approached Licensed Practical Nurse #9 during a medication pass. The resident was moaning and pointing to their stomach. The nurse said stomach?. Licensed Practical Nurse #9 did not attempt to use the white communication board or laminated pictures and the resident wheeled away. - on 1/6/2025 at 8:18 AM, there was a notebook on their dresser in the resident's room. The notebook appeared to have been written in by the resident and a staff member. There were laminated communication sheets in a basket on the bed. The white communication board was not observed in the room. - on 1/6/2025 at 3:27 PM, the attempting to enter the conference room with the health care surveyors. An unidentified staff walked past resident and did not approach to attempt to communicate with the resident to find out what was needed. During an observation and interview on 1/7/2025 at 10:38 AM, Licensed Practical Nurse #25 was teaching a nurse aide student about the resident's communication needs and told the student the resident was deaf. They stated the resident had lived at the facility for a while and the staff were all aware that the resident had a communication board, and laminated pictures for simple requests. They also had a spiral notebook for communication with pen and paper. During the interview they stated all staff were aware of the resident's communication needs and staff should not just walk by the resident when they were trying to communicate. Staff should stop and try to figure out what was wrong. New staff should always ask the nurse if they were having trouble communicating with the resident. During an interview on 1/7/2025 at 10:46 AM, Registered Nurse Unit Manager #14 stated the resident's needs were listed in the resident profile in the electronic record. During orientation staff the new aides were told the resident had a picture board on the back of their wheelchair. They frequently had to put it back on because the resident would take it off. It was difficult to understand the resident. Staff should use the laminated sheets to see what the resident needed and should not walk by the resident when they were trying to communicate their needs. Staff knew they should get the dry board and communication sheets. Resident #13 just liked to touch and hug and needed frequent reassurance. Staff could just stop and hold the resident's hand and attempt to communicate with the resident. During an interview on 1/7/2025 at 11:56 AM, Certified Nurse Aide #26 stated they were responsible for the resident's care on 1/2/2025. They stated the resident was here for a long time and was deaf. They tried their best to communicate with the resident and used a pen and paper if they really did not understand what the resident wanted. They stated if the resident was poking at the staff or pulling at them, staff should see what the resident needed. They stated they were not aware staff walked by the resident, they should have gotten a pen and paper to figure out what the resident needed. During an interview on 1/7/2025 at 3:48 PM, the Director of Activities stated the resident could use sign language or the laminated sheets and symbols. Some days the resident used sign language, lip reading, or wrote on paper. Staff should always try to see what the resident was trying to communicate. Any staff member should stop and try to understand what the resident needed. 10NYCRR 415.12(a)(3)

Based on record review and interviews during the recertification and abbreviated (NY00359258) surveys conducted 1/2/2025-1/7/2025, the facility did not ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing for 1 of 2 residents (Resident #15) reviewed. Specifically, Resident #15 had a new skin impairment that was not assessed and treated timely by a qualified individual. Findings include: The facility policy, Pressure Injury Prevention and Management, dated 3/2021, documented a registered nurse would conduct a comprehensive skin assessment when a significant change was identified. The nurse was responsible to document a comprehensive nursing note when a pressure ulcer was identified. All wounds should be noted on 24-hour report. Resident #15 had diagnoses including hypertension and diabetes. The 9/24/2024 Minimum Data Set assessment (health screening tool) documented the resident had moderate cognitive impairment, did not reject care, required maximum assistance for bed mobility, had an indwelling urinary catheter, was frequently incontinent of bowel, did not have any unhealed pressure ulcers, was at risk for developing pressure ulcers/injuries, had a pressure reducing device for chair and bed, and received application of nonsurgical dressings and ointments/medications. The 9/18/2024 at 6:20 PM, Registered Nurse Unit Manager #14's admission progress note, and evaluation documented the resident did not have any pressure ulcers and was mildly at risk for developing pressure ulcers. The Comprehensive Care Plans initiated on 9/18/2024 and 09/19/2024, documented the resident was at risk for impaired skin integrity and activity of daily living deficits related to impaired mobility. Interventions included to keep skin clean and dry and to use extensive assistance of two to turn and reposition every two hours and as necessary. The 9/29/2024 at 3:41 AM, Licensed Practical Nurse #22 progress note documented the resident had sheared areas on both buttocks and excoriation (wearing off of skin) in the peri area. There was no documented evidence the area on the buttocks was assessed by a qualified professional. The 9/30/2024 Medical Director/Attending Physician #16's admission progress note documented the resident had recent weight loss with failure to thrive. The progress note did not include any documentation related to the buttocks skin impairment discovered on 9/29/2024. A Dermal Tracker sheet (wound assessment sheet) was initiated by Registered Nurse Unit Manager #14 on 10/1/2024 and documented an unstageable (full thickness tissue loss in which the base of the ulcer is covered by dead tissue) pressure injury to the left buttock that measured 6 centimeters x 5 centimeters x 0.1 centimeters. There was scant serosanguinous drainage and no signs of infection. The date the area was first noted was blank. A 10/1/2024 physician order documented to check the alternating pressure mattress (a special mattress to alleviate pressure) every shift for functioning. The 10/2/2024, Registered Nurse Unit Manger #14 progress note documented the resident had a facility acquired Stage 2 (a shallow open ulcer with a red/pink wound bed) pressure ulcer on the sacrum, that measured 1.2 centimeters by 1.1 centimeters by 0.1 centimeters, an Unstageable pressure ulcer/deep tissue injury on the right gluteus (buttock) measuring 6 centimeter x 5 centimeter x 0.1 centimeter, and a Stage 2 pressure ulcer to the left gluteus measuring 3 centimeter x 2 centimeter x 0.1 centimeter. There were no signs and symptoms of infection. The resident was bedfast all or most of the time, and the resident has a pressure reducing device to bed, and often refused to get out of bed. The 10/02/2024, physician order documented to cleanse the resident's sacrum, right and left buttock with wound cleanser, apply Calcium Alginate and cover with Optifoam dressing daily. There was no documented evidence the shearing identified on 9/29/2024 had a treatment ordered until 10/2/2024. During an interview on 1/6/2025 at 10:58 AM, Licensed Practical Nurse Unit Manager #6 stated Resident #15 required total care for all their activity of daily living needs. The resident frequently resisted care but would do it with encouragement. They were unsure if the resident was admitted to the facility with a wound. They relied on the registered nurses to do those assessments. During an interview on 1/6/2025 at 1:25 PM, Certified Nurse Aide #19 stated Resident #15 required total assistance of two for their care. It took two staff members to roll and reposition the resident. The resident would get mad when they had to provide care. The resident had not been acting the same lately, refusing their meals and throwing things. During an interview on 1/6/2025 at 4:27 PM, the Director of Nursing stated when a resident was admitted to the facility a nursing admission assessment would be completed by Registered Nurse Unit Manager #14. Resident #15's pressure ulcer on their buttocks started as a sore on 10/1/2024. The wounds should be monitored on weekly wound rounds, with the wound nurse practitioner, and their assessment was documented on a Skin Tracker Sheet. During an interview on 1/7/2025 at 11:02 AM, Registered Nurse Unit Manager #14 stated the resident was admitted without any skin issues, and shortly after one of the floor nurses mentioned the resident's bottom was red. When it was assessed, it was assessed as a pressure ulcer. The resident's skin was checked weekly when they get a shower by the licensed practical nurse. They stated the resident did not have any pressure ulcer/skin wounds when they were admitted on [DATE] and a complete and thorough skin assessment was done. The first identification of the pressure ulcer on the resident's buttock was in October 2024. The resident did not move much, did not eat well, and often refused repositioning. They believed the nurse practitioner was notified of the pressure ulcer on 10/8/2024 but was not sure as there was no documentation. When a resident had a new pressure ulcer, the nurse should notify the medical provider. They would also notify the Director of Nursing so they could see the resident and ensure the resident had a treatment and was seen on wound rounds. During a telephone interview on 1/7/2025 at 3:11 PM, the Medical Director/Attending Physician stated Resident #15 was at risk for developing pressure ulcers. A skin assessment should be completed upon admission and then the wound care team should be notified of any wounds, and treatment started accordingly. They were not sure when the resident developed pressure ulcers. 10 NYCRR 415.12(c)(2)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00356805) surveys conducted 1/2/2025-1/7/2025, the facility did not ensure there was an effective pest control program for 1 of 4 hallways (East Hall) and 1 of 2 kitchenettes (South kitchenette). Specifically, fruit flies and an unknown insect were observed in the East Hall and South kitchenette. Findings include: The facility policy, Pest Control, revised 10/2023 documented to report any signs of infestation to the supervisor immediately. The purpose of the policy was to prevent entry of insects and rodents into the facility and reduce the threat of infection and disease, and to provide a safe and sanitary environment. The Pest Control Vendor Service Reports from 6/28/2024 through 11/27/2024 documented no signs of pest activity were found at the time of service. The following observations were made: - on 1/2/2025 at 9:30 AM, in the South kitchenette there was a flying black fruit fly. - on 1/2/2025 at 10:20 AM, in room [ROOM NUMBER] there was a flying black fruit fly. - on 1/2/2025 at 11:51 AM, in room [ROOM NUMBER] there was a small black flying bug. - on 1/3/2025 at 9:33 AM, between rooms [ROOM NUMBERS] there was a small black flying bug. - on 1/7/2025 at 7:41 PM, in the conference room there was 1-inch-long black flying bug with antennas and wings. During an interview on 1/6/2025 at 4:55 PM, Resident #27 stated they saw ants and fruit flies in their room. They told staff, and they told the resident they were not allowed to use pesticides. They stated they often dropped food on the floor, and it took staff until the next day to clean their room. They stated the food on the floor was leading to the bugs. During an interview on 1/3/2025 at 10:52 AM, Certified Nurse Aide #7 stated they saw spiders, cock roaches, fruit flies, and stink bugs frequently in the building and the resident's complained to them about the bugs. They took care of the bugs when the resident's complained. The presence of bugs could make the residents feel unclean and it was not homelike. They stated it was housekeeping's responsibility to take care of pests. During an interview on 1/6/2025 at 1:00 PM, Licensed Practical Nurse Unit Manager #6 stated if food was left on the floor it could lead to pests. The Maintenance Department was responsible for pest control. It was not homelike to have food on the floor or pests. During an interview on 1/6/2025 at 1:41 PM, the Maintenance Director stated they oversaw housekeeping, laundry, and maintenance of the facility. They had been told about fruit flies, spiders, and flies in the building. They used a pest control vendor, and the pest problem had improved. The vendor came monthly. They placed tags and if they noted presence of flies or ants they would treat the area. They stated it was not homelike, and they were supposed to stop the bugs. Bugs were not supposed to be in the building. During an interview on 1/7/2025 at 2:36 PM, the Director of Nursing stated they did not expect to see pests. They stated they had seen flies, fruit flies, and stink bugs. Residents had told them a couple times about flies, and they took care of it. During an interview on 1/7/2025 at 4:26 PM, the Administrator stated they did not expect to see food or bugs on the floor for an extended period of time. Food on the floor could lead to pests. 10 NYCRR: 415.29(j)(5)

Based on observation and interviews during the abbreviated survey (NY00314353) the facility failed to ensure each resident had the right to a dignified existence for 11 of 13 residents reviewed (Residents #1-11). Specifically, Residents #1-11 were observed with multiple concerns related to a dignified existence including incontinence care needs, cleanliness of their surroundings, clothing/footwear, call bell access, and personal grooming. Findings include: The Maintaining Resident Dignity policy effective 3/2021 documented the facility promotes care for residents in a manner and in an environment that maintains and enhances each resident's dignity and respect in full recognition of his or her individuality. Areas of focus included: - Respecting care needs: grooming residents as they wish to be groomed (e.g., shaving, nail care); assisting residents to dress in their own clothes appropriate for time of day and preferences; and toileting continent residents as needed. - Maximizing the dining experience. - Respecting residents' room and personal space. The policy did not address incontinence care, or cleanliness of resident rooms and common areas. The undated CNA (certified nurse aide) Job Description documented CNA duties included: - assisting residents to dress/undress; - taking care of residents' clothing; - changing linens and making beds; - mopping the floor when an accident has occurred, keep lounge neat and clean and in order; - caring for the resident unit; and - proving assistance with resident care where applicable Resident #1 had diagnoses including autistic disorder and anxiety disorder. The 2/10/23 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment and required extensive assistance of 2 staff for transfers, dressing, toileting, and personal hygiene and was always incontinent of bladder and bowel. Resident #2 had diagnoses including cerebral infarction (stroke), and hemiplegia and hemiparesis (paralysis/weakness) affecting the dominant right side. The 1/25/23 MDS assessment documented the resident had severe cognitive impairment and required extensive assistance of 2 staff for transfers, dressing, toileting, and personal hygiene. Resident #3 had diagnoses including dementia, anxiety disorder, and adult failure to thrive. The 2/23/23 MDS assessment documented the resident had severe cognitive impairment and required extensive assistance of 1 staff for bed mobility, dressing, and toileting, extensive assistance of 2 staff for transfers and personal hygiene, and was always incontinent of bladder and bowel. Resident #4 had diagnoses including congestive heart failure (CHF), respiratory failure, and major depressive disorder. The 12/26/22 MDS assessment documented the resident had severe cognitive impairment, required extensive assistance of 2 staff with bed mobility, dressing, toileting, and hygiene, and was totally dependent on 2 staff for transfers. The resident was frequently incontinent of bladder and bowel. Resident #5 had diagnoses including osteomyelitis (infection spreading to the bone), narcolepsy (sleeping disorder), and anxiety disorder. The 2/2/23 MDS assessment documented the resident had severe cognitive impairment and required extensive assistance of 2 staff for bed mobility, dressing, and personal hygiene and limited assistance of 2 staff for transfers and toileting. The resident was frequently incontinent of bladder and bowel. Resident #6 had diagnoses including rheumatoid arthritis and adult failure to thrive. The 2/20/23 MDS assessment documented the resident had severe cognitive impairment, required extensive assistance of 1 staff for bed mobility, dressing, toileting, and personal hygiene, and was always incontinent of bladder and bowel. Resident #7 had diagnoses including hemiplegia and hemiparesis following cerebral infarction and chronic obstructive pulmonary disease (COPD). The 12/14/22 MDS assessment documented the resident had intact cognitive function and required supervision and assistance of 1 staff for transfers, dressing, toileting, and personal hygiene. Resident #8 had diagnoses including acquired absence of left leg above knee, and Alzheimer's disease. The 10/22/22 MDS assessment documented the resident had severe cognitive impairment, required limited assistance of 2 staff for bed mobility, extensive assistance of 2 staff for dressing, toileting, and personal hygiene, and was frequently incontinent of bladder and bowel. Resident #9 had diagnoses including Parkinson's Disease and dementia. The 2/17/23 MDS assessment documented the had severe cognitive impairment, required extensive assistance of 2 staff for bed mobility, dressing, toileting, and personal hygiene, and was always incontinent of bladder and bowel. Resident #10 had diagnoses including intracranial injury, schizoaffective disorder, and epilepsy. The 1/3/23 MDS assessment documented the had severe cognitive impairment, required extensive assistance of 1 staff for bed mobility, dressing, toileting, and personal hygiene, and was always incontinent of bladder and bowel. Resident #11 had diagnoses including dementia, edema, and muscle weakness. The 11/4/22 MDS assessment documented the resident had severe cognitive impairment, required extensive assistance of 1 staff for transfers, dressing, toileting, and personal hygiene, walked the corridor independently with 1 person assistance, and was frequently incontinent of bladder and bowel. On 4/9/23 the following was observed: - At 7:03 PM, in the North/West (N/W) dining room: Resident #1 was in their wheelchair at a table, there was a large pool of liquid directly under their chair, socks on their feet, and food and paper items on the floor beneath them, and no cups or spilled liquids in the area; Resident #2 was seated at another table, the table had multiple spills and dried liquid on it, the floor beneath the resident was visibly soiled with dried spills, spots, and various areas of food items covered in ants. - At 7:08 PM, in the hall near the N/W nursing station, Resident #9 was in a scoot chair (specialized wheelchair lower to the floor to promote mobility), their fingernails were long with a brown substance underneath, their feet were bare and directly on the floor, the floor was visibly soiled and contained areas of dirt and bits of trash. - At 7:10 PM, Resident #11 was walking in the area near the N/W nursing station and halls with a hospital gown tied at the back, no robe or covering, in view of other residents in the area. The resident had bare feet and the floors where they walked were visibly soiled and there were other residents were in the area. - At 7:15 PM, Resident #3 was in bed, dressed and lying on their right side. The linens under the resident had multiple brown, dry stains, and their incontinence brief was visibly soaked with urine. The resident had emesis under their chin, on the pillow, bottom and top sheets and stated they had vomited. Licensed practical nurse (LPN) #19 was present in the room and asked the resident if they had vomited, the resident replied yes. The LPN stated at that time to the surveyor, the resident's incontinence brief was soaked and left to direct staff to provide care. The call bell was on the floor out of the resident's reach. LPN #19 stated in an interview at that time, Resident #3 was able to use the cal bell. - At 7:20 PM, Resident #4 was in bed in a hospital gown that was unsecured and off their upper body. The gown and resident's bottom sheet had dried spills or food; their top sheet was on the floor mat near the bed. The resident had long whiskers covering their chin and some dried food. The call bell cord was under the floor mat and wrapped around the other bed in the room. The floor contained bits of trash, 2 AA batteries, a piece of plastic, and an old bandage dated 4/8/23. The floor mat near the resident's bed had multiple areas of food, crumbs, and visible dirt. - At 7:27 PM, Resident #6 was in bed and LPN #19 reported to the surveyor at that time, they were totally soaked. - At 7:30 PM, Resident #5 was lying across the bed's width, a wheelchair leg was at the bottom of the bed, and they reported they self-transferred. They stated they needed the urinal, and it was full, LPN #19, who was present, emptied the urinal and returned it to the resident. The resident remained positioned across the bed without back support. - At 7:33 PM, Resident #7 was in their room. A pile of clothing was on the floor near the doorway, their urinal was full and on the overbed table. - At 7:36 PM, Resident #8 way lying in bed, visible from the doorway. They had only a shirt and incontinence brief on and no sheet or blanket. The bedding was soiled with dried feces and the resident had dried feces on their buttocks and on their incontinence brief. The call bell was on the floor and the room had a soiled floor. - At 8:10 PM, Resident #9 remained in the scoot chair by the N/W nursing station, attempting to stand, had bare feet and their incontinence brief was very full. - At 8:11 PM, Resident #2 remained in the N/W dining room, there was food on the floor covered in ants and dried spills and food at the table in which they sat. - At 8:34 PM, Resident #9 remained near the nursing station, with a visibly swollen/soaked incontinence brief, bare feet on the floor, and trying to stand from their chair. - At 8:46 PM, Residents #3 and 4 remained in their beds with no change from prior observations. Resident #3 remained dressed with soiled linens and emesis on their pillow and sheets, Resident #4 remained in a hospital gown with dried food, soiled bedding, and trash and food on the floor. On 4/10/23 at 11:32 AM, Resident #4 was observed in bed. They wore a hospital gown that had bits of food on it. The resident's call bell was on floor under the bed and their floor mat was soiled with dirt and food. The resident had visibly long whiskers covering their chin. On 4/11/23 at 9:55 AM, Resident #10 was observed in bed, visible from the hall at the doorway. They had only a shirt and brief on and no blanket or sheet covering them. The resident's brief was swollen and soaked with urine and not [NAME] covering the resident's buttocks. During an interview with LPN #19 on 4/9/23 at 8:50 PM, they stated they asked the staff in the N/W halls to take care of Resident #3 following their observation of the resident in bed with incontinence care needs and emesis on their bed (on 4/9/23 at 7:15 PM) and will ask them again. After Resident #8 was observed in bed and soiled, they asked CNA #21 to go take care of them. When asked if the LPN expected staff to provide the care without being told, they stated it depended on the staff. The LPN stated they made it a practice to do rounds and check on residents to ensure staff were addressing their needs or it would not get done. During an interview with Resident #4 on 4/11/23 at 11:32 AM, they stated they needed assistance for bathing and shaving and did not want to have hair on their chin. The resident stated they could use their call bell and did not know where it was. They had to remain in bed and was not aware of the reason. During a telephone interview with certified nurse aide (CNA) #9 on 4/20/23 at 10:37 AM, they stated on 4/9/23, there were 2 CNAs on the N/W unit during the day and evening shifts. CNA #9 stated the housekeeping staff that worked during the day assisted with resident meals and transport to and from dining areas. Housekeeping staff were never present after 3:00 PM and the CNAs were expected to clean common areas such as dining rooms and hallways as well as maintain resident rooms during the evening shift. When they were short-staffed, which was often, it was difficult for CNAs to address the facility cleaning and resident care. CNA #9 stated on 4/9/23 they observed multiple areas of the building that needed cleaning and had to address resident care first. They could not recall Resident #3 being in bed with emesis or a soaked brief or being told by LPN #19 to take care of them. CNA #9 stated sometimes residents chose to not have any clothing on, or just gowns and they had to follow their requests. Resident dignity meant adhering to residents' requests and allowing them to make choices. During a telephone interview with LPN Manager #13 on 4/20/23 at 12:23 PM, they stated CNAs were expected to keep resident rooms and common areas clean after housekeeping left, including cleaning spills and picking up debris from the floor where observed. It was not dignified for residents to be in an unclean environment, left exposed in their briefs, or being in public areas in hospital gowns, or having bare feet. Staff were expected to address resident care needs timely. One and a half hours was not appropriate to wait to clean a resident who needed incontinence care or other hygiene needs. Staff were expected to ensure call bells were within reach of all residents. 10NYCRR 415.3(a)

Based on observation and interview during the abbreviated survey (NY00314353), the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for multiple areas throughout the facility and 2 resident rooms (rooms [ROOM NUMBERS]). Specifically, 2 dining areas had unclean floors, spills, food debris, and ants; hallways contained scattered debris on the floors and odors of urine and feces; the West Hall had stains on the wall; room [ROOM NUMBER] had scattered debris and food on the floor, overflowing trash, a call bell under a floor mat; and room [ROOM NUMBER] had a pile of laundry on the floor. Findings include: The Facility Cleaning- General P&P policy effective 7/2020 documented it was the policy of the facility to keep a clean, safe, and sanitary environment for the benefit of all residents. Guidelines that must be followed included but were not limited to: - wiping exposed areas such ad bed frames, rails, chairs, bedside tables, furniture; - call bell cords should be checked for function and connection to the wall; - changing beside paper bags; - dusting furniture, lights, televisions; - mopping floors daily; and - beds to be pulled out and cleaned behind. There were no days or times noted for a cleaning schedule or after-hours plan. On 4/9/23 the following was observed: - At 5:40 PM, the main lobby/front area floor contained multiple areas of dirt, dried spills, surgical gloves, and debris; a resident was in the area in their wheelchair and a visitor. - At 5:41 PM, the main dining room had unclean tables with food and liquid spills, the floor had food, dried spills, debris, and clothing protectors scattered about; several residents were seated in the dining room. - At 6:50 PM, the East Hall had debris on the floor including surgical gloves, papers, dirt, and areas of dried liquid/spills and a strong odor of urine was noted. - At 7:00 PM, the North/West (N/W) dining room contained tables with food and liquid spills, the floor had food covered in ants, and one resident sat over a large pool of liquid on the floor with playing cards and food wrappers under them. - At 7:08 PM, the area near the N/W nursing station had unclean floors and there were multiple papers, wrappers on the floor. - At 7:20 PM, room [ROOM NUMBER] had a used bandage dated 4/8/23 under the A bed, bits of food, papers, 2 AA batteries, a piece of plastic under the B bed, the unoccupied B bed had no linens, and the mattress had a large brown, dried stain and the surface was cracked throughout. The floor mat was next to the A bed had food and dirt on it, the call bell cord for the A bed was wrapped around the leg of the B bed and under the floor mat. A trash container was overflowing, and the lid was not able to be closed all the way. - At 7:22 PM, the wall outside of room [ROOM NUMBER] had a large area of dry brown liquid drips from mid to upper part of the wall. - At 7:33 PM, room [ROOM NUMBER]-B had a pile of laundry on the floor. - At 8:02 PM, the North and West halls had a strong odor of urine and feces. - At 8:45 PM, the areas noted above remained as previously observed. During an interview on 4/11/23 at 11:00 AM with housekeepers #27 and 28, they stated housekeeping staff worked on a full-time basis and alternated weekend shifts. Their shifts were from 6:00 AM to 2:00 PM. There were no evening or night shifts for housekeeping staff. Housekeeping duties included cleaning floors, common areas, dining areas, and resident rooms. In resident rooms, housekeeping staff were expected to sweep and mop the floors, empty trash, clean the bathrooms, and general tidiness. Resident rooms and public areas were done on a daily basis. On 4/9/23, housekeeping staff assisted with passing resident trays and they did not recall any issues with being able to complete their duties. During a telephone interview with certified nurse aide (CNA) #9 on 4/20/23 at 10:37 AM, they stated on 4/9/23, there were 2 CNAs on the N/W unit during the day and evening shifts. The CNA stated the housekeeping staff that was on during the day assisted with resident meals and transport to and from dining areas. Housekeeping staff were never present after 3:00 PM. CNAs were expected to clean common areas such as dining rooms and hallways as well as maintain resident rooms during the evening shift. When they were short-staffed, which was often, it was difficult for CNAs to address the facility cleaning and resident care. CNA #9 stated on 4/9/23 they observed multiple areas of the building that needed cleaning and had to address resident care first. During a telephone interview with licensed practical nurse (LPN) Manager #13 on 4/20/23 at 12:23 PM, they stated CNAs were expected to keep resident rooms and common areas clean after housekeeping left, including cleaning spills and picking up debris from the floor where observed. 10NYCRR 415.29

Based on record review and interviews during the abbreviated survey (NY00313936), the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for 1 of 1 residents (Resident #12). Specifically, Resident #12 required continuous delivery of oxygen and was discharged from the facility without the needed oxygen tubing, traveled for 45 minutes without oxygen, and was unresponsive upon arrival to their destination. Findings include: The Oxygen Therapy policy revised ,d+[DATE] documented: - Oxygen included an oxygen cylinder or concentrator, signs, nasal cannula or mask and tubing, and oxygen tube label. - A physician order was required to initiate oxygen therapy, except in an emergency. The policy did not address designation of a responsible party to ensure proper implementation of oxygen or oxygen equipment. The Discharge Planning Process policy effective [DATE] documented: - The social worker will be responsible for a safe and orderly discharge to an appropriate community housing option and to provide services for community reintegration. The policy did not address medical equipment or designation of a responsible party to ensure needed medical equipment was addressed upon discharge. Resident #12 had diagnoses including congestive heart failure (CHF), acute bronchiolitis, and chronic respiratory failure. The [DATE] Minimum Data Set (MDS) assessment documented the resident had intact cognitive function, required supervision and set up assistance for transfers and eating; supervision and assistance of 1 for walking and dressing, utilized a walker, and received oxygen therapy. The [DATE] physician order documented oxygen (O2) at ,d+[DATE] liters per minute (lpm) via nasal cannula (NC) every shift. The ,d+[DATE] Medication Administration Record (MAR) documented the resident had O2 at ,d+[DATE] lpm every shift from [DATE] to [DATE] during the day shift, there were no documented refusals. The [DATE] comprehensive care plan (CCP) documented the resident ambulated with contact guard assistance and a front wheeled walker and the resident was on oxygen therapy related to CHF. Interventions included for ambulatory residents, provide extension tubing or portable oxygen apparatus, provide medications as ordered, O2 settings at ,d+[DATE] lpm. The [DATE] nurse practitioner (NP) progress note documented the resident was to be discharged home in the next couple of days and was on oxygen at home at 3 lpm. The [DATE] progress note entered by the Director of Social Services at 10:23 AM documented they reviewed the transfer/discharge paperwork with the family via telephone, the resident will discharge to the assisted living facility on [DATE] via medical transport. No concerns noted by the family. The resident had a walker they will be bringing with them and homecare services to be determined. The [DATE] at 11:25 AM progress notes entered by licensed practical nurse (LPN) Manager #13 documented: - The resident was transported in a facility wheelchair with an oxygen tank on the back, the transport was to return the wheelchair and tank to the facility. - The resident was discharged to the assisted living facility, all personal belongings including prescriptions were sent with the resident, report was called to the intaking facility, all questions answered at this time. Nursing progress notes from [DATE] to [DATE] did not contain any documented evidence the resident removed their oxygen or refused to wear it. The [DATE] at 1:37 PM Admission progress note from the assisted living facility, by registered nurse (RN) #29 documented: - The resident arrived from the nursing facility slumped out of their wheelchair with no leg rests on. - RN #29 was called to the lobby where the resident's lips were blue, and they were in and out of consciousness. - The resident was supposed to be on 3 lpm of O2 via NC and did not arrive with any oxygen on. - The resident was quickly placed on oxygen by a personal tank provided by the family and 911 was called. - The resident recovered on oxygen and full assessment by emergency medical services (EMS). - The transport company said they (the facility) did not say anything about oxygen. - The resident stated they (the resident) asked before leaving (the facility) and no one gave them anything. The [DATE] EMS Patient Care Report (PCR) documented: - They were called at 12:27 PM and arrived to the assisted living facility at 12:35 PM. - Upon arrival, Resident #12 was sitting in a chair and staff reported the resident arrived as a new admission, appeared to be out of it, and was supposed to be on 3 lpm of O2 at all times. - The resident was not on oxygen at this time, staff placed the resident on O2 at lpm via NC and the resident returned to their baseline. -The resident stated they were transported to the facility without oxygen on for over an hour. In an interview with assisted living facility RN #29 on [DATE] at 1:10 PM, they stated when the resident arrived from the nursing facility on [DATE], they were called to the lobby for immediate assistance. The resident's lips were blue, and they were unresponsive. The resident was in a wheelchair with an oxygen tank on the back and no tubing connected to the tank. RN #29 did a sternal rub, the resident opened their eyes and moaned. The resident's family members were present and one of them obtained an oxygen tank and tubing from their vehicle to place on the resident. Once the O2 was on the resident, they responded and returned to baseline. The transport driver stated they asked about oxygen upon pick-up at the facility and they did not have it during the transport. The transport driver told RN #29 they do not provide oxygen during transport. RN #29 stated they called the facility's Director of Nursing (DON) and left a message letting them know about this event. During an interview with the resident's family member on [DATE] at 3:56 AM, they stated they were already at the assisted living facility on [DATE] when the resident arrived as they were preparing for the resident's arrival. When the resident was brought in from the medical transport van, their feet were dragging, their skin was grey, lips were blue, and they were unresponsive. There were no oxygen tubes on the tank on the wheelchair and the family member ran to their car to get tubing they had for the resident. They called 911 and RN #29 brought the resident to another area and connected to oxygen and the resident revived. The family member called the facility and spoke to the social worker, who stated they were certain oxygen tubes were sent with the resident upon discharge. The relative did not speak to anyone else. During an interview with the owner of the medical transportation company on [DATE] at 8:59 AM, they stated their transportation service did not include provision or management of oxygen. Drivers were not expected to monitor for oxygen or oxygen needs during the transport. For Resident #12's transportation on [DATE], the facility set it up and did not provide any information related to the resident having oxygen. Typically, facilities will notify the transportation company if the resident had oxygen as they usually request the oxygen tank to be brought back after the transportation. During an interview with the transportation company driver on [DATE] at 9:06 AM, they stated they arrived at the facility to pick up Resident #12 on [DATE] at approximately 11:30 AM. The driver maintained their own log of trips and stated they reviewed it and there was no information provided related to oxygen. They would typically make a note of oxygen for information related to the resident as well as for the facility as they often wanted the oxygen tank returned. The driver did not observe the resident to have on any oxygen and they had no tubing, they could not recall if a tank was on the chair. Upon arrival to the assisted living facility, approximately one hour later, the driver noted the resident was out of it, was not able to pick up their feet in the wheelchair, there were no leg rests, and had to pull them in reverse into the building. Staff and family members immediately responded to the resident. The driver did not return to the facility with the wheelchair, as it remained with the resident and was not notified of a need to return. In an interview with LPN Manager #13 on [DATE] at 12:23 PM, they stated they discharged the resident and recalled they had the oxygen tank. They had to use a facility wheelchair and get an oxygen tank because the transport company did not provide one. Receptionist #32 would have set up the transportation. LPN #13 recalled the resident had oxygen on when they discharged them. In an interview with Receptionist #32 on [DATE] at 12:39 PM, they stated they did not set up transportation for Resident #12's discharge. They only set-up medical transportation for current residents to go to appointments. The Director of Social Serviced was responsible for setting up transportation for discharges. During an interview with the Director of Social Services on [DATE] at 12:45 PM, they stated they coordinated Resident #12's discharge including transportation to the assisted living facility. When a resident was on oxygen, they notified the transportation company to ask if they provided the tank or if the facility provided it. For resident #12, they stated the facility provided the tank. The Directer was not present the day the resident was discharged and stated they were certain the resident would have had the tubing and the oxygen tank with them. They stated they received a call over the weekend from the assisted living facility and was left a message about the resident not having on oxygen upon arrival. The Director of Social Serviced followed up with LPN Manager #13 and the DON after receiving the call. 10NYCRR415.11(d)(3)

Based on observation, record review, and interview during the abbreviated survey (NY00313544), the facility failed to ensure residents had the right to be free from neglect for 37 of 89 residents (Residents #1-37). Specifically, - Facility Administration received allegations against licensed practical nurse (LPN) #1 who was drowsy/sleeping while on duty. There was no documented evidence the facility immediately removed LPN #1 from having access to residents while investigations were pending, no documented evidence thorough investigations were completed to rule out neglect, and no documentation allegations were addressed immediately when received by Administration. - Facility staff did not immediately report all concerns of possible resident neglect immediately to facility Administration. - There was no documented evidence investigations were completed to ensure no misappropriation of resident narcotics occurred when LPN #1 was relieved of their medication administration duties when unable to perform those duties. - The facility did not report allegations of neglect to the New York State Department of Health (NYS DOH) as required. Findings include: The facility policy Controlled Substance: Access to Narcotics Storage and Locked Drug Areas effective 10/2019 documented: - At the beginning and end of each shift, all narcotics and controlled substances would be accounted for by having 2 nurses (one from the current shift and one from the oncoming shift) count narcotics and sign the appropriate accountability records. - any discrepancies would be reported to the Nursing Supervisor immediately; the off-going nurse must not leave the facility until the Nursing Supervisor had addressed the situation by either finding the missing narcotic or starting an investigation into the matter. - If the narcotic key must be given up before the end of the shift, for any reason, the nurse giving up the key must count the narcotics with the nurse receiving the key, and this must be documented on the narcotic change of shift sheet. - Anytime the narcotic keys were exchanged between nurses, the narcotics must be counted and documented on the narcotic shift change sheet. The facility policy Reporting Resident Abuse, Mistreatment, Neglect, or Misappropriation of Property reviewed 4/2021 documented: - Whenever there was reasonable cause to believe that resident physical abuse, mistreatment, neglect, or misappropriation of property had occurred by staff or a family member, the suspecting individual must call the NYS DOH. - Alleged violations and injuries of unknown source must be reported immediately, but no longer than 2 hours after the allegation was made if the events that caused the allegation involved abuse or resulted in serious bodily injury. - The results of all investigations would be reported to the DOH in accordance with state laws within 5 working days of the incident. During a telephone interview with registered nurse Supervisor (RNS) #16 on 4/12/23 at 11:03 AM, they stated on a night in early March 2023 (later identified as 3/3/23), they removed LPN #1 from the medication cart because they suspected LPN #1 to be under the influence. RNS #16 stated they absolutely thought [LPN #1] was under the influence of something based on how [they] were acting, nodding off. RNS #16 stated they called the Assistant Director of Nursing (ADON) and asked them to come to the facility to observe LPN #1's condition because they suspected LPN #1 to be under the influence. The ADON did not arrive before LPN #1 left. LPN #5 called 911 because they were worried LPN #1 was not safe to drive. LPN #1's entire medication pass (3 PM to 11 PM shift) had not been completed when LPN #1 left. RNS #16 stated they spoke to the ADON the following day and reiterated their concerns that LPN #1 was under the influence while working. LPN #1's time sheet documented they punched out at 12:03 AM on 3/4/23. During a telephone interview on 4/5/23 at 8:59 AM with LPN #5 they stated on 3/3/23, when they arrived to work for the 11:00 PM to 7:00 AM shift, LPN #1 had been relieved of their medication cart duty by RNS #16. LPN #5 observed LPN #1 in the front vestibule of the building and stated LPN #1 appeared to be under the influence. They stated LPN #1 was incoherent. LPN #5 notified the ADON they thought LPN #1 was under the influence and asked the ADON to come to the facility. LPN #1 left the building and LPN #5 was concerned about their ability to drive so they notified 911. LPN #5 stated they notified the Administrator and Director of Nursing (DON) via text message stating they sent LPN #1 home and that they notified the police due to the suspicion LPN #1 was under the influence. The DON replied asking if LPN #1 was on the schedule for the weekend and then the DON called LPN #5 and asked them to take LPN #1 off the schedule for the weekend until the DON could talk to LPN #1. LPN #5 stated they were concerned about the safety of the residents and the LPN's ability to drive, as they were completely incoherent. The audio recording of the call from the facility to the county 911 center on 3/4/23 at 12:14 AM was reviewed. The call was made by LPN #5 who identified themselves by name and reported the following: - LPN #1 was on the road and they suspect [they] are inebriated. LPN #5 stated LPN #1 was nodding out at the medication cart. - LPN #5 reported LPN #1 was sleeping for numerous hours, they pulled LPN #1 from the medication cart because they suspected LPN #1 was under the influence, told LPN #1 to sit in the office to sleep, and they contacted the ADON, who was on the way to evaluate the situation when LPN #1 took off. - LPN #5 stated they wanted the officers to keep an eye out for LPN #1, as they were definitely a danger, they could not keep LPN #1 at the facility, and LPN #1 was barely even coherent to walk. LPN #5 stated they tried to convince LPN #1 to stay, and LPN #1 just left. A text message from LPN #5 to the DON and Administrator dated 3/4/23 at 12:58 AM documented: - [LPN #1] was under the influence, RNS #16 took the medication cart from LPN #1 and told them to rest at the facility. The ADON was notified. LPN #5 called and left a voicemail for the ADON to let them know LPN #1 left prior to the ADON's arrival. LPN #5 tried to keep LPN #1 there, but they went out the back door. Police were notified by LPN #5. - The DON's text message reply stated Ok, is [LPN #1] on the schedule for this weekend? LPN #5 replied yes. A statement completed by the DON on 3/29/23 documented on 3/3/23, LPN #5 called the DON and the Administrator around 1:00 AM to notify them LPN #1 was drowsy and falling asleep; the LPN was relieved of their medication cart, and LPN #1 was resting in the front office. The DON took LPN #1 off the schedule for the weekend and spoke to LPN #1 the following Monday (3/6/23). LPN #1 reported they took migraine medication which caused them to be drowsy. The LPN appeared without any impairments and clear communication and was placed back on the schedule. There was no documented evidence an investigation was completed to address the concerns as reported by RNS #16 and LPN #5 on 3/4/23, including a medication review, narcotic reconciliation, or statements from staff to rule out resident neglect. On 3/28/2023, complaints from an anonymous staff member and multiple third parties were reported to the NYS DOH alleging LPN #1 was sleeping while administering medications. The complaint included a video that was posted to social media. The video was viewed, and the following was observed: a 33 second video of a staff member (later identified as LPN #1) standing at a medication cart. A drawer to the medication cart was open and the staff member was having difficulty standing up, leaning over the medication cart, and had their eyes closed at times. In addition to the third-party complaint, on 3/28/23, the facility reported that on 3/28/2023 at 12:00 PM, they became aware of a video posted to social media which showed the legs of Resident #4 in the background. They reported certified nurse aide (CNA) #2 was the accused staff member who took the video. The facility report contained no documentation related to allegations of neglect against LPN #1. On 3/28/2023 at 5:22 PM, a surveyor arrived at the facility and observed the staff member from the video in the front office. The DON stated at that time, the staff member in the video was LPN #1 and LPN #1 was there to provide a statement. The DON offered the following information to the surveyor on arrival: - The video posted on social media was recorded on 3/26/2023 between 9:00 PM and 9:30 PM and was recorded by CNA #2 who told the facility about the video on 3/27/23. - At 8:30 PM on 3/26/2023, the DON spoke with LPN #1 regarding Resident #23's catheter and the DON had no concerns with LPN #1's demeanor. LPN #1 followed directions and spoke clearly. - LPN #1 reported that after speaking with the DON on 3/26/23, they received a disturbing telephone call and put their head down at the medication cart in response to the call. - After they received the disturbing call, LPN #1 called 911 for Resident #23, sent the resident out, and interacted with emergency medical services (EMS). - The DON felt LPN #1 was reacting to disturbing news from the telephone call when they were observed on the video bending over. - Resident #4 told them they witnessed the recording of the video when LPN #1 bent over at the medication cart. - The facility initiated an investigation and talked with all staff who worked on 3/26/2023. On 3/28/2023 at 6:15 PM, Resident #4 stated in an interview, they witnessed LPN #1 at the medication cart on 3/26/2023 when other staff members recorded LPN #1 on their phones. Resident #1 stated there were at least 2 staff recording but the staff were new, and they did not know their names. Resident #4 saw LPN #1 put their head down and thought they had a headache. They stated LPN #1 gave them medications later in the shift and they did not think there were any issues with LPN #1 at that time. On 3/28/23, the DON provided a timeline and statements to the surveyor related to the 3/26/23 video posted to social media. The DON's timeline documented: - on 3/27/2023 at 8:30 AM, facility Administration was notified of the video of LPN #1 on social media and started interviewing staff. - On 3/28/2023, LPN #1 wrote a statement about the events on 3/26/2023 and documented they worked the evening shift after a long day the day prior. They received a disturbing personal call while working so they brought the medication cart to a quiet area away from residents. While getting ready to complete the second part of the medication pass, 2 CNAs told LPN #1 that Resident #23 pulled out their catheter. LPN #1 called the DON to get instructions and called 911 for the resident. While waiting for EMS, LPN #1 put their head down for a quick minute. LPN #1 was not aware they were being recorded. LPN #1 then went to the copy machine to print records for the resident being sent to the hospital and talked with EMS. After EMS left, LPN #1 finished their medication pass. - On 3/27/2023, CNA #2's statement documented last night they worked with LPN #1 and was told by CNA #4 that LPN #1 was not passing medications and appeared to be under the influence. CNA #2 documented LPN #1 was asleep and not answering staff when they asked them questions. A second investigation written by the DON, provided by the facility, documented it was a Video Investigation on 3/28/2023, and included: - At 12:00 PM, the facility's {Social Media} Administrator was notified that a video was tagged to the facility's Facebook page that was a video of LPN #1 falling asleep at the nursing station. - A narcotic audit was done for 3/26/2023 and no issues were identified. - CNA #3's statement dated 3/29/23 documented on 3/26/23, LPN #1 seemed extremely tired when they came in for their shift and kept falling asleep at their (medication) cart. CNAs #3 and 4 kept talking to LPN #1 to keep them awake. CNA #3 woke up LPN #1 to send a resident to the hospital. - CNA #4's undated statement documented on 3/26/23, LPN #1 seemed extremely tired around dinner time and started nodding off and falling asleep at their (medication) cart. CNA #4 along with CNA #3 would wake up LPN #1 and keep the LPN company so they would not fall asleep. - CNA #2 self-terminated on Tuesday 3/35/23 (3/28/2023). - No residents were affected, and no negative outcomes were found. - The investigation was signed and dated by the DON on 3/31/2023. There was no documented evidence in the investigation of a medication administration review or documentation of the referenced narcotic audit that occurred. The Change of Shift Controlled Medication Count sheet did not contain any documentation that nurses completed a shift to shift count on 3/26/23 for the day, evening, or night shifts. No nurses signed the sheet as counting off the narcotics when passing the keys to one another on that date. The audio recording of the call from the facility to the county 911 center on 3/26/23 at 8:55 PM (for a resident to be transferred) was reviewed. The call was made by LPN #1 who identified themselves by name and included: - LPN #1 stated a resident had removed their suprapubic catheter (urine is drained directly from the bladder through a small opening and tubing). - The 911 operator asked how old the patient was, LPN #1 replied [they're] ok. - the 911 operator repeated the question and LPN #1 then answered the question. - The 911 operator asked if the resident had been seen by a nurse or physician in the last 2 hours, the LPN replied no. - When asked if the facility had a nurse on staff, LPN #1 replied Oh yeah, I mean, I thought you said doctor. - The 911 operator repeated nurse or doctor, the LPN replied yes, yeah. The LPN's speech pattern was delayed, and LPN #1 was slow to respond to questions asked by the 911 operator. During an interview with emergency medical technician (EMT) #24 on 4/26/23 at 4:19 PM, they stated they responded to the facility on [DATE] to pick up Resident #23 at approximately 9:00 PM. Upon arrival, the nurse described as LPN #1 directed them to the resident's room. The EMT addressed the resident in the room, and that resident was not aware of the reason the EMT was there. LPN #1 did not follow them to the room or provide any information. After speaking to the resident, the EMT realized it was not the resident they were there to transport, and their partner went to the nurse's desk to find out where Resident #23 was. The EMT then heard another unidentified nurse in the hall directing their partner to the correct resident's room. The EMT reported LPN #1 seemed confused as to the reason they were there and did not have any further interaction with them. A timeline of LPN #1's employment signed and dated by the DON On 3/29/2023 documented: - LPN #1 started working at the facility on 2/16/2023 and worked 28 shifts; 13 were 12 hour shifts or double shifts and LPN #1 worked 8 days in a row leading up to 3/26/2023. - On 3/3/2023, LPN #1 worked overnights and at 1:00 AM, the DON and Administrator received a call from LPN #5 that LPN #1 was falling asleep, relieved of medication cart duties, and was asleep in the front office. Facility staff offered to call 911 and LPN #1 declined. - On Monday 3/6/2023, LPN #1 came in and spoke with Administration and reported taking migraine medication that caused drowsiness. LPN #1 was placed back on the schedule. - On 3/16/2023, it was reported that LPN #1 was drowsy on the overnight shift on 3/15/2023 and agreed they would not work double shifts. - On 3/20/223, LPN #1 was found sleeping in their car after their shift by LPN Unit Manager #13 who knocked on the car window and woke them up. LPN #1 reported they were sleeping prior to driving home. - 3/24/2023, spoke with LPN #1 about the upcoming weekend and the need to be on time. The plan going forward due to reported personal issues and lack of sleep was they would only work scheduled shift and would not stay for additional shifts. Disciplinary Action Reports documented: - On 3/6/2023, LPN #1 was late on 6 occasions and was counseled on being on time for shifts and shift report. - On 3/21/2023, LPN #1 was counseled for staying on the overnight shift when fatigued and they were advised not to work past the 3 PM-11 PM shift to ensure the employee was on time and well rested. - On 3/24/2023, LPN #1 was late for their shift on 11 occasions and was spoken to regarding routine habits, if trouble with sleep patterns, and suggested strategies to combat fatigue. There was no documented evidence any of the above Reports were reviewed with LPN #1 when they were prepared. All were signed by LPN #1 on 3/30/2023 and no one else signed the forms. The spot for signatures of the person completing the discipline, a witness, Manager, and Administration were blank. On 4/3/2023 at 11:26 AM, CNA #3 stated in an interview, they worked on the evening shift on 3/26/2023 and when LPN #1 came in they looked fine but when they got to the medication cart, they started dozing off. When CNA #3 talked to LPN #1, they stayed awake but when left alone, LPN #1 fell asleep. After dinner, LPN #1 continued to fall asleep and aroused when CNA #3 said their name. After the video was taken, LPN #1 went to the copy machine to prepare papers for a resident going out and CNA #3 saw them dozing off at the copy machine. CNA #3 reported these concerns to LPN #6 who said to keep an eye on LPN #1 and keep them awake by talking with them. In an interview on 4/3/23 at 1:49 PM, LPN #6 stated on 3/26/2023, they worked on the other side of the facility from LPN #1 and: - LPN #6 only worked with LPN #1 a few times and LPN #1 always looked tired, like they were going to pass out, slurred their speech, swayed at times, was always leaning on the medication cart, often seemed disoriented, and was typically absent most of the shift, up to 5 to 6 hours out of an 8-hour shift. LPN #6 did not report the occasions when LPN #1 was absent during their shift, as LPN #6 did not want to make assumptions about LPN #1. - LPN #6 observed LPN #1 to be nodding off at the medication cart before. - On the evening of 3/26/23, LPN #1 was worse than normal and something was definitely off. LPN #1 was supposed to work until 3:00 AM on 3/27/23 and was sent home by LPN #5 when LPN #1 was found crawling on the floor. LPN #6 observed a video of LPN #1 on the floor, someone recorded it for professional purposes to have it investigated by Administration. - Before the video of LPN #1 sleeping at the medication cart was posted to social media, LPN #6 was talking to Supervisors about concerns LPN #1 was possibly under the influence. - On 3/26/23, LPN #1 was not able to be found much of the shift and this was common, LPN #1 was often in the bathroom or out in their car. When LPN #1 could not be found, staff reported to LPN #6 and LPN #6 would check on LPN #1's residents. - On 3/26/23, LPN #1 almost sent out the wrong resident to the hospital and LPN #6 intervened. - There may have been talk about LPN #1 sleeping at the medication cart on 3/26/23 but LPN #6 did not know it was as bad as what was later observed in the video that was posted to social media on 3/27/23. Staff only reported that it was hard to find LPN #1. - After LPN #1 was relieved of their duties on 3/26/23, the LPN stayed in their car until about 3:00 AM, intermittently hitting the horn. Residents complained of the lights shining in their windows from the vehicle. During a telephone interview with LPN #5 on 4/5/23 at 8:59 AM, they stated: - On 3/26/23, they arrived to work for the 11:00 PM -7:00 AM shift and LPN #1 was scheduled to work until 3 AM. Staff reported people were taking videos and no one stepped in. - When LPN #5 arrived, CNA #23 reported LPN #1 had been in the bathroom at least 45 minutes to one hour and LPN #5 instructed CNA #23 to notify them immediately when LPN #1 came out of the bathroom. - When CNA #23 notified LPN #5 that LPN #1 had come out of the bathroom, they observed LPN #1 on the floor crawling around, reaching around for things that were not there. - Multiple staff recorded LPN #1 while they were on the floor, the 2 other LPNs that were on duty knew what was going on, and no one intervened. LPN #5 heard multiple evening shift (3:00 PM-11:00 PM) staff had taken videos of LPN #1. - LPN #1 got up from the floor and surrendered their narcotics keys to LPN #5. LPN #5 did a narcotic count with LPN #1 and noted no narcotics had been signed out. LPN #5 entered the date and did not enter the times, as they did not know when the narcotics were administered. LPN #5 had to point and show LPN #1 where to sign on the narcotic sheets. LPN #1 could not focus to sign as LPN #1 was so out of it. The protocol for narcotics was to sign for each medication as it was administered to the resident, but LPN #1 did not sign out any narcotics during the shift. - LPN #5 asked LPN #1 if they were under the influence of something and LPN #1 was so incoherent, LPN #5 could not understand them. LPN #1 exhibited signs and behaviors that made LPN #5 believe LPN #1 was under the influence of some substance. - LPN #5 sent a message to the ADON and/or the DON (could not recall if one of them or both) stating they were sending LPN #1 home and received no response. - When LPN #1 left the building, they sat in their car and kept hitting the horn, as if they were falling asleep and hitting their head, it was on and off. When LPN #5 approached the car, the engine was running, and LPN #1 left and parked in the parking lot across the street. LPN #5 attempted to notify the police and received no response. LPN #1 remained in the car for about 1 1/2 hours. - LPN #5 spoke to the ADON in the morning (Monday 3/27/23) and provided a written statement. The Administrator asked LPN #5 for a statement and LPN #5 told them it was already provided to the ADON. - The LPN added that when speaking to management, there were times they were instructed to refrain from saying they suspected LPN #1 was impaired. LPN #5 refused to refrain from expressing their suspicions because they did believe LPN #1 was impaired and was concerned about the safety of the residents. During an interview with LPN Unit Manager #13 on 4/13/23 at 10:15 AM, they stated at the end of a shift, the oncoming nurse was to verify the narcotic count with the off going nurse. LPN Unit Manager #13 saw the narcotic sheets about once weekly. If any discrepancies were noted, they would call the nurse and have them sign. The LPN Manager was unaware of any discrepancies in the narcotic count sheets. During an interview with the ADON on 4/13/23 at 10:37 AM, they stated they could not recall the date (identified as 3/3/23) when RNS #16 notified them around 11:30 PM of taking LPN #1's medication cart keys away due to them nodding off. The ADON asked if RNS #16 wanted them to go to the facility and was notified by LPN #5 that LPN #1 left before the ADON arrived. The ADON stated LPN #5 reported LPN #1 was sleeping, had their keys taken away, and LPN #5 could not wake them up. The ADON could not recall if LPN #5 reported calling 911 on 3/3/23 and did not think LPN #5 reported concerns that LPN #1 was under the influence. The ADON stated they should have questioned more people and handled it in the wrong manner, related to the night of 3/3/23 -3/4/23. The ADON had discussions with the DON and Human Resources (HR) Coordinator related to LPN #1 being late by 2 to 4 hours and that LPN #1 was to work only 8-hour shifts, not double shifts. During an interview with the HR Coordinator on 4/13/23 at 12:08 PM, they stated they were involved in employee discipline, attendance, and violations of general policies. LPN #1 had significant issues with arriving to work late and they felt it was due to the LPN staying later into the overnight shift. LPN #1 was counseled for sleeping issues and the HR Coordinator felt those issues were related to working late or being tired. The HR Coordinator prepared the counseling forms related to LPN #1's tardiness on 3/6/23, 3/21/23, and 3/24/23 and would leave them for the ADON to complete. The plan for LPN #1 was not to work past the 3:00 PM-11:00 PM shift and the HR Coordinator was unaware of the reason the LPN continued to work past that shift. The supervisors made staffing decisions based on the schedule and consulted with the DON. The HR coordinator did not know if the supervisors would have known that LPN #1 was not supposed to work past the 3:00 PM -11:00 PM shift. The HR Coordinator stated the DON and ADON were responsible to communicate that to the supervisors. During an interview with the DON on 4/13/23 at 12;39 PM, they stated: - they were unaware of a facility policy related to suspicions of substance abuse. - on 3/4/23, they received a text message from LPN #5 stating that RNS #16 relieved LPN #1 of their duties and LPN #1 was in the office. The DON stated they were never told by LPN #5 or RNS #16 of suspicions that LPN #1 was under the influence or impaired by. When LPN #5 reported they called 911, the DON was initially uncertain of the reason aside from LPN #1 being tired, and then stated LPN #5 was dramatic and likely why they called 911. The DON then stated they meant to say LPN #5 did the right thing by calling 911. On 3/4/23, the DON called LPN #1 and advised the LPN they were not to go to work until the DON and HR Coordinator spoke to them. On Monday (3/6/23), they met with LPN #1 who reported they had a migraine, took medication, and could not function. There was no investigation related to LPN #1 being sent home on 3/3-3/4/23. The DON stated they never suspected substance abuse. The plan was for LPN to not work past their 3:00 PM-11:00 PM shift and was not scheduled past 11:00 PM. The DON was unaware of the reason LPN #1 continued to work past 11:00 PM. The HR Coordinator was to communicate to supervisors to ensure they knew not to schedule or allow LPN #1 to work past their 3:00 PM - 11:00 PM shift. On the night of 3/26/23, the DON stated they were not made aware LPN #1 was sent home. The LPN had no knowledge of any issues until the social media post was brought to their attention on the morning of 3/27/23. The DON did not speak to anyone on the night shift from 3/26-3/27/23 and was not aware of the reason. There was no written documentation of a medication review or narcotic reconciliation from 3/3-3/4/23 or 3/26/23-3/27/23. The DON was unaware of the reason there was no documented narcotic reconciliation on 3/26/23. The DON expected any staff who observed concerns with LPN #1 sleeping at the medication cart to report immediately. During an interview with the Administrator on 4/13/23 at 1:30 PM, they stated they were unaware of a policy or protocol for suspicions of substance abuse by staff. They could not recall being made aware of LPN #1 being sent home on 3/3/23-3/4/23 or of any concerns reported that LPN #1 was suspected of being under the influence. The Administrator could not recall any other concerns leading up to the 3/26/23 video of LPN #1 sleeping and stated the DON, ADON, and HR Coordinator would have followed up. The Administrator could not recall if anyone notified them LPN #1 was sent home on 3/26/23 prior to the video being released to social media. The Administrator expected staff to report any concerns to a supervisor. The incident regarding the video was not reported to NYS DOH due to not being able to make a determination of neglect related to LPN #1. During an interview with CNA #2 on 4/13/23 at 3:23 PM, they stated on the night of 3/26/23, they were notified by CNA #4 that LPN #1 was sleeping at the medication cart. CNAs #7 and 11 accompanied CNA #2 to the front of the building and observed LPN #1 asleep at the cart for approximately 10 minutes. LPN #1 would not respond when they tried speaking to them. CNA #2 recorded LPN #1 sleeping at the cart and sent the video to the HR Coordinator at 9:34 PM that evening. They received no response and notified the facility the following morning. CNA #2 reported to LPN #12 that night that LPN #1 was asleep at their cart and was told it was none of LPN #12's business. CNA #2 did not see any other LPNs in the building and was unaware of who else to notify to report the concern. An untitled, unsigned statement received from the facility on 4/13/23 at 3:31 PM, documented: 3/27/23, Unit 1, audit completed on descending individual patients' narcotic count sheets compared to the MAR (medication administration record) time span from 2/16/23 to 3/27/23. Medications were signed out appropriately and times aligned. All narcs (narcotics) were accounted for and no discrepancies. Residents were interviewed and stated they received their narcotics as dispensed. LPN #1 did not have access to Omnicell (on-site medication dispensing machine). 10NYCRR 415.4(b)

Based on observation, record review, and interview during the abbreviated survey (NY00313544), the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 37 of 89 residents (Residents #1-37). Specifically, facility Administration, including nursing management, was notified when licensed practical nurse (LPN) #1 was unable to perform their job duties and failed to: - immediately remove LPN #1 from having access to residents while thorough investigations were completed. - ensure the corrective action plan they developed to assist LPN #1 with performance issues (limiting work hours) was implemented. - complete a thorough investigation into narcotics reconciliation after being notified the nursing Supervisor removed LPN #1 from having access to medications after they suspected LPN #1 was under the influence. Findings include: Refer to F600 - Free From Abuse and Neglect During a telephone interview with registered nurse Supervisor (RNS) #16 on 4/12/23 at 11:03 AM, they stated on a night in early March 2023 (later noted to be the night shift of 3/3/23 into 3/4/23), they removed LPN #1 from the medication cart because they suspected LPN #1 was under the influence as they were nodding off. They called the Assistant Director of Nursing (ADON) and asked them to come to the facility to observe LPN #1's condition. LPN #1 left the facility before the ADON arrived and staff called 911 because they did not think LPN #1 was safe to drive. RNS #16 stated they spoke to the ADON the following day and reiterated their concerns that LPN #1 was under the influence while working. During a telephone interview with LPN #5 on 4/5/23 at 8:59 AM, they stated they worked from 11:00 PM on 3/3/23 to 7:00 AM on 3/4/23 and LPN #1 was relieved of their duties by RNS #16 as LPN #1 was incoherent. LPN #5 notified the ADON and stated they thought LPN #1 was under the influence. LPN #5 stated they notified the Administrator and Director of Nursing (DON) of their concerns and told them they sent LPN #1 home and notified the police due to a suspicion LPN #1 was under the influence. The DON replied to take LPN #1 off the schedule for the weekend until the DON could talk to LPN #1. A text message from LPN #5 to the DON and Administrator dated 3/4/23 at 12:58 AM documented: - [LPN #1] was under the influence, RNS #16 took the (medication) cart from LPN #1 and told them to rest to keep them at the facility. The ADON was notified of the event and was to come in, and LPN #5 called and left a voicemail for the ADON to let them know LPN #1 left. LPN #5 tried to keep LPN #1 there, but LPN #1 went out the back door. Police were notified by LPN #5 as they were concerned LPN #1 was unsafe to drive. - The DON's text message reply documented ok, is [LPN #1] on the schedule for this weekend? LPN #5 replied yes. A statement completed by the DON on 3/29/23 documented on 3/3/23, LPN #5 called the DON and the Administrator around 1:00 AM to notify them LPN #1 was drowsy and falling asleep and the LPN was relieved of their medication cart and was resting in the front office. LPN #5 offered to call 911 and LPN #1 declined. The DON took LPN #1 off the schedule for the weekend and spoke to LPN #1 the following Monday. LPN #1 reported they took migraine medication which caused them to be drowsy. The LPN appeared without any impairments and was placed back on the schedule. Disciplinary Action Reports documented: - on 3/6/2023, LPN #1 was late on 6 occasions and was counseled on being on time for shifts and shift report. - On 3/21/2023, LPN #1 was counseled for staying on the overnight shift when fatigued and they were advised not to work past the 3:00 PM-11:00 PM shift to ensure the employee was on time and well rested. - On 3/24/2023, LPN #1 was late for their shift on 11 occasions and was spoken to regarding routine habits, if trouble with sleep patterns, and suggested strategies to combat fatigue. There was no documented evidence any of the above reports were reviewed with LPN #1 when they were prepared. All were signed by LPN #1 on 3/30/2023 and none were signed by the person completing the discipline, a witness, Manager, or Administration. The reports were noted as prepared by the Human Resources (HR) Coordinator. A timeline of LPN #1's employment signed and dated by the DON on 3/29/2023 documented: - LPN #1 started working on 2/16/2023 and worked 28 shifts; 13 were 12 hour shifts or double shifts and LPN #1 worked 8 days in a row leading up to 3/26/2023. - On 3/3/2023, LPN #1 worked overnights. At 1:00 AM, the DON and Administrator received a call from LPN #5 that LPN #1 was falling asleep, relieved of medication cart duties, and was asleep in the front office. Facility staff offered to call 911 and LPN #1 declined. - On Monday 3/6/2023, LPN #1 came in and spoke with Administration and reported taking migraine medication that caused drowsiness. LPN #1 was placed back on the schedule. - On 3/16/2023, it was reported that LPN #1 was drowsy on the overnight shift on 3/15/2023 and agreed they would not work double shifts. - On 3/20/223, LPN #1 was found sleeping in their car after their shift by LPN Unit Manager #13 who knocked on the car window and woke them up. - On 3/24/2023, spoke with LPN #1 about the upcoming weekend and need to be on time. The plan going forward due to reported personal issues and lack of sleep was they would only work scheduled shift and would not stay for additional shifts. LPN #1's Timesheet documented they continued to work double shifts/night shifts following the identified concern and the documented plan they would not work doubles or extra shifts: - on 3/17/23 from 5:19 PM to 3:10 AM on 3/18/23; - on 3/19/23 from 11:49 PM to 7:22 AM on 3/20/23; - on 3/20/23 from 5:30 PM to 8:21 AM on 3/21/23; - on 3/23/23 from 3:25 PM to 12:15 AM on 3/24/23; - on 3/24/23 from 4:25 PM to 1:00 AM on 3/25/23; and - on 3/26/23 from 4:00 PM to 12:45 AM on 3/27/23. On 3/28/2023, complaints from a staff member and multiple third parties were reported to the New York State Department of Health (NYS DOH) alleging LPN #1 was sleeping while administering medications. The complaint included a video that was posted to social media. The video was viewed, and the following was observed: a 33 second video of a staff member (later identified as LPN #1) standing at a medication cart. A drawer to the medication cart was open and the staff member was having difficulty standing up, leaning over the medication cart, and had their eyes closed at times. The facility's 3/27/23 and 3/28/23 investigation included staff statements from CNAs #2, 3, and 4 stating LPN #1 was observed to be sleeping at the medication cart on the evening of 3/26/23. The Change of Shift Controlled Medication Count sheet did not contain any documented entries for 3/26/23. None of the nurses who worked signed as counting narcotics with the oncoming shift that date. There was no documented evidence of a medication review or narcotic review for the residents on LPN #1's assignment on 3/26/23. In an interview on 4/3/23 at 1:49 PM, LPN #6 stated: - LPN #1 always looked tired, like they were going to pass out, slurred their speech, swayed at times, was always leaning on the medication cart, often seemed disoriented, and was typically absent most of the shift, up to 5 to 6 hours out of an 8-hour shift. - LPN #6 did not observe LPN #1 to be sleeping while on duty but had observed them to be nodding off at the medication cart. - On the evening of 3/26/23, LPN #1 was worse than normal and something was definitely off. - LPN #1 was supposed to work until 3:00 AM on 3/27/23 and was sent home by LPN #5 when LPN #1 was found crawling on the floor. LPN #6 observed a video of LPN #1 on the floor, someone recorded it for professional purposes to have it investigated by Administration. - Before the video of LPN #1 sleeping at the medication cart was posted to social media, LPN #6 was talking to supervisors about it because of concerns LPN #1 was possibly under the influence. During a telephone interview with LPN #5 on 4/5/23 at 8:59 AM, they stated: - On 3/26/23, when they arrived for work for the 11 PM -7 AM shift, CNA #23 reported LPN #1 had been in the bathroom at least 45 minutes to one hour. - When LPN #1 came out of the bathroom, LPN #5 observed LPN #1 on the floor crawling around, reaching around for things that were not there. - LPN #1 got up from the floor and surrendered their keys to LPN #5. LPN #5 did a narcotic count with LPN #1 and noted no narcotics had been signed out. LPN #5 entered the date and did not enter the times, as they did not know when the narcotics were administered. LPN #5 had to point and indicate to LPN #1 where to sign on the narcotic sheets, LPN #1 could not focus to sign as they were so out of it. The protocol for narcotics was to sign for each medication as it was administered to the resident, but LPN #1 did not sign out any narcotics during the shift. - LPN #5 asked LPN #1 if they were under the influence of something and LPN #1 was so incoherent LPN #5 could not understand them. LPN #1 exhibited signs and behaviors that made LPN #5 believe LPN #1 was under the influence of some substance. - LPN #5 spoke to the ADON in the morning (Monday 3/27/23) and provided a written statement. - The Administrator asked LPN #5 for a statement and LPN #5 told them it was already provided to the ADON. In an interview on 4/13/23 at 10:37 AM, the ADON stated sometime in early 3/2023 they received a call from RNS#16 at around 11:30 PM stating LPN #1 was nodding off, they took the medication keys from LPN #1, and relieved them of their duties. The ADON stated they were aware LPN #5 said they were calling 911 and did not know why 911 would be called for someone being tired. The ADON stated they should have questioned this situation more. The ADON had discussions with the DON and HR Coordinator related to LPN #1 being late by 2 to 4 hours and that LPN #1 was to work only 8-hour shifts, not double shifts. During an interview with the HR Coordinator on 4/13/23 at 12:08 PM, they stated LPN #1 had significant issues with arriving to work on time and they felt it was due to the LPN staying later into the overnight shift. LPN #1 was counseled for sleeping issues and the HR Coordinator felt those issues were related to working late or being tired. The HR Coordinator prepared the counseling forms related to LPN #1's tardiness on 3/6/23, 3/21/23, and 3/24/23 and would leave them for the ADON to complete. The plan for LPN #1 was not to work past their 3:00 PM-11:00 PM shift and the HR Coordinator was unaware of the reason the LPN continued to work past that shift. The supervisors made staffing decisions based on schedule and consulted with the DON and did not know if the supervisors would have known that LPN #1 was not supposed to work past the 3:00 PM -11:00 PM shift. The DON and ADON would have been responsible to communicate that to the supervisors. During an interview with the DON on 4/13/23 at 12:39 PM, they stated on 3/4/23 the DON received a text message from LPN #5 stating that RNS #16 relieved LPN #1 of their duties and the LPN was in the office. The DON stated they were never told by LPN #5 or RNS #16 of suspicions that LPN #1 was under the influence or impaired. The DON stated LPN #5 called 911 for LPN #1 as LPN #5 was dramatic. The DON stated they reviewed everything after this, there were no red flags and they found no issues. The plan was for LPN #1 to not work past their 3:00 PM-11:00 PM shift and was not scheduled past 11:00 PM. The DON was unaware of the reason LPN #1 continued to work past 11:00 PM. The HR Coordinator was to communicate to supervisors to ensure they knew not to schedule or allow LPN #1 to work past their 3:00 PM - 11:00 PM shift. The DON stated they were not made aware LPN #1 was sent home on the night of 3/26/23. The LPN had no knowledge of any issues until the social media post was brought to their attention on the morning of 3/27/23. There was no written documentation of a medication review or narcotic reconciliation from 3/3-3/4/23 or 3/26/23-3/27/23. The DON was unaware of the reason there was no documented narcotic reconciliation on 3/26/23. During an interview with the Administrator on 4/13/23 at 1:30 PM, they stated they could not recall being made aware of LPN #1 being sent home on 3/3/23-3/4/23 or of any concerns reported that LPN #1 was suspected of being under the influence. The Administrator could not recall any other concerns leading up to the 3/26/23 video of LPN #1 sleeping and stated the DON, ADON, and HR Coordinator would have followed up. The Administrator could not recall if anyone notified them LPN #1 was sent home on 3/26/23 prior to the video being released to social media. An untitled, unsigned statement received from the facility on 4/13/23 at 3:31 PM documented: 3/27/23, Unit 1, audit completed on descending individual patients' narcotic count sheets compared to the MAR [medication administration record] time span from 2/16/23 to 3/27/23. Medications were signed out appropriately and times aligned. All narcs were accounted for and no discrepancies. Residents were interviewed and stated they received their narcotics as dispensed. LPN #1 did not have access to the Omnicell (on-site medication dispensing machine). 10NYCRR 415.26(a)

Based on record review and interview during the abbreviated survey (NY00310988), the facility failed to ensure that all alleged violations involving abuse and neglect were reported to The New York State Department of Health (NYS DOH) as required for 1 of 5 residents reviewed (Resident #9). Specifically, the facility received an allegation of sexual abuse related to Resident #9 on 2/21/23 and it was not reported to the NYS DOH as required. Findings include: The Reporting Resident Abuse, Mistreatment, Neglect, or Misappropriation of Property policy dated 4/2021 documented: - Whenever there is reasonable cause to believe that resident physical abuse, mistreatment, neglect, or misappropriation of property has occurred by staff or a family member, the suspecting individual must call the NYS DOH. - Alleged violations and injuries of unknown source must be reported immediately, but no longer than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury. - The results of all investigations will be reported to the DOH in accordance with state laws within 5 working days of the incident. Resident #9 had diagnoses including dementia, acute and chronic respiratory failure, and anemia. The 1/18/23 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment and exhibited behaviors of rejection of care and wandering on 1 to 3 days of the assessment period. The resident required supervision with staff assistance for their activities of daily living (ADL). Resident #10 had diagnoses including dementia, hypertension, and heart disease, The 1/19/23 MDS assessment documented the resident had moderate cognitive impairment and did not exhibit behavioral symptoms. The resident required supervision and staff assistance for ADLs. On 2/16/23, a complaint was received by the NYS DOH from the local police department reporting Resident #9's roommate (Resident #10) told Resident #9's family member that the resident was sexually assaulted for the last few nights they were at the facility. Resident #10 was not able to provide dates but gave a description as a white male with very dirty sneakers. The report further documented Resident #10 reported the male would exit the room through the bathroom into the adjoining room. Resident #10 reported the accused staff member was married to another certified nurse aide (CNA) who also worked on the unit. The facility's 2/21/23 Investigation Summary documented: - The Director of Nursing (DON) was made aware of a complaint made to the police and NYS DOH that Resident #10 made a statement to Resident #9's family member that Resident #9 was sexually assaulted the past 3 nights. - The detective interviewed Resident #10, who told them they never saw anyone in the room, only shadows. Resident #9 yelled, and then Resident #10 yelled, staff responded and reported no one was in the room. - The detective reported to the DON Resident #10's statement was much different from the original statement they received. - On 2/22/23, the detective notified the DON they were closing the case. - The investigation included statements from CNAs #19, 20, and 22. - There was no documented statement from Resident #10. There was no documented evidence the facility reported the allegation of sexual abuse to the NYS DOH following receipt of the allegation from the police department on 2/21/23. During an interview with Resident #10 on 2/27/23 at 11:30 AM, they stated they recalled telling Resident #9's family that the resident had been sexually assaulted in their room for 3 nights prior to Resident #9 going to the hospital. Resident #10 heard screaming and saw only shadows and called for help. Resident #10 stated they recalled a police detective coming to see the resident and they told the detective the same thing. Resident #10 could not recall if anyone else spoke to them about the allegation. During an interview with the DON on 2/28/23 at 12:02 PM, they stated they were uncertain of the reason the allegation was not reported to NYS DOH following the notification from the police detective. The DON stated an allegation of abuse was reportable, however they had not experienced receiving an allegation from an outside source. The police detective notified the facility the police department reported the allegation the NYS DOH and that possibly led to the facility not following up with their own report. In reviewing the issue, the DON stated it should have been reported to the NYS DOH as required, even if the police stated they reported the allegation. During a telephone interview with the Administrator on 3/7/23 at 1:00 PM, they stated the facility was first made aware of the alleged sexual assault on 2/21/23 when the police detective arrived. The detective provided limited information related to the allegation and asked that they speak to Resident #10 alone. The detective returned in approximately 5-10 minutes and stated they had determined the allegation was not credible. The Administrator was satisfied with the detective's conclusion and did not feel the allegation was reportable to NYS DOH based on their conclusion. The Administrator stated they conducted an investigation and felt it was concluded within 2 hours of being notified by the police. 10NYCRR 415.4 (b)(2)(3)

Based on record review and interview during the abbreviated survey (NY00310988), the facility failed to ensure all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated for 1 of 5 residents reviewed (Resident #9). Specifically, the facility received a report of alleged sexual abuse on 2/21/23 related to Resident #9 and there was no documented evidence the investigation was completed timely or thoroughly. Findings include: The Abuse Investigation and Reporting policy revised 7/2017 documented: - All reports of resident abuse, neglect, exploitation, or misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. - The role of the Administrator included assignment of the investigation to the appropriate individual. - The role of the assigned investigator included: completion of documentation forms; interviewing any witnesses; interviewing the resident's physician to determine the resident's current level of cognitive function and medical status; interview staff members on all shifts who had contact with the resident during the time of the alleged incident; interview the resident's roommate, family, and visitors; interview other residents whom the accused employee provided care or services; and review all events leading up to the alleged incident. Resident #9 had diagnoses including dementia, acute and chronic respiratory failure, and anemia. The 1/18/23 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment and exhibited behaviors of rejection of care and wandering on 1 to 3 days of the assessment period. The resident required supervision with staff assistance for their activities of daily living (ADL). Resident #10 had diagnoses including dementia, hypertension, and heart disease, The 1/19/23 MDS assessment documented the resident had moderate cognitive impairment and did not exhibit behavioral symptoms. The resident required supervision with staff assistance for ADLs. The facility's 2/21/23 Investigation Summary documented: - The Director of Nursing (DON) was made aware of a complaint made to the police and NYS DOH that Resident #10 made a statement to Resident #9's family member that Resident #9 was sexually assaulted the past 3 nights. - Resident #9's relative filed a police report on an unknown date and on that date, the police detective informed the facility it was reported that on 2/9/23, 2/10/23, and 2/11/23, an unknown male entered the room, removed their clothing, and got into bed with Resident #9. - The detective interviewed Resident #10, who told them they never saw anyone in the room, only shadows. Resident #9 yelled, and then Resident #10 yelled, staff responded and reported no one was in the room. - The detective reported to the DON the statement from Resident #10 was much different from the original statement they received. - On 2/22/23, the detective notified the DON they were closing the case. - The facility investigation included statements from certified nurse aides (CNA) #19, 20, and 22. - There were no statements from multiple other staff who worked and there was no statement from Resident #10 included. There was no documented evidence the investigation included a review of other staff or residents to rule out abuse occurring. During an interview with Resident #10 on 2/27/23 at 11:30 AM, they stated they recalled telling Resident #9's family that the resident had been sexually assaulted in their room for 3 nights prior to Resident #9 going to the hospital. Resident #10 heard screaming and saw only shadows and called for help. Resident #10 stated they recalled a police detective coming to see the resident and they told the detective the same thing. Resident #10 could not recall if anyone else spoke to them about the allegation. During an interview with the DON on 2/28/23 at 12:02 PM, they stated: - on 2/21/23, a detective from the police department arrived and reported they received an allegation of sexual assault related to Resident #9. - The detective told the DON that Resident #10 told Resident #9's family member that Resident #9 had been sexually assaulted the past 3 nights. - The DON was told the alleged staff was the spouse of another employee and named CNA #15. CNA #15 was questioned by the detective, who stated their spouse did not work there. CNA #15 stated another CNA with a similar sounding name had a significant other who was also a CNA and they both worked the night shift (CNAs #20 and 25). - The detective spoke to Resident #10 on 2/21/23 and stated Resident #10's story changed from the initial report. The detective concluded the allegation was not credible and the facility used that for their determination of their own investigation. - The facility had little information from the police and relied on the police department to complete the investigation. - The facility did not speak to Resident #10. - Resident #10 had been on quarantine and returned to the room they shared with Resident #9 on 2/2/23. Resident #9 had been discharged to the hospital on 2/5/23 and the facility determined those were the only days the alleged events could have occurred. - The DON could not think of any male staff to fit the description of a spouse of another employee who worked on the night shift. - CNA #25 did not work 2/2/23 to 2/5/23. - The DON did not finish gathering statements from staff and did not obtain statements for other staff on other shifts, as they focused on the night shift. - The DON stated there were some unanswered questions in the investigation and it could have included more to be complete. During a telephone interview with the Administrator on 3/7/23 at 1:00 PM, they stated the facility was first made aware of the alleged sexual assault on 2/21/23 when the police detective arrived. The detective provided limited information related to the allegation and asked that they speak to Resident #10 alone. The detective returned after approximately 5-10 minutes and stated they determined the allegation was not credible. The Administrator was satisfied with the detective's conclusion and stated they relied on the police investigation as there were no credible findings of abuse. The facility initiated an investigation and felt it was concluded within 2 hours of being notified by the police. 10NYCRR 415.4(b)

Based on interview and record review during an abbreviated survey (NY00291127), the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 of 4 residents (Resident #3) reviewed. Specifically, Resident #3 had a fall when a handrail they were holding fell off the wall. Resident #3 was admitted to the facility with diagnoses including dementia and history of a traumatic brain injury. The 12/20/21 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition; required supervision for most activities of daily living (ADL) including ambulation; utilized a walker and had no falls since reentry or the previous assessment. The comprehensive care plan (CCP) initiated 8/4/21 documented the resident was at moderate risk for falls due to gait and balance problems and psychoactive drug use. Interventions included to make sure the resident was wearing appropriate footwear when ambulating or mobilizing in their wheelchair and educate the resident about safety reminders and what to do if a fall occurs. The CCP revised 9/1/21 documented the resident had an ADL self-care and physical mobility deficit. Interventions included the resident required extensive assistance for locomotion on the unit using FWW and recommended utilizing WC (wheelchair) at this time. An Incident Report dated 1/3/22 at 4:20 PM completed by MDS Coordinator #13, documented the resident was not using their walker and was applying their weight to the hallway handrail to keep upright. The railing came down after the resident applied their body weight to it. Maintenance hung the handrail back up and checked all the handrails in the facility. A nursing progress note by MDS Coordinator #13 dated 1/3/2022 at 4:40 PM documented they observed Resident #3 lying on the floor in the hallway between rooms [ROOM NUMBERS] with the railing from the wall on the floor next to them. The resident stated they were walking down the hall; the rail went down and so did they. There were no injuries noted, the resident had full range of motion (ROM) and was able to bear weight. During an interview on 3/8/23 at 9:58 AM, MDS Coordinator #13 stated when the resident fell , they found the resident on the floor and the handrail had fallen off the wall. The resident was noncompliant and would self-transfer. The resident was supposed to use a walker and was noncompliant with walker use. The resident grabbed onto the handrail and fell with the handrail. During an interview on 3/8/23 at 11:48 AM, the Director of Maintenance stated they put up a handrail that morning after it was knocked off the wall with a medication cart. Another handrail had fallen off the wall recently, as well. They did not recall Resident #3's fall. They stated handrails needed to be secured as the residents used them to scoot around in their wheelchairs and residents could get hurt if they were not secured. The Director stated they checked the security of the handrails by banging on them. 10NYCRR 415.12(h)(1)

Based on record review and interview during the abbreviated survey (NY 449) the facility did not ensure residents who needed respiratory care were provided with care consistent with professional standards of practice for 1 of 3 residents (Resident #1) reviewed for respiratory care. Specifically, for Resident #1 who required continuous oxygen: - the resident did not have an oxygen order after 4/15/2019 resulting in her receiving continuous supplemental oxygen. - there was no documentation oxygen saturation levels were regularly monitored when the oxygen delivery rate was titrated (adjusting oxygen flow to resident's needs). - the resident was found to be cyanotic (bluish nail/skin color) with an oxygen saturation level in the 40s (normal range 95-100% in a person without lung disease) when her oxygen concentrator (device that produces oxygen from surrounding air) malfunctioned. When her oxygen saturation level did not rise above the 70s, medical was not notified timely. The resident continued with oxygen saturation levels in the 70s until the next shift arrived at the facility. The physician was contacted, and the resident was transferred to the hospital for evaluation. This resulted in actual harm that was not immediate jeopardy to Resident #1. Findings include: The facility's policy, Oxygen Therapy, revised 9/2016, documented titration of oxygen required a separate physician's orders [REDACTED]. Documentation of the outcome of titration was required in nursing notes and were to include the change in oxygen delivery rate, oxygen saturation level 30 minutes after the change in delivery rate, and the resident's response to the titration. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 3/20/2019 Minimum Data Set (MDS) assessment documented the resident's cognition was moderately impaired and she received oxygen. The 4/1/2019 through 4/14/2019 Treatment Administration Record (TAR) documented to titrate oxygen to keep oxygen saturation level greater than 85%, document the resident's oxygen saturation and liters of oxygen provided every shift. The oxygen saturation levels were documented for the time period of the TAR and ranged from 82% to 96%. The liters (L) of oxygen provided to the resident was not documented. The comprehensive care plan (CCP), updated on 4/2/2019, contained no documentation the resident received supplemental oxygen. The Director of Nursing (DON) provided the surveyor with a copy of the resident's orders from 4/1-4/15/2019 (from the old EMR) and the orders in place from 4/15/2019 going forward (in the new EMR) which included: - The printed current physician orders [REDACTED]. - The resident's orders with a date range of 4/1/2019-6/30/2019 (in the new medical record system) did not contain an order for [REDACTED].>- The resident's TAR from 4/15 through 4/30/2019 and for the month of 5/2019, contained no documentation of an oxygen order and no documentation of oxygen saturation levels. Respiratory therapist (RT) #7's progress notes documented he saw the resident on 5/1, 5/7, 5/9, and 5/13/2019. He documented the resident was on 4 L oxygen at each visit. He checked her oxygen saturation level at each visit and documented levels ranged from 83 to 91%. The 5/22/2019 RT #7's progress note at 1:19 PM documented the resident's oxygen saturation level was 79% on 4 L of oxygen. He asked registered nurse (RN) #1 to increase the resident's oxygen to 5 L and to follow-up. The 5/22/2019 at 2:30 PM RN #1's progress note documented she gave the resident a respiratory treatment and switched her to an oxygen tank from a concentrator. She encouraged the resident to do deep breathing and coughing due to low oxygen saturation levels and the resident's lungs sounded junky. She documented the resident's oxygen saturation level was 85% on 4 1/2 L oxygen. No other vital signs were documented by RN #1. The 5/26/2019 at 3:53 AM, licensed practical nurse (LPN) #2's progress note documented she found the resident lethargic, clammy, and her nail beds and lips were cyanotic. Her oxygen saturation level was 40% and the oxygen concentrator was not working. She placed the resident on an oxygen tank and called for the RN. After placing the resident on an oxygen tank and elevating her head of bed, she became alert and responded to verbal stimuli. The resident's oxygen saturation level went up to 75%. The 5/26/2019 at 4:05 AM, RN #3's progress note documented at 2:00 AM she was called to the room because the resident's oxygen saturation level was 40%. The LPN noticed a problem with the concentrator and addressed the issue. When the RN arrived at the room, the resident was on 4 L oxygen via a tank and her saturation level was rising to 50%. Oxygen was increased to 6 L, she was clammy, and had some wheezing with cyanotic nails. After 15 minutes, the resident returned to her baseline which was being responsive to yes and no questions. Oxygen was kept at 6 L and her saturation levels increased to 76%. At that point, her oxygen was decreased back to 4 [MI] The oxygen concentrator began working properly and she was placed back on the concentrator. There was no documentation medical was notified of the resident's respiratory status. The 5/26/2019 at 6:59 AM, LPN #2's progress note documented the resident's oxygen saturation level was 76%. A 5/26/2019 at 9:15 AM physician order [REDACTED].#4 documented a telephone order was received from the physician to send the resident to the hospital due to oxygen saturation of 72% on 5 L of oxygen. The 5/26/2019 hospital history and physical documented the resident was obtunded (altered level of consciousness) and presented with labored breathing and was on continuous positive airway pressure ([MEDICAL CONDITION], provides air pressure on a continuous basis to people who cannot breathe spontaneously). The report documented in the emergency room the resident was hypoxic (low oxygen levels) and required bi-level positive airway pressure ([MEDICAL CONDITION], provides air pressure to those who cannot breathe spontaneously) and her chest x-ray showed left lobe pneumonia. The resident's laboratory tests were significant for lactic acidosis (a buildup of lactic acid caused by oxygen deficit). On 5/26/2019, a new problem was added to the resident's CCP documenting the resident had altered respiratory status and was oxygen dependent. The goal was to keep oxygen saturation levels above 88-90% with 4 L of oxygen and respiratory treatments. The interventions for the CCP documented to provide the resident with 3 L of oxygen. The CCP listed two different plans for the rate of supplemental oxygen delivery. On 6/3/2019 at 11:40 AM, RN #1 was interviewed. She stated on 5/22/2019 during the day shift, RT #7 asked her to see the resident because her oxygen saturation levels were 78%. RN #1 gave the resident a respiratory treatment and the resident's oxygen level improved to about 82 or 83%. She stated she was not satisfied with those numbers so she got an oxygen tank, applied a non-rebreather mask (allows for delivery of higher oxygen concentration) to the resident, and increased the oxygen delivery rate to 10 [MI] She stated the resident's oxygen saturation level went back up to 88% after about 20 minutes on the non- rebreather mask and she decreased her supplemental oxygen down to 4 1/2 [MI] RN #1 stated to her knowledge, the resident had a titrate order and they could increase her oxygen up to 5 L to keep her oxygen saturation levels above 85%. She reviewed the physician's orders [REDACTED]. She stated when the resident was sent out on 5/26/2019, LPN #4 had called her that morning at around 8:45 AM and told her the resident's oxygen saturation level was in the 70s. LPN #4 told her she was calling the physician to have the resident sent out to the hospital. LPN #4 also told her the resident's oxygen saturation level had dropped to the 40s during the night shift. RN #1 stated she was not present in the facility at that time but if someone's oxygen saturation level was in the 40s, she would call medical, so the person could be sent to the hospital. RN #1 stated she was working days that day and when she arrived to the facility around 9:30 AM, the resident had already been transferred to the hospital. On 6/3/2019 at 1:15 PM, LPN #4 stated in an interview, she found out in report between 7:00 AM-7:30 AM on 5/26/2019 that the resident's oxygen saturation level had been low overnight and was in the 70s at that time. She stated to her knowledge, the resident had an order to titrate oxygen up to a maximum of 5 L to keep oxygen saturations around 80-82%. She stated she went to the resident's room after report and checked the resident. Her oxygen saturation was 76%. She administered a breathing treatment and re-checked the oxygen saturation and it was 72%. She felt the oxygen level should have increased after administering the treatment, so she called medical and RN #1 to get an order to send the resident to the hospital. She stated she then started the paperwork to send the resident out. She stated a couple of hours went by between when she first checked the resident and when the resident was sent to the hospital because she had to complete the paperwork prior to transferring the resident to the hospital. On 6/3/2019 at 1:40 PM, LPN #2 was interviewed and stated during the night shift on 5/26/2019, she was rounding with the certified nurse aide (CNA) between 2:00 AM and 2:30 AM and they found the resident not responding per her usual and her nails and lips were discolored. The oxygen concentrator was not working, and she sent the CNA to get an oxygen tank and to notify the RN. She placed the resident on the oxygen tank and was able to get the concentrator working again by unhooking the water bottle and hooking it up again. She stated the resident's oxygen saturations increased to the 70s and the resident was responding per her usual. She stated because the resident was responding and she knew her oxygen saturation levels had been in the 70s before, she did not titrate her oxygen to a higher rate. She administered the resident medications at about 6:00 AM and the resident woke up to take the medications. She stated the resident had an order to titrate oxygen and keep saturation levels in the 80s. She did not call the physician and she stated it was the RN's decision whether to call medical or not. On 6/3/2019 at 2:10 PM, RN #3 was interviewed and stated she was told by LPN #2 on 5/26/2019 the resident's concentrator was not working, and her oxygen saturation was in the 40s. When the resident's saturation increased to the 70s using 6 liters of oxygen she was no longer cyanotic and clammy and answered yes and no questions. She stated LPN #2 told her this was the resident's baseline. She did not check the resident's orders and did not know if she had an order to keep oxygen saturation levels above a certain percentage. She stated she did not call medical because LPN #2 knew the resident well and told her the resident was at her baseline. On 6/4/2019 at 11:35 AM, the Director of Nursing (DON) stated in an interview, she was not aware the resident did not have an oxygen order after 4/15/2019 when they changed medical record systems. She stated the facility changed from one electronic medical record (EMR) system to another EMR system on 4/15/2019. She stated on 4/15/2019, the nurses took the orders from the old medical record system and entered them into the new medical record system. She reviewed the electronic medical record for the resident's orders and the TAR and stated she also was not aware the staff were not documenting the resident's oxygen saturation levels after 4/15/2019. The resident's oxygen order must have been dropped when they changed medical record systems. She stated when the resident's oxygen saturation level was in the 40s, the RN assessed her right away but did not notify medical. She stated the RN should have followed up with medical to see if they wanted to send the resident to the hospital. On 6/4/2019 at 12:30 PM, the attending physician stated in a telephone interview, residents who required oxygen should have orders in place. She stated oxygen saturation levels should be taken as ordered or more often if nursing felt there was a need to take one. She stated she would expect the on-call medical provider to be notified if a resident had an oxygen saturation level in the 40s and was cyanotic. She could not recall specific details regarding Resident #1. On 6/4/2019 at 12:45 PM, certified nurse aide (CNA) #8 stated in an interview, she came in at 3 PM on 5/25/2019 and worked until 7 AM on 5/26/2019. She stated she saw the resident on the 3 PM to 11 PM shift and she was fine. She did her care at around 11 PM and then the next time she saw her was on 5/26/2019 at 2 AM when herself and LPN #2 checked on her. She stated the resident was cold and clammy and her coloring was pale. LPN #2 asked her to get an oxygen tank and the Supervisor. She stated when the RN responded to the room, they told her to continue caring for other residents so she left the room. On 6/5/2019 at 8:55 AM, RT #7 stated in interview, he saw the resident weekly when he was at the facility. He stated the resident's oxygen saturation level usually ran in the low 80s and she functioned normally at those levels. He stated when he saw her on 5/22/2019, she was in the 70s and that was lower than her normal, so he immediately asked RN #1 to monitor her and follow-up. He stated when he returned to the facility the following week, he heard the resident's oxygen saturation level had dropped to the 40s and she was in the hospital. He stated he was not aware of the resident's oxygen saturation level ever dropping that low before and if he was in the building when that occurred, he would have recommended that nursing call medical so that the resident could be transferred to the hospital to determine the cause of the low oxygen saturation and to manage her care. 10NYCRR #415.12 (k)(6)

Based on observation, interview and record review conducted during the standard survey, it was determined for 1 of 3 residents (Resident #8), reviewed for behavior concerns the facility did not ensure residents who displayed adjustment difficulty received appropriate treatment and services to correct the assessed problem. Specifically, when the facility changed their resident smoking policy Resident #8 was not offered the opportunity to continue smoking, in an area that maintained the resident's quality of life, and the resident became more withdrawn, and angry, with increased depressive behaviors. This resulted in actual harm that is not immediate jeopardy. Findings include: Resident #8 had [DIAGNOSES REDACTED]. An initial psychological diagnostic interview was completed by the psychiatric social worker on 7/16/2013 and documented the resident reported a depressed mood with feelings of hopelessness. The therapist documented the resident was having difficulty with impulsivity related to depression and recent losses. On 7/17/2013 the occupational therapist (OT) completed the Resident Smoking Assessment and documented the resident was able to light his own cigarette safely, and safely dispose of the cigarette in the designated area. The resident was assessed to need assistance with opening the doors to go outside to the designated smoking area. The smoking agreement signed by the resident and the Director of Social Services on 7/17/2013 documented the resident was permitted to go outside in front of the building to smoke. The resident's smoking materials were to be locked in the nurses' medication cart. The comprehensive care plan (CCP) initiated on 7/17/2013 documented the resident was independent with smoking. The resident was to be monitored to ensure he smoked only in the designated area; all smoking materials were kept at the nurses' station; oxygen was off when smoking; and a smoking apron was used. A social work progress note dated 7/23/2013 documented a smoking schedule was made with the resident. The resident was in agreement with the schedule as long as staff assisted him with going outside. On 10/14/2013 the social worker documented she spoke to the resident regarding the New York State smoking law going into effect on 10/29/2013, and he stated he would sign himself out of the facility once he was no longer able to smoke at the facility. The social worker documented this concern was voiced to the resident's family member. On 10/28/2013 the social worker documented she reminded the resident the facility was going to be smoke free as of 10/29/2013. A social work progress note dated 10/30/2013 documented the resident was smoking outside, and the resident was reminded about the current resident smoking policy and the New York State Law. The resident was reminded he could not leave the premises to smoke by himself. The social worker documented the resident refused assistance to quit smoking. On 10/31/2013, the social worker documented the resident was asking for his cigarettes and lighter, was reminded he could not smoke alone, and was not able to go out without family. The social worker documented the resident was informed if he left the facility against medical advice (AMA), he would not be allowed to return. An Elopement Risk assessment dated [DATE] documented the resident was at risk for elopement, as he was at risk for leaving AMA in his electric wheelchair, and was non compliant with the resident smoking policy. The assessment documented the resident stated he was not going to try to leave, he just wanted to smoke. The CCP documented on 10/31/2013 the resident was non compliant with the resident smoking policy and wanted to leave the property unattended despite re-education for safety. As a result, the resident was on 15 minute checks, and a Wanderguard was placed on his wheelchair. On 11/1/2013, the Director of Social Services documented in a progress note, the resident's family were reminded not to leave cigarettes with the resident, reiterated the resident smoking policy and informed the family member in the presence of the resident, that if the resident had cigarettes after the family member left, "law enforcement will be called." Nursing progress notes dated 11/1/2013 - 11/26/2013 documented the resident requested a cigarette without family present on 11/3, 11/8,11/14, and 11/20/2013. The resident became upset when informed he was unable to smoke on these occasions. During this same time period, nursing and social services documented the following: - On 11/2/2013 the resident refused to get out of bed all day and stated "I have nothing else to do." - On 11/4/2013 the resident was described to be in a "low mood" due to not being able to smoke on the facility property anymore. - On 11/6/2013 the resident was out of the building and bought a pack of cigarettes. The cigarettes were locked in the social work office and the resident was informed he could not smoke until a family member was with him. - On 11/15/2013 the resident (who was diabetic) was observed eating a large candy bar. When counseled regarding his diabetes, he stated "well, I can't smoke so I may as well eat candy." Nursing and social service progress notes dated 12/3/2013 -2/26/2013 documented the resident requested to go out and smoke without family present on 12/3, 12/6, 12/8/ 12/16, 12/18, 12/24 and 12/26/2014. On 12/6 and 12/16/2013, the resident asked several times and when informed of the resident smoking policy, became upset with staff. During the month of 1/2014, the following was documented in nursing progress notes: - On 1/6/2014 the resident offered a certified nurse aide (CNA) money in exchange for a cigarette. - On 1/12/2014 the resident stated "I'm shaking so bad I need a cigarette" and stated he was upset as he was unable to have a cigarette "in my own place." - On 1/26/2014 the resident stated he was very depressed, and on 1/27/2014 a new order was written for a psychological evaluation, and the resident's [MEDICATION NAME] (antidepressant) was increased from 50 milligrams (mg) daily to 75 mg daily. The social work note dated 1/28/2014 documented the resident was sleeping heavily when psychologist went to his room to meet with him. The note recorded "Psych will meet with resident next Tuesday or earlier if needed." There was no documentation in the medical record the resident was seen by psychology the next Tuesday. During the month of 2/2014, nursing documented the resident requested a cigarette and was reminded of the resident smoking policy on 2/2, 2/21, 2/24, 2/25 and 2/26/2014. The resident became upset and belligerent with staff when denied the ability to smoke. The resident complained of being depressed, and nervous, as he was unable to smoke. On 2/25/2014 nursing documented in a progress note, the resident attempted to leave the facility, and "ran over the supervisor" with his electric wheelchair. On 2/26/2014 nursing documented the resident was unsafe with his electric wheelchair and it was taken away from him. The resident was provided a regular manual wheelchair. On 2/26/2014 the social worker documented in a progress note, the resident did not appear to be able to accept the rules and limitations. On 2/27/2014 the social worker documented the resident was informed other placement was being pursued due to his behavior, and he would have to take any bed that was offered. The resident stated he had other plans and asked the social worker to "hand him a gun." The social worker documented when questioned the resident stated he did not want to hurt himself, and only said these things when he was angry. The resident stated he wanted to leave AMA, and was informed the police and Adult Protective Services would be notified if he left. On 2/28/2014 nursing documented the resident said there was no point in eating because he had nothing to look forward to. The resident was documented to be on "strict" 15 minute checks. On 3/1/2014 nursing documented the resident stated to a CNA he had cigarettes, and a lighter in his coat pocket. On 3/2/2014 nursing documented a lighter was on the resident's bed, and a pack of cigarettes was falling out of his jacket pocket. The resident was notified his cigarettes and lighter were to be kept in the medication cart. On 3/4/2014 the social worker documented in a progress note, the psychiatric social worker asked the resident if he wanted to talk about recent behaviors and/or moods, and the resident declined stating he only wanted someone to help him go outside to smoke. The licensed clinical social worker - registered (LCSW - R) note dated 3/25/2014 documented the resident was asleep when the LCSW - R attempted to see him. The note documented the LCSW - R would attempt to see the resident next week. There was no documented evidence the resident was seen by the LCSW - R the following week. On 4/21/2014, at 1:25 PM, the resident was observed sitting in his room in his wheelchair with the television on and his meal in front of him. During an interview with the resident at 1:25 PM, the resident stated he spent all of his time in the room, and watched television all day. He stated he was a Yankee fan, and was not as interested as he had been in the past. The resident stated he no longer smoked which was the only thing he "enjoyed." During an interview with the Director of Social Services on 4/22/2014 at 3:45 PM, she stated the facility knew on admission the resident was a smoker, and the resident was assessed to be independent for smoking. The social worker stated, prior to the change in the resident smoking policy, the resident was able to go out per the smoking schedule set up by nursing and the resident. The social worker thought a letter was sent out regarding the change in the resident smoking policy. She did not know if the resident or a family member received the letter. The social worker said she was unable to locate the letter. She stated the change in the resident smoking policy was on a billboard in the front lobby, and in the facility newspaper. She stated on 10/23/2013, she informed the resident smoking was not permitted on the facility's property. The social worker stated the resident's behavior, specifically anger, seemed to increase with the change in the resident smoking policy, and when the electric wheelchair was taken away from him. The social worker stated the resident's behavior changed when he lost his independence. In an interview on 4/23/2014 at 2:30 PM the Director of Social Service sated the resident often refused psychology services. In an interview on 4/23/2014 at 5:45 PM the psychologist stated he did not write a progress note, when the resident refused to be seen, as that was not considered billable hours. 10NYCRR 415.12(f)(1)